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Chapter 29: Bites, Venoms, Stings, and Marine Poisonings

MAMMALIAN BITES

  • Each year, there are ∼300 dog and cat bites per 100,000 population in the United States, with most bites inflicted by pet animals.

  • The microbiology of bite wounds typically reflects the oral flora of the biting animal.

  • Bites from many different animals can transmit rabies and tularemia.

DOG BITES

  • Epidemiology: Dogs bite ≥4.7 million people per year, causing 80% of all animal bites; 15–20% of dog bites become infected.

  • Bacteriology (Table 29-1): Includes aerobic and anaerobic organisms, such as β-hemolytic streptococci; Eikenella corrodens; Capnocytophaga canimorsus; and Pasteurella, Staphylococcus, Actinomyces, Prevotella, Neisseria, and Fusobacterium species.

  • Clinical features: Typically manifest within 8–24 h after the bite as local cellulitis with purulent, sometimes foul-smelling discharge. Systemic spread (e.g., bacteremia, endocarditis, brain abscess) can occur. C. canimorsus infection can present as sepsis syndrome, disseminated intravascular coagulation (DIC), and renal failure, particularly in pts who are splenectomized, have hepatic dysfunction, or are otherwise immunosuppressed.

TABLE 29-1Management of Wound Infections Following Animal and Human Bites
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TABLE 29-1Management of Wound Infections Following Animal and Human Bites
BITING SPECIES COMMONLY ISOLATED PATHOGENS PREFERRED ANTIBIOTIC(S)a ALTERNATIVE IN PENICILLIN-ALLERGIC PT PROPHYLAXIS ADVISED FOR EARLY UNINFECTED WOUNDS OTHER CONSIDERATIONS
Dog Staphylococcus aureus, Pasteurella multocida, anaerobes, Capnocytophaga canimorsus Amoxicillin/clavulanate (250–500 mg PO tid) or ampicillin/sulbactam (1.5–3.0 g IV q6h) Clindamycin (150–300 mg PO qid) plus either TMP-SMX (1 DS tablet PO bid) or ciprofloxacin (500 mg PO bid) Sometimesb Consider rabies prophylaxis.
Cat P. multocida, S. aureus, anaerobes Amoxicillin/clavulanate or ampicillin/sulbactam as above Clindamycin plus TMP-SMX as above or a fluoroquinolone Usually Consider rabies prophylaxis. Carefully evaluate for joint/bone penetration.
Human, occlusional Viridans streptococci, S. aureus, Haemophilus influenzae, anaerobes Amoxicillin/clavulanate or ampicillin/sulbactam as above Erythromycin (500 mg PO qid) or a fluoroquinolone Always  
Human, clenched-fist As for occlusional, plus Eikenella corrodens Ampicillin/sulbactam as above or imipenem (500 mg q6h) Cefoxitinc Always Examine for tendon, nerve, or joint involvement.
Monkey As for human bite As for human bite As for human bite Always For macaque monkeys, consider B virus prophylaxis with acyclovir.
Snake Pseudomonas aeruginosa, Proteus spp., Bacteroides fragilis, Clostridium spp. Ampicillin/sulbactam as above Clindamycin plus TMP-SMX as above or a fluoroquinolone Sometimes, especially with venomous snakes Administer antivenin for venomous snakebite.
Rodent Streptobacillus moniliformis, Leptospira spp., P. multocida Penicillin VK (500 mg PO qid) Doxycycline (100 mg PO bid) Sometimes  
Aquatic animal (alligator, piranha, shark, moray eel, barracuda) Aeromonas hydrophila, marine Vibrio spp. (Vibrio vulnificus) Third-generation cephalosporin (e.g., ceftriaxone, 1 g IV q24h) plus doxycycline (100 mg PO bid) Clindamycin plus levofloxacin (750 mg PO qd) plus doxycycline Always Obtain prompt surgical consultation, as risk for necrotizing infection is high with Aeromonas and Vibrio spp.

aAntibiotic choices should be based on culture data when available. These suggestions for empirical therapy need ...

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