it s a dog eat man world out there l.
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It’s a dog eat man world out there Management of Dog Bites Case – part 1 57yo male with PMH of HTN, GERD, past Etoh abuse attacked by his neighbor’s Chow while walking down the street. Dog’s last rabies vaccination 3/01 – dog taken into custody.

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case part 1
Case – part 1
  • 57yo male with PMH of HTN, GERD, past Etoh abuse attacked by his neighbor’s Chow while walking down the street. Dog’s last rabies vaccination 3/01 – dog taken into custody.
    • Seen is the ED: wounds irrigated, rabies immune globulin and rabies vaccine #1 administered, and 1 gm of IV Ancef given
    • Given a Rx for Augmentin 875 mg po tid x 7 days, and discharged to home, with instructions on completing his postexposure rabies prophylaxis
epidemiology
Epidemiology
  • Dog/cat bites comprise 1% of all ED visits per year combined
  • 1 in every 775 persons seek emergency care for dog bites per year
  • 1 dog bite fatality: 16,000 ED visits for dog bites
  • 1 dog bite fatality: 670 dog bite hospitalizations
slide4
Men > women
  • Children > adults
    • Highest risk group = boys, ages 5-9
  • Upper extremities > lower extremities, trunk
slide5
Some breeds are bigger offenders than others
    • German Shepherd, Pit Bull, mixed breed
      • German shepherd & mixed breeds bite most often
      • Pit Bull breed is #1 in dog bite fatalities, usually secondary to exsanguination, due to severity and sheer number of bites
microbiology of dog bite wounds
Microbiology of dog bite wounds
  • Normal canine mouth flora is complex
    • S. aureus, streptococci, gram negative bacteria, & anaerobes
  • Pasturella species are the most common isolates from wound cultures
    • P. canis is most common in dog bite cultures
    • P. multocida found in 20-50% of dog bite cultures
history
History
  • Review the circumstances of the bite
    • Was the bite provoked or unprovoked?
    • Is the dog available for observation?
    • Is the dog’s vaccination status known?
    • Did the bite occur domestically or abroad?
    • When did the bite occur?
    • Who is the owner?
  • Does the patient have RA, DJD, or prosthetic joints?
  • Is the patient immunocomprised by chronic steriod use, HIV or chemotherapy?
  • Cirrhotic? Alcoholic?
  • What is the patient’s tetanus vaccination status?
physical
Physical
  • Number & location of bites
      • Hand, joint or bone involvement?
  • Puncture vs. laceration vs. tear
  • Signs of infection
    • Pain and swelling are most common
    • Purulent drainage (40%)
    • Lymphangitis (20%)
    • Regional adenopathy (10%)
management of uninfected wounds
Management of Uninfected Wounds
  • Thorough washing with povidone-iodine & soap
  • Wound cultures generally not helpful
    • Puncture wounds and small tears require swab cultures after irrigation
  • Wound closure is controversial
    • Puncture wounds and injuries to the hand should not be closed primarily
    • Crush injuries, extensive debridement required
      • delayed primary closure
prophylactic measures
Prophylactic measures
  • Antibiotic prophylaxis
  • Tetanus immunization
  • Rabies prophylaxis
antibiotic prophylaxis
Antibiotic prophylaxis
  • Controversial topic
  • High risk scenarios in which antibiotic prophylaxis in universally recommended:
    • hand bites
    • deep puncture wounds
    • bite in a limb with existing lymphatic/venous insufficiency
    • wounds that need surgical debridement
    • wounds in older &/or immunocomprised patients
    • bites in or near a prosthetic joint
slide12
Cummings, P. Antibiotics to prevent infection in patients with dog bite wounds. Annals of Emergency Medicine. 1994.
    • Meta-analysis of 8 randomized controlled trials
    • Major outcome was wound infection
    • Found a relative risk in the treated groups of 0.56
    • Found a Number Needed To Treat of 14
slide13
1st anitbiotic dose should be administered IV ASAP
    • 1st choice: Unasyn, Timentin, Zosyn
    • Clinda/Cipro if PCN allergic
  • 3-5 days of oral therapy to follow
    • 1st choice: Augmentin
    • Clinda/Cipro if PCN allergic
tetanus immunization
Tetanus immunization
  • There have been no studies examining the risk of tetanus infection after a dog bite
  • Nevertheless, dog bites are considered tetanus prone wounds
    • Td booster should be given if the patient has not had a booster immunization within 5 years and has completed the primary immunization
    • If tetanus status is unknown or primary immunization was not completed, tetanus toxoid and tetanus immune globulin should be given
rabies
Rabies
  • Background
    • Universally fatal
    • 50,000 rabies deaths/year
      • only 36 cases of rabies in the US 1980-2000
        • 12 cases were exposures to dog bites abroad
        • 21 cases were exposures to bats
    • Postexposure prophylaxis (PEP) costs $1500 per person for the HRIG and vaccines alone
      • 40,000 people in the US receive PEP/year
slide16
Moran et al., Appropriateness of rabies postexposure prophylaxis treatment for animal exposures. Emergency ID Net Study Group. JAMA, 2000.
    • Prospective study of university-affiliated, urban EDs
    • Found that PEP was given inappropriately in approximately 40% of cases
rabies prophylaxis
Rabies prophylaxis
  • Animal control must be notified of ALL bites
  • A healthy dog should be observed for 10 days
    • if dog becomes ill, veterinary evaluation is required
      • should the dog be euthanized for rabies testing?
  • An ill dog should be euthanized for testing
  • If the dog is not available for observation, it should be considered rabid
slide18
Administration of Rabies prophylaxis
    • Day 0:
      • 20 IU/kg of human rabies immune globulin
        • infiltrated directly in and around the wound
        • that which cannot be directly infiltrated should be given IM with a clean syringe
      • Dose 1 of 5 rabies vaccines
        • given IM in the deltoid muscle
    • Days 3, 7, 14, 28:
      • doses 2-5 rabies vaccines IM in the deltoid muscle
slide19
Check titers in immunocompromised patients
    • check 2-4 weeks after the completion of the PEP
    • should failure to respond occur, contact the CDC
  • Safe in pregnancy
  • Antimalarial agents decrease Ab response to the vaccine
  • If PEP was not completed or non-standard biologics used
    • Check an Ab titer
    • Readminister PEP if titer inadequate
case part 2
Case - part 2
  • Patient returns to ED on Days 2 and 3
    • gets wounds checked, dressings changed, and rabies vaccine 2/5
  • Lost to follow-up until 6/17/02
    • presents to ED with fever, chills and obvious infection of the puncture wound on the dorsum of his L foot
    • Patient reports not taking his Augmentin
management of infected wounds
Management of Infected Wounds
  • Wound and drainage cultures
  • Photos for law enforcement
  • Copious irrigation
  • Xray to evaluate for underlying bone fragmentation or foreign material
  • Consultation with a surgeon for possible I&D
antibiotics for infected wounds
Antibiotics for infected wounds
  • 1st choice:
    • Parenteral - Unasyn, Timentin, Zosyn
    • Oral – Augmentin
  • Patients with non-life threatening PCN allergy
    • Cefuroxime
  • Patients with life threatening PCN allergy
    • Clindamycin and Cipro
slide23
Infection that develops within 24-48 hrs of bite, strongly suggests P. multocida
    • ABx choice must include coverage for this bacterium
  • Treatment length is 10 days
    • longer if there is septic arthritis or osteomyelitis
  • Close follow-up
    • Daily office visits until infection clearing
when to hospitalize
When to hospitalize
  • No firm recommendations, but situations that lean towards inpatient treatment are:
    • signs/symptoms of sepsis
    • rapidly developing/advancing cellulitis
    • heavy suspicion of vascular, neurologic, musculoskeletal involvement
    • failure of oral therapy
    • questions about patient competence &/or compliance
case part 3
Case - part 3
  • Patient admitted to Orthopedic Surgery for I&D and IV Unasyn
  • Tetanus booster not documented in database, so Td booster given during admission
  • Rabies vaccine 3/5 administered in ED on DOA
  • Received 4 days of IV Unasyn
    • discharged with Rx for 7 days of Augmentin
  • Rabies vaccines 4 & 5 scheduled to be given in ED on 6/24 and 7/7/02
    • Patient did not show up for vaccine on 6/24/02