The patient, a 14-year-old boy, comes to you the same day he was bitten by a dog. In the examination room, he is comfortably seated in the chair, his right hand and arm bandaged.
PATIENT PROFILE:
The patient, a 14-year-old boy, comes to you the same day he was bitten by a dog. In the examination room, he is comfortably seated in the chair, his right hand and arm bandaged.
The patient was walking with his mother near his home when a large dog ran out and jumped on him. The patient raised his right arm defensively and was thrown to the ground as the dog sank his teeth into his arm. After a brief scuffle, the dog ran away. The patient ran home; His mother quickly wrapped gauze around his arm and called your office.
The patient and his mother are pretty sure they recognized the dog that lives in the neighborhood. The dog has barked at them on walks, but has never approached them. The mother has not informed anyone about the event, but gives you information about the dog and the location of the attack.
The patient is otherwise healthy and has no significant medical history. He doesn't take any daily medication. His mother suspects a penicillin allergy. You flip through his chart and find documentation that confirms this. His last tetanus shot was 2 years ago.
The patient is afebrile. There is no evidence of other injuries other than a large, gash across his wrist. The wound is nearly semi-circular in shape and extends from halfway between the fourth and fifth metacarpals on the dorsum of the hand to the ulnar styloid. There are no underlying tendons or bones visible, and you don't see any puncture wounds.
Despite some pain, the patient can move all fingers well. They test the sensation that the patient can feel with the blunt end of a needle along their third, fourth, and fifth fingers. They press over the nails of the same fingers and its capillary refill is brisk.
WHAT WOULD YOU DO NOW?
A.Send the patient to the local emergency room for evaluation by a hand surgeon.
B.Get X-rays of his hand and wrist to rule out a foreign body or fracture.
C.Irrigate and primarily close the wound. Send the patient home without antibiotics.
D.Dress the wound and send the patient home with information about the signs and symptoms of infection.
CHOICE OF CONSULTANTS:option B
X-rays are indicated for patients whose hands have been bitten by an animal. The same goes for children who have been bitten on the scalp or face. If you are concerned about an underlying structural injury or joint space involvement, x-rays may show occult fractures and/or foreign objects.
In the case of this patient, there is no need to involve a hand surgeon as there is no concern for an underlying tendon or bone compromise. His hand is neurovascularly intact distal to the wound. However, you may need to call a hand surgeon or orthopedist if X-ray films show an occult fracture.
The radiologist calls you to say that the patient's x-rays show no evidence of fractures or foreign bodies. Then numb the area, irrigate the wound and debride the devitalized tissue.
WHAT WOULD YOU DO NOW?
A.Cover the wound with a bandage, send the patient home with a prescription for antibiotics, and contact local health authorities about the need for rabies prophylaxis.
B.Cover the wound with a bandage, give an initial dose of rabies vaccine, and send the patient home with an antibiotic. Plan a follow-up for the administration of additional vaccine doses.
C.Primarily close the wound and send the patient home with antibiotics but no rabies prophylaxis.
D.Primarily close the wound and send the patient home without antibiotics or rabies prophylaxis.
CHOICE OF CONSULTANTS:Possibility A
Of an estimated 4 million Americans who are bitten each year, only 500,000 seek medical attention. Most bites are inflicted by dogs and cats. Children between the ages of 5 and 14 are most commonly affected.
Most bites occur on the upper extremities as the patient tries to fight off the attacking animal. Dogs typically cause gashes when peeling off tissue, while cats tend to inflict puncture wounds. Dogs have powerful jaws that can cause crush injuries to the skin and underlying structures.
ANIMAL BITES
Several factors must be considered when treating animal bites, including the need for rabies and tetanus prophylaxis, wound closure, and prophylactic antibiotics.
Treatment begins with an assessment of the depth of the wound, the amount of devitalized tissue, and any signs of infection. After anesthetizing the site, remove surgical wound edges and debride devitalized tissue. The wound should be irrigated copiously with high-pressure saline. A thorough examination is required, especially in children, to rule out other sites of injury.
X-rays are indicated if you suspect an occult fracture, retained foreign body, or injury to a joint space. A child who has suffered bite wounds on the skull and/or face also needs an X-ray examination.
Primary closure of bite wounds depends on the location of the wound, the type (e.g., gaping, contusion, or puncture), time to presentation, and adequate cleaning. In general, all puncture wounds and all hand wounds should be left open, as both are associated with an increased risk of infection. Areas with good blood circulation, such as the face and scalp, can primarily be closed. Wounds that are difficult to irrigate (eg, puncture wounds) or already show signs of infection should be left open. Likewise, large wounds that are easy to irrigate can be primarily closed.
All persons who have been bitten by an animal are at risk for tetanus: persons who have not received a booster dose in the last 5 years should receive tetanus diphtheria toxoid (Td) (0.5 ml intramuscularly). Anyone who has not completed the basic immunization should also receive tetanus immunoglobulin (250 units intramuscularly).
The use of antibiotics is controversial. However, antibiotics should be prescribed in all risk situations: these include dog bites to the hands, puncture wounds, and all cat bites. Amoxicillin/clavulanate is the first-line treatment for dog, cat, and human bites.
If the patient is to be followed up as an outpatient, give a single parenteral dose of ampicillin/sulbactam (1.5 g) along with a 3 to 5 day oral dose of amoxicillin/clavulanate (875/125 mg twice daily). For adults allergic to penicillin, cefuroxime (500 mg twice daily) or clindamycin (300 mg every 4 hours) plus ciprofloxacin (500 mg twice daily) is recommended. For children allergic to penicillin, cefuroxime (30 mg/kg/d divided into 2 times daily) or clindamycin (8 to 25 mg/kg/d divided into 3 or 4 times daily) plus trimethoprim/sulfamethoxazole (8th up to 12 mg/kg/d divided into 2 times a day) recommended.
All patients with an animal bite must be followed up closely within 24 to 48 hours to check the site for signs of infection.
Bacteria most commonly associated with animal bites are listed inTisch.The most common complications of animal bites are infection and cellulitis. Asplenic patients bitten by an animal are susceptible to sepsis as a result of infection with the Gram-negative aerobes,Capnocytophaga canimorsus,although that is rare. In this case, prophylaxis with penicillin is recommended.
References:
REFERENCES:
1.
Human Rabies Prevention – United States, 1999 Recommendations of the Advisory Committee on Immunization Practices (ACIP). Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/00056176.htm.
Retrieved March 24, 2006.
2.
Weber EJ, Callaham ML. mammal bites. In: Marx JA, Hockberger RS, Walls RM, et al, eds.
Rosen's Emergency Medicine.
5. Aufl. St. Louis: Mosby Inc.; 2002:774-783.
3.
Weber EJ. Rabies. In: Marx JA, Hockberger RS, Walls RM, et al, eds.
Rosen's Emergency Medicine.
5. Aufl. St. Louis: Mosby Inc.; 2002: 1834-1841.
FOR MORE INFORMATIONS:
•Badour LM. Soft tissue infections from dog and cat bites. Up to date. 2004. Available at:
http://www.uptodate.com
. Retrieved March 24, 2006.
•Garbutt F, Jenner R. Top Evidence Topic Report. Animal bite wound closure.
Show up with J
2004;21:589-590.
• Garth AP, Harris NP. bites, animal. e-medicine. 2004. Available at:
http://emedicine.medscape.com/article/768875-overview
. Retrieved March 23, 2006.
•Schwab RA, Powers RD. Puncture wounds and mammalian bites. In: Tintinalli JE, Kelen GD, Stapczynski JS, eds.
Emergency Medicine: A Comprehensive Study Guide.
6th ed. New York: McGraw-Hill; 2004:327-328.
• Sztajnkrycer MD, Trott AT. wounds and soft tissue injuries. In: Knoop KJ, Stack LB, Storrow AB, eds.
Atlas of Emergency Medicine.
2nd ed. New York: McGraw-Hill; 2002:594-595.
• Talan DA, Citron DM, Abrahamian FM, et al. Bacteriological analysis of infected dog and cat bites. Working Group on Emergency Medicine Animal Bite Infections.
N Engl. J Med.
1999;340:138-140.
FAQs
What is best antibiotic for dog bite if allergic to penicillin? ›
Alternative regimens for adults allergic to penicillin or beta-lactams include doxycycline, OR TMP-SMX, OR a fluoroquinolone (ciprofloxacin or levofloxacin) PLUS metronidazole, OR moxifloxacin (may be used as monotherapy).
Why do you need antibiotics after a dog bite? ›Facial bites can often be closed primarily. Although rarely necessary, antibiotic prophylaxis decreases the risk of infection to 1%.
How soon after dog bite do I need antibiotics? ›Prophylactic therapy for three to five days appears to have some benefit in reducing infection if initiated within 12 to 24 hours after injury. Antibiotic prophylaxis commonly is recommended for moderate to severe wounds of the face, hands (bites tend to involve the dominant hand), feet or genital area.
How long after a dog bite does infection set in? ›After being bitten, most people who become ill will show symptoms within 3 to 5 days, but this can range anywhere from 1 to 14 days. Most Capnocytophaga infections usually occur with dog or cat bites.
What kind of antibiotics do they give you for a dog bite? ›Amoxicillin-clavulanate potassium (Augmentin) is the antibiotic of choice for a dog bite. For patients who are allergic to penicillin, doxycycline (Vibramycin) is an acceptable alternative, except for children younger than eight years and pregnant women.
What should I not take if allergic to penicillin? ›It is generally recommended that you avoid all drugs in the immediate penicillin family (amoxicillin, ampicillin, amoxicillin-clavulanate, dicloxacillin, nafcillin, piperacillin-tazobactam as well as certain drugs in the cephalosporin class (a closely related class to penicillins).
Why do you have to wait 10 days after a dog bite? ›The 10-day confinement and observation period for dogs and cats that bite humans has stood the test of time as a way to prevent human rabies. This quarantine period avoids the need to destroy the biting dog or cat in order to test its brain for the rabies virus.
Should I go to hospital after dog bite? ›How Necessary Is Medical Care For a Dog Bite? In general, most experts recommend seeking medical care within 24 hours after you've been bitten—especially if the bite has broken the skin. Dog bites can cause medical problems that aren't immediately obvious, such as rabies.
What to do if a dog bites you and breaks the skin? ›See your provider within 24 hours for any bite that breaks the skin. Call your provider or go to the emergency room if: There is swelling, redness, or pus draining from the wound. The bite is on the head, face, neck, hands, or feet.
What is a Level 1 dog bite? ›Level 1: No skin-contact by teeth – can be exuberant obnoxious behavior or aggression. Level 2: Skin contact made but no punctures. There may be small lacerations. Level 3: One-four shallow punctures from a single bite and potentially small lacerations from pulling the biting dog or victim body part away.
What percent of dog bites get infected? ›
Risks of Infection After a Dog Bite
According to the Academy of Pediatrics, infection occurs in about 10 to 15 percent of dog bites. Dog bites that go untreated without proper cleaning and medical care are at increased risk of developing infections, which can be passed to another through bacteria.
If a dog bite pierces a person's skin, bacteria from the animal's mouth can get into the body, which can cause an infection. Washing the wound thoroughly can remove the bacteria from the body and help prevent infection. If the bacteria stay in the body, they can cause an infection, such as tetanus, rabies, or sepsis.
Do you always need a tetanus shot after a dog bite? ›A tetanus shot may be required if you have not had one within 10 years; if you are not sure when you had your last tetanus shot, and you've been bitten, you should get one within 72 hours after your injury. If bitten, but the bleeding is minor, cleanse and treat the wound as you would a minor wound.
How do hospitals treat dog bites? ›- Wash the wound with soap and warm water.
- Gently press a clean cloth over the wound to stop the flow of blood.
- Apply an antibacterial ointment to the wound.
- Cover with a sterile bandage.
- Watch for signs of infection.
The IDSA recommends amoxicillin-clavulanate as empiric therapy for treatment of human bite wounds. Ampicillin-sulbactam is an alternative that can be administered intravenously. In patients who are unable to tolerate beta-lactam antibiotics, moxifloxacin is recommended.
Which vaccine is given after dog bite? ›Rabies vaccine is given to persons who have been exposed (eg, by a bite, scratch, or lick) to an animal that is known, or thought, to have rabies. This is called post-exposure prophylaxis. Rabies vaccine may also be given ahead of time to persons who have a high risk of getting infected with rabies virus.
How serious is a penicillin allergy? ›In some cases, an allergy to penicillin can result in anaphylaxis. This is a life-threatening condition that may be marked by dizziness or lightheadedness, difficulty breathing, swelling of the tongue or throat, seizures, very low blood pressure, vomiting, diarrhea and abdominal cramps.
What happens if someone who is allergic to penicillin takes it? ›Common signs and symptoms of penicillin allergy include hives, rash and itching. Severe reactions include anaphylaxis, a life-threatening condition that affects multiple body systems.
Can I take Benadryl if I'm allergic to penicillin? ›If your body is currently reacting to penicillin but your reaction is not life-threatening, your doctor may prescribe an antihistamine or recommend an over-the-counter antihistamine (Benadryl) that can block immune system chemicals that are activated during an allergic reaction.
What are the do's and don'ts after dog bite? ›Wash the bite area with soap and water. If the bite is bleeding, put pressure on it using sterile gauze or a clean cloth. If the bleeding has stopped, put antibiotic ointment on the area. Cover the area with a bandage or sterile gauze.
What if a fully vaccinated dog bites you? ›
q 14: do you have to take vaccination against rabies if a vaccinated dog bites you? No, not if the dog is properly vaccinated against rabies and the efficacy of the vaccine is confirmed by laboratory evidence. Otherwise an appropriate post-exposure prophylaxis (PEP) should be given.
What happens if you don t get a tetanus shot after a dog bite? ›A bite from a dog increases the risk that tetanus bacteria can enter your body. If you don't get a vaccination and you develop tetanus, symptoms include: Muscle spasms, especially in the stomach. Difficulty swallowing.
What is the first thing to do after a dog bite? ›Clean the blood and apply an antibacterial ointment. If the wound is bleeding - apply and press a clean cloth to the area to stop bleeding. Clean the area and apply a sterile bandage. It is important to seek immediate medical attention in case of a bleeding dog bite wound.
Is Neosporin good for dog bites? ›Treat the dog bite
For small wounds, apply an antibiotic cream such as Neosporin or Bacitracin to the injury and wrap it in a clean bandage. For deep wounds, apply pressure using a clean, dry cloth until the bleeding stops and then bandage the injury.
You should always see a primary care provider if you're bitten.” No matter what, make sure you see a doctor within eight hours of a dog bite, he says. Waiting longer raises your infection risk. If you have diabetes or are immunocompromised, your infection risk is even greater.
Can cephalexin treat a dog bite? ›For dog bite wounds, dicloxacillin and cephalexin are both good choices because they cover most of the broad spectrum of infecting pathogens; dicloxacillin is significantly cheaper. If the patient is pencillin allergic, erythromycin is a good alternative.
Can azithromycin treat dog bite? ›For dog and cat bites should cover Pasteurella, streptococci, staphylococci and anaerobes. Pasteurella are generally susceptible to ampicillin, penicillins, second and third generation cephalosporins, doxycycline, trimethoprim-sulfamethoxazole, fluoroquinolones, clarithromycin and azithromycin.
What happens if you take amoxicillin and you are allergic to penicillin? ›Common signs and symptoms of penicillin allergy include hives, rash and itching. Severe reactions include anaphylaxis, a life-threatening condition that affects multiple body systems.
Is Cipro good for dog bites? ›This new guide specified that IV co-amoxiclav, or IV ciprofloxacin, and IV metronidazole for those with a penicillin allergy, should be used for severe dog bites12.
Is Keflex a penicillin? ›These drugs belong to different drug classes. Keflex is a cephalosporin antibiotic and amoxicillin is a penicillin-type antibiotic.
How much cephalexin should I take for a dog bite? ›
For other at risk wounds, cephalexin 500 milligrams four times daily, or a macrolide, are recommended. In general, prophylactic antibiotics should be continued for 5 to 7 days. Ciprofloxacin is not recommended for routine use in children for prophylaxis.
How do you treat a dog bite without antibiotics? ›Running water over the wound for five to 10 minutes can flush dirt and bacteria away. After flushing the bite, wash it with gentle soap and water. Be sure to rinse it thoroughly.
Does Benadryl help with dog bites? ›5. Antihistamine Cream – Over the counter topical antihistamine creams, such as Benadryl, can help reduce the histamine release responsible for itching and swelling post-insect bite.
What to do if a patient is allergic to penicillin? ›...
Treatment
- Withdrawal of the drug. If your doctor determines that you have a penicillin allergy — or likely allergy — discontinuing the drug is the first step in treatment.
- Antihistamines. ...
- Corticosteroids. ...
- Treatment of anaphylaxis.
Rashes — Several different types of rashes can appear while people are taking a penicillin medication: Rashes that involve hives (raised, intensely itchy spots that come and go over hours) or occur with other allergic symptoms like wheezing or swelling of the skin or throat suggest a true allergy (picture 1).