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Microbiology and Management ofAnimal BitesByHeba AL Sayed AL Degla
Assistant lecturer of Medical Microbiology and Immunology
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Animal bites
frequency
1% of annual ER visits and cost $30 million per year
HCP treat 1-2 million animal bite patients per year
10% of animal bite wounds require medical attention
1 to 2% require hospitalization
10 to 20 human deaths per year primarily of infantsand children
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1. Infection which may be life threatening
2. Mechanical trauma
Superficial skin breaks with or without bleeding, Puncture wounds,
Lacerations,
Fractures,
Tendon damage
Disability and cosmetic problems due to scar formationand loss of tissue
Problem of animal
bites
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Infections
Most bacteria reside in the animal's oral cavity.
Bacteria on the victim's skin.
Most infections involve several pathogens
Over 130 disease-causing microbes have beenisolated
Dog bites do more damage, but only 5 to 15 %
become infected.Cat bites: up to 80 % become infected if proper careis not taken
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Disease Risk by Species
Dogs and Cats:
Rabies
Bacterial infections
Cats: Cat scratch fever (Bartonella henselae, B. quintana)
Sporothrix schenckii (bite or scratch)
Rodents (domestic): bacterial infections.
Rodents (wild):
Rabies
Bacterial infection (including tetanus and tularemia)
Rat bite fever rare
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Wild Animals e.g., skunk, fox, raccoon, opossum
Rabies
Bacterial pathogens (tetanus and tularemia).
Bats: rabies. Primates (non-human)
Rabies
Bacterial infections
Simian B herpesvirus (macaques)
Hepatitis A, B, and C (certain great apes).
skunk
raccoon
opossum
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Horse, donkey, pig and sheep bites
Actinobacillus spp, staphylococci, streptococci,Pasteurella spp , Yersinia and anaerobes
Camel bites Pseudomonas, Staphylococci,Streptococci and Clostridium tetani
Seal bites: give rise to the
seal finger: swelling and blisteringat the site of injury due to infection
with a Mycoplasma organism
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Risk group
Occupational: veterinarians, farmers.
Children (5 to 15 years): head or neck
With dog bites, adults are bitten on an extremity Boys are twice as likely to be bitten by a dog
Girls receive twice as many cat bites.
Most of the animals live in the victim's neighborhood(75%) or home (15%)
Bites are provoked by humans.
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Infection risk
Factors related to the victim
1. Age over 50 years
2. Diabetes, circulatory problems, liver disease,alcoholism, or HIV/AIDS
3. Organ transplant
4. Chemotherapy or long-term steroids treatment5. Splenectomy
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Factors related to the animal:
Cat bites (40-50%) Dog bites (5-15%)
Human bites (15-40%)
Factors related to the bite wound
Location: Hand (20-35%), arm or leg (10-15%),face (5-10%)
Type of wound: Puncture with laceration (15-25%),laceration alone (10-12%)
Interval between bite and medical care: If >24 hr,risk of infection increases
Infection risk
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Dog bites
Children younger than 10years
Involve the head and neck. Male dogs are six fold more
likely to bite than are femaledogs.
The wounds are crushing andlacerations rather thanpuncture wounds
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Certain breeds: German Shepherds
pit bull terriers, and mixed breeds.
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Infections associated
with dog bite
A. Infectious organisms specific to canine saliva.1- Pasteurella spp.
Small Gram-negative facultative anaerobic rods
The most common bite-associated infection
Up to 80% with cat bite, 12%-50% with dog bite infections
Multiple species: P. multocida subsp. multocida, subsp.septica, P. stomatis, P. dagmatis, and P. canis
Inflammatory response, within the first 24 hours
Fulminant soft tissue inflammation in 3 hours.
Purulence, lymphangitis, regional adenopathy andnecrotizing fasciitis
P. multocida can cause septic arthritis
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2- Capnocytophaga canimorsus and C. cynodegmi.
Fastidious gram-negative rods
C. canimorsus is more dangerous
Very rare infection, but so dangerous Fulminant sepsis, meningitis and severe soft tissue
infection particularly in compromised people.
Up to 30 % of septicemia cases are fatal.
Early symptoms: nausea, headache, muscle aches, andtiny reddened patches on the skin.
C. cynodegmi cause localized soft tissue inflammation
Infections associated
with dog bite
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B- Dogs may be infected by infectious organisms
and transmit this pathogen to humans through saliva
Brucella canis resulting in local wound infection, and the
nonspecific symptomatology associated with brucellosis. Rabies
C-Other pathogens: Staphylococci, Streptococci, Proteus,anaerobes, Moraxella, Corynebacterium, Neisseria, tetanus,
and tularemia.
With this plethora of potential pathogens in canine saliva only 5-15% of dog bites result in soft tissue infections
Infections associated
with dog bite
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Cat bite
Victims are adult females
On the upper extremities and face.
Feline bites are of particular concern
because the sharp and long teeth of
cats can penetrate skin,
creating a deep puncture wound with
microorganisms inoculated into thesoft tissues or even deeper
into the periosteum or into a joint
and result in osteomyelitis or septic arthritis.
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1-Pasteurella spp. (with the exception ofP. canis)
Cats are the source of 60 to 80% of human P.
multocida infections Commensals of the feline respiratory tract and can be
cultured from the oral cavities of >90 % of cats
Wounds inflicted by cats more commonly progress tothe serious sequelae such as osteomyelitis, sepsis,and meningitis.
Infections associated
with cat bite
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2- C. canimorsus and C. cynodegmi
Part of the normal feline oral flora Local soft tissue infection, fulminant sepsis and
meningitis, are more common with cat bites.
Corneal infection with C. canimorsus following eye
trauma due to a cat bite cat's tooth keratitis
Infections associated
with cat bite
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Infections associated
with cat bite
3- Cat scratch disease
Slowly progressive, self-limiting, chronic lymphadenopathy
Children (2-14years)
Due to infection with Bartonella henselae Gram negative rods formerly placed in the genus
Rochalimaea.
It infects kittens and remains in their blood for long periods.
Bacteremic cats infect their owners via bites or scratches
Also transmission to humans via contact with the cat fleas(Ctenocephalides felis)
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Transmission
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Cat scratch
disease
Incubation period of 1-2 weeks
Primary lesion: cutaneous red
painless papules or pustules atthe scratch or bite.
After 3-10 days regionallymphadenopathy in 90% of
cases. Fever, malaise, and other
systemic symptoms
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In the most severe cases,the organism disseminatewidely throughout the
human host
Infecting the liver, spleen,eye, and CNS, which
present as seizures dueto encephalitis
Cat scratch
disease
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DiagnosisClinical diagnosis is made if 3 of the following 4 criteria
are met:
1. History of cat contact resulting in a scratch orprimary lesion of the dermis, eye, or a mucousmembrane
2. Positive skin test response to antigen or positive
indirect fluorescent antibody test
3. Negative lab investigation for lymphadenopathy
4. Characteristic lymph node lesions.
Cat scratch
disease
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Therapy
Symptomatic care
Swollen lymph nodes will resolve in 1-6 months.
The infection will resolve in 90% of untreated patients
For extensive lymph node swelling Azithromycin for 4weeks
Retinitis: Doxycycline + Rifampin for 4-6 weeks. Endocarditis: Doxycycline 6 weeks + Gentamicin for 14
days.
Encephalopathy; Rifampin, Ciprofloxacin,
trimethroprim/sulfamethoxazole, or azithromycin.
Cat scratch
disease
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4- Cowpox, or catpox
Uncommon viral infection of cats found in Europeancountries.
Member of the family Orthopoxvirus.
Infection contained to the soft tissue surroundingthe bite itself.
Painful hemorrhagic pustule, which may developinto a black eschar.
Infections associated
with cat bite
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5- Francisella tularensis
Cause a potentially fatal infection in cats
Tick-borne infection, rarely by cat bite
Tender papule progress to an ulcer with a yellow orblack base
Extraordinarily rare.
6- Other bacteria found in cat wounds Actinomyces, Proprionibacterium, Bacteroides, and
Fusobacterium.
Infections associated
with cat bite
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Rat bite fever (RBF), also known as Haverhill fever
Caused byActinobacillus muris and Spirillum minus
Both are part of the normal oropharyngeal flora of rats
Most cases occur in Japan, but also in Australia, Africa,North and South America, and Europe.
Human infection most commonly occurs via a bite
Some cases may occur through contact with urine, oral orconjunctival secretions
The source of the infection is a rat, other animals such assquirrels, weasels, and gerbils.
Infections associated
with rat bite
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Rat-bite fever due toActinobacillus muris
Fever, chills, headache, and muscle pain within 10
days of exposure. After three days diffuse rash in the extremities.
Inflammation of One or several large joints
If untreated, severe complications including infectionof the heart valves may occur.
Rat bite fever
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RBF caused by Spirillum minus
Common in Asia, particularly Japan, called sodoku.
Skin rash characterized by red or purple plaques
Previously healed wound bite may reactivate
Relapsing fever and regional lymphadenitis
Joint involvement is rare
Rat bite fever
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Diagnosis
Detection of the organism in skin, blood, joint fluid, orlymph nodes
Blood antibody tests.
Treatment
Penicillin, Amoxicillin Clavulanate, Erythromycinor Tetracyclines for 7-10 days.
Rat bite fever
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Prognosis
Excellent with early treatment.
Complications
Pericarditis
Endocarditis
Parotitis
Tenosynovitis
Abscesses of the brain or soft tissue
Rat bite fever
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Snakebite
Soft tissue infection may not be the victim's foremostpriority
Infection withAeromonas hydrophila Local soft tissue necrosis and cutaneous abscesses
at the site of injury.
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Grizzly or black
bear bites
Have been cultured forA. hydrophila.
Soft tissue infections are polymicrobial
consisting ofE. coliand Proteus spp.,
S. epidermidis and S. aureus
It is unknown if these organisms are particular tobear saliva or carried by the claws from soil orother sources.
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Horse bites
2% of all animal bites.
Young girls.
Severe bite may result in amputation, or severehematoma, fat necrosis, and muscle rupture,without an external wound.
Few bites develop into an infective state
Mainly Pasteurella, Actinobacillus, and Yersinia. A. actinomycetemcomitans, causes infective
endocarditis
Other bacterial pathogens, such as S. aureus.
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Monkey bites
Bacteroides spp, Fusobacterium spp, streptococci,enterococci, tetanus and Eikenella corrodens
Simian herpes virus (herpes B virus) is, rarely,
transmitted by bites from monkeys of the macaquegenus (native to Asia and northern Africa)
Rapidly progressive encephalomyelitis, with a mortality
around 70% Asymptomatic patients: prophylactic aciclovir
Established infection should be treated with aciclovir
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Wild animal bites
Rare but more serious, given the risk of rabies and otherinfections.
Rabies is caused by a virus that infects nervous system and
can affect all warm-blooded animals, including people. Once symptoms appear, infected people almost always die.
Rabies is found naturally in wild animals especially skunks,wolfs, foxes and bats.
Wild animals can transmit infection to dogs and cats whichthen transmit it to people (or people can catch it directly fromwild animals).
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Rabies
Transmission
Bite of a rabid animal
Non-bite exposures to rabies are very rare.
Scratches, abrasions, open wounds, or mucousmembranes contaminated with saliva from a rabidanimal
Other contact, such as petting a rabid animal orcontact with the blood, urine or feces of a rabidanimal, does not constitute an exposure and is not anindication for treatment.
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Clinical presentation (human)
Two stages.
The first stage (10 days): headache, fever,
decreased appetite, vomiting, general malaise, pain,itching, and tingling at the wound site.
Stage two, difficulty in swallowing, agitation,disorientation, paralysis, and coma.
At this point there is no known effective treatment.
Without treatment, it is 100 % fatal
Rabies
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How do I know if an animal has rabies?1-Vicious rabies
Changes in personality.
Refusal to eat; unusual excitability or restlessness;snarling at moving objects; and excessive drooling andfoaming at the mouth.
Ends in paralysis and death within several days
2- Dumb rabies Rapidly progressing paralysis in 3-5 days ends in death.
Dropped jaw.
Rabies
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What should I do if an animal bites me?
Wash the bite wound
Contact a physician to assess
rabies risk
Begin rabies ttt, if necessary. .
Animal quarantined or tested.
If the animal cannot be found,
treat with (HRIG/RIG) and human diploid cell vaccine
Rabies
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Rabies
What should be done with the biting
animal?
Capture the animal and cage it.
If cannot be captured, kill it butDO NOT shoot it in the head.
The head should be removed and
the brain examined for rabies by
direct fluorescent antibody test
Non- stray animals will require
to be quarantined.
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How long should the animal be confined for
observation?
10 days.
If animal had rabies at the time of biting, it will showsigns of rabies and/or die within ten days.
Stray or wild animals should be killed immediately
and the brain examined for rabies.
Rabies
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Rabies prophylaxis
Indications
1- laboratory evaluation found that the animal wasrabid
2- Animal was not captured
3- After exposure to bats even if no bite.
As soon as possible after exposure.
Rabies
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Regimen
1- Patients not vaccinated previously
receive both human rabies vaccine
(5 doses IM in the deltoid area) and
rabies immune globulin (20 IU/Kg),
infiltrated in and around the wound
and the remainder IM.2- Individuals received a complete vaccination
receive only two does of vaccine three days apart.
Rabies prophylaxis
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Prevention
Do not try to separate fighting animals
Avoid animals that appear sick or act strangely.
Leave animals, alone when they are eating or sleeping.
Keep pets on a leash when out in public.
Never leave a young child alone with a pet.
Dont tease an animal by waving sticks,
throwing stones, or pulling a tail.
Be sure your pet is vaccinated.
Do not play with any wild animal.
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Human bites
In child, on the face, upper extremities, or trunk.
The force of bite drive oral bacteria into the tissueand spread to the adjacent joints or it directlypenetrate the joint.
Staphylococci, Streptococci, Eikenella corrodens,Clostridium tetani, and Bacteroides.
Possible transmission of hepatitis B, hepatitis C,herpes simplex virus, and HIV.
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Management
History
The length of time since injury,
The type of animal and its present location,
Immunization status and health,Physical examination
Musculoskeletal and neurologic examination
Inspection of the wound for signs of infection.
Rapidly developing Cellulitis is a clue to P. multocida A cellulitis that develops gradually is more likely the result of
Gram-positive cocci or other pathogenic bacteria
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History
The length of time since injury,
The type of animal and its present location,
Immunization status and health,Physical examination
Musculoskeletal and neurologic examination
Inspection of the wound for signs of infection.
Rapidly developing Cellulitis is a clue to P. multocida A cellulitis that develops gradually is more likely the result of
Gram-positive cocci or other pathogenic bacteria
Management
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Radiological studies
Necessary for deep puncture wounds to look forforeign objects and bone injuries.
Initial assessment:
Primary assessment of bites must involve ABCs.
Hemostasis must be achieved.
The effect on vital organs should be assessed.
Next, the wound itself should be addressed:
Management
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Cleaning and exploration:
Clean the wound with copious amounts of soap andwarm sterile water or saline for 15 min and inspect it.
Wash with an antiseptic solution
Apply antibiotic ointment and cover the wound withgauze or a bandage.
If severe wound, or if you have risk factors, seekmedical advice at once.
Be sure no foreign bodies into the wound.
Elevation of the affected part and immobilization
Management
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Suturing: Cutaneous wounds should be treated and left open if
1. They are punctures rather than lacerations,
2. Not disfiguring,
3. Inflicted by humans,4. Involve the legs and arms (particularly hands)
5. Bites to the arms and legs seen after 6 to 12 hours.
6. Bites to the face seen after 12 to 24 hours.
Facial lacerations are almost always closed.
Debridement of all devitalized tissue and attention to wound care
Wounds that are clearly infected should not be closed.
Management
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Infection prophylaxis:Standard management:
85 % of bites harbor potential pathogens.
Adherence to standard principles of woundmanagement
Copious irrigation at high pressure
Dbridement of devitalized tissue
Cultures obtained at the time of injury cannot predictwhether infection will develop or, if it does, thecausative pathogens.
Management
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Antibiotics:Indications
High-risk patients: young children, older patients,
patients with chronic medical problems, andimmunocompromised patients.
High-risk injuries: crush injuries, deep puncturewounds, systemic signs of infection, rapidly
spreading cellulitis, septic arthritis, osteomyelitisthose require surgical repair, and those involvinghands and face.
Management
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Ampicillin-sulbactam.
In penicillin allergy: clindamycin plus trimethoprim-sulfamethoxazole.
Broad-spectrum antibiotics If the wound infected withhospital acquired or community acquired bacteria,until culture sensitivity results.
Intravenous antibiotics for infected hand bites, severeinfections at other sites, and systemic symptoms
Management
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Rabies prophylaxis
Tetanus prophylaxis:
After bites of all kinds, tetanus immune globulin andtetanus toxoid should be administered to patientswho have had two or fewer primary immunizations.
Tetanus toxoid alone can be given to those who have
completed a primary immunization In human bites, proper vaccination for hepatitis and
prophylactic treatment for HIV
Management
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Late Care Scarring needs to corrected.
Tendon injuries and nerve injuries should be corrected assoon as feasible.
When to refer
Complex wounds that require surgical repair
Bites to the face or hand that require plastic surgery
Infected wounds not responding to initial treatment
Children with human bites from an adult
When to admit
Infected wounds requiring intravenous antibiotics
Extensive facial wounds requiring skilled nursing care
Management
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