Microbiology and Management of Animal Bites

By

Heba AL Sayed AL Degla

Assistant lecturer of Medical Microbiology and Immunology

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 infants and children

Problem of animal bites

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 formation and loss of tissue

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 been isolated Dog bites do more damage, but only 5 to 15 % become infected. Cat bites: up to 80 % become infected if proper care is not taken

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

 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

 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 blistering at the site of injury due to infection with a Mycoplasma organism

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.

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 treatment 5. Splenectomy

Infection risk
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

Dog bites
Children younger than 10 years Involve the head and neck. Male dogs are six fold more likely to bite than are female dogs. The wounds are crushing and lacerations rather than puncture wounds

 Certain breeds: German Shepherds pit bull terriers, and mixed breeds.

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 and necrotizing fasciitis P. multocida can cause septic arthritis

Infections associated with dog bite

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, and tiny reddened patches on the skin. C. cynodegmi cause localized soft tissue inflammation

Infections associated with dog bite

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 515% of dog bites result in soft tissue infections

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 the soft tissues or even deeper into the periosteum or into a joint and result in osteomyelitis or septic arthritis.

Infections associated with cat bite

1-Pasteurella spp. (with the exception of P. 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 to the serious sequelae such as osteomyelitis, sepsis, and meningitis.

Infections associated with cat bite

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

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)

Transmission

Cat scratch disease

Incubation period of 1-2 weeks Primary lesion: cutaneous red painless papules or pustules at the scratch or bite. After 3-10 days regional lymphadenopathy in 90% of cases. Fever, malaise, and other systemic symptoms

Cat scratch disease

In the most severe cases, the organism disseminate widely throughout the human host Infecting the liver, spleen, eye, and CNS, which present as seizures due to encephalitis

Cat scratch disease

Diagnosis Clinical diagnosis is made if 3 of the following 4 criteria are met: 1. History of cat contact resulting in a scratch or primary lesion of the dermis, eye, or a mucous membrane 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

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 4 weeks Retinitis: Doxycycline + Rifampin for 4-6 weeks. Endocarditis: Doxycycline 6 weeks + Gentamicin for 14 days. Encephalopathy; Rifampin, Ciprofloxacin, trimethroprim/sulfamethoxazole, or azithromycin.

Infections associated with cat bite

4- Cowpox, or catpox
Uncommon viral infection of cats found in European countries. Member of the family Orthopoxvirus. Infection contained to the soft tissue surrounding the bite itself. Painful hemorrhagic pustule, which may develop into a black eschar.

Infections associated with cat bite

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 or black base Extraordinarily rare. 6- Other bacteria found in cat wounds Actinomyces, Proprionibacterium, Bacteroides, and Fusobacterium.

Infections associated with rat bite

Rat bite fever (RBF), also known as Haverhill fever Caused by Actinobacillus 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 or conjunctival secretions The source of the infection is a rat, other animals such as squirrels, weasels, and gerbils.

Rat bite fever

Rat-bite fever due to Actinobacillus 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 infection of the heart valves may occur.

Rat bite fever

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

Diagnosis
Detection of the organism in skin, blood, joint fluid, or lymph nodes Blood antibody tests.

Treatment Penicillin, Amoxicillin Clavulanate, Erythromycin or Tetracyclines for 7-10 days.

Rat bite fever

Prognosis Excellent with early treatment. Complications Pericarditis Endocarditis Parotitis Tenosynovitis Abscesses of the brain or soft tissue

Snakebite
Soft tissue infection may not be the victim's foremost priority Infection with Aeromonas hydrophila Local soft tissue necrosis and cutaneous abscesses at the site of injury.

Grizzly or black bear bites

Have been cultured for A. hydrophila. Soft tissue infections are polymicrobial consisting of E. coli and Proteus spp., S. epidermidis and S. aureus It is unknown if these organisms are particular to bear saliva or carried by the claws from soil or other sources.

Horse bites
2% of all animal bites. Young girls. Severe bite may result in amputation, or severe hematoma, 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.

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 macaque genus (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

Wild animal bites

Rare but more serious, given the risk of rabies and other infections. 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 which then transmit it to people (or people can catch it directly from wild animals).

Rabies
Transmission Bite of a rabid animal Non-bite exposures to rabies are very rare. Scratches, abrasions, open wounds, or mucous membranes contaminated with saliva from a rabid animal Other contact, such as petting a rabid animal or contact with the blood, urine or feces of a rabid animal, does not constitute an exposure and is not an indication for treatment.

Rabies
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
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 and foaming 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
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
What should be done with the biting animal? Capture the animal and cage it. If cannot be captured, kill it but DO 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.

Rabies
How long should the animal be confined for observation? 10 days. If animal had rabies at the time of biting, it will show signs of rabies and/or die within ten days. Stray or wild animals should be killed immediately and the brain examined for rabies.

Rabies
Rabies prophylaxis Indications 1- laboratory evaluation found that the animal was rabid 2- Animal was not captured 3- After exposure to bats even if no bite. As soon as possible after exposure.

Rabies prophylaxis
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.

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.

Human bites
In child, on the face, upper extremities, or trunk. The force of bite drive oral bacteria into the tissue and spread to the adjacent joints or it directly penetrate the joint. Staphylococci, Streptococci, Eikenella corrodens, Clostridium tetani, and Bacteroides. Possible transmission of hepatitis B, hepatitis C, herpes simplex virus, and HIV.

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

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

Management
Radiological studies Necessary for deep puncture wounds to look for foreign 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
Cleaning and exploration: Clean the wound with copious amounts of soap and warm sterile water or saline for 15 min and inspect it. Wash with an antiseptic solution Apply antibiotic ointment and cover the wound with gauze or a bandage. If severe wound, or if you have risk factors, seek medical advice at once. Be sure no foreign bodies into the wound. Elevation of the affected part and immobilization

Management
Suturing:
1. 2. 3. 4. 5. 6. Cutaneous wounds should be treated and left open if They are punctures rather than lacerations, Not disfiguring, Inflicted by humans, Involve the legs and arms (particularly hands) Bites to the arms and legs seen after 6 to 12 hours. 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
Infection prophylaxis: Standard management: 85 % of bites harbor potential pathogens. Adherence to standard principles of wound management Copious irrigation at high pressure Dbridement of devitalized tissue Cultures obtained at the time of injury cannot predict whether infection will develop or, if it does, the causative pathogens.

Management
Antibiotics: Indications High-risk patients: young children, older patients, patients with chronic medical problems, and immunocompromised patients. High-risk injuries: crush injuries, deep puncture wounds, systemic signs of infection, rapidly spreading cellulitis, septic arthritis, osteomyelitis those require surgical repair, and those involving hands and face.

Management
Ampicillin-sulbactam. In penicillin allergy: clindamycin plus trimethoprimsulfamethoxazole. Broad-spectrum antibiotics If the wound infected with hospital acquired or community acquired bacteria, until culture sensitivity results. Intravenous antibiotics for infected hand bites, severe infections at other sites, and systemic symptoms

Management
Rabies prophylaxis Tetanus prophylaxis: After bites of all kinds, tetanus immune globulin and tetanus toxoid should be administered to patients who 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
Late Care Scarring needs to corrected. Tendon injuries and nerve injuries should be corrected as soon 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