Bite wounds to the hand - a review.

Bite wounds occur as a result of bite by an animal or a human. They are relatively frequent due to the growing number of pets living with people, as well as from inadequate human-animal interactions. The knowledge of most surgeons about the management of these injuries is relatively outdated, whereas the current literature points to important changes in this field. The article presents several aspects concerning epidemiology, classification, bacteriology, and characteristics of bite wounds to the hand. Based on the actual literature, detailed rules for the management of these injuries are described. This information may prove useful in the daily practice of surgeons and doctors at emergency departments who are frequently faced with bite wounds.

Mordida posterior a anestesia odontológica / Lip biting following dental local anesthesia

Niña de 6 años de edad, acude a la consulta odontológica24 horas después de una atención previa, mostrando una lesión en el labio inferior, blanco-amarillenta, con áreas de ulceración cubiertas por fibrina (A). La paciente relata prurito y sensación urente con hiperestesia en el área. No hay compromiso del estado general. Descartada una reacción alérgica y angioedema, el diagnóstico fue una úlcera traumática, como resultado de una mordida posterior a la anestesia del nervio alveolar inferior. El tratamiento consistió en ibuprofeno (suspensión oral, 200 mg / 5 ml, en dosis de 10mg / kg cada 8 horas por 5 días) y control clínico cada dos días (primer control, B). La resolución definitiva ocurrió 10días después de la primera atención. Con el fin de prevenir lesiones de los tejidos blandos, el odontólogo debe indicara los padres y cuidadores la importancia del monitoreo del niño por varias horas, luego de la atención odontológica que implique procedimientos con anestesia local por bloqueo troncular (nervio alveolar inferior), recordando que es más seguro para el paciente comer luego de que el efecto del anestésico desaparece (1).

Bites (Mammalian).

INTRODUCTION: Mammalian bites are usually caused by dogs, cats, or humans, and are more prevalent in children (especially boys) than in adults. Animal bites are usually caused by the person's pet and, in children, frequently involve the face. Human bites tend to occur in children as a result of playing or fighting, while in adults they are usually the result of physical or sexual abuse. Mixed aerobe and anaerobe infection is the most common type of infection, and can occur in up to half of human bites. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions to prevent complications of mammalian bites? What are the effects of treatments for infected mammalian bites? We searched: Medline, Embase, The Cochrane Library, and other important databases up to October 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found five systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: antibiotic prophylaxis (human bites, non-human bites), antibiotics, debridement, decontamination, irrigation, primary wound closure, and tetanus vaccination (after mammalian bites).

A 4-year review of human bite injuries presenting to emergency medicine and proposed evidence-based guidelines.

Human bite injuries are a common injury, roughly accounting for around 0.1% of attendances to Emergency Medicine departments. Morbidities associated with such injuries are legion. Of paramount importance is the potential for infection of the wound site, both bacterial and viral. A retrospective 4-year review of 3136 case notes was conducted, identifying 421 human bites. This amounts to one every 3 days! The majority of those bitten were young males (male:female ratio=3:1; 44% comprising the age group 16-25 years). The management of these wounds was found to be poor. 17% of patients did not receive any antibiotic cover; 21% of patients either did not have tetanus prophylaxis administered when required or had a tetanus booster when they were already covered; 34% of patients either did not receive a hepatitis B booster when one was required or received one when they were already covered. This lack of effective documentation, along with errors in addressing prophylaxis of the infective agents, may have profound medico-legal consequences. The author believes that the findings will be reproduced in other centres and in view of the inadequacies highlighted by this work, it is necessary to introduce an evidence-based protocol for the comprehensive management of the human bite. Using United Kingdom Department of Health evidence-based guidelines, the author proposes such a pathway.

A case of human bite by an 11-year old HIV positive girl in a paediatrics ward.

Biting is a possible mode of transmission of HIV infection, though the risk of such transmission is believed to be low. Children infected with HIV are at risk of psychological complications as a result of direct or indirect effects associated with the disease. We report the case of an 11 year old HIV positive girl with clinical stage IV disease, who was involved in multiple disputes while on admission on the ward. During one of the disputes she inflicted a deep bite injury on a 10-year old boy, HIV post-exposure prophylaxis (PEP) was commenced 6 hours after the bite and he has remained HIV negative 12 months later. What is peculiar about this case is that the incident occurred in a hospital setting and biting is not usually expected among children of this age. In the era of HIV/AIDS, it is recommended that persons involved in childcare be aware of this potential risk during interactions among children. It is also essential for health care personnel to have sufficient knowledge about PEP in order to reduce the risk of HIV transmission in similar settings. In addition, a multidisciplinary approach to the management of children living with HIV is important in order to identify and address psychosocial factors that may influence symptoms and medical treatment outcome. The risk of transmission of HIV through human bites and the psychosocial impact of the disease on children are also discussed.

Factors associated with delay to emergency department presentation, antibiotic usage and admission for human bite injuries.

OBJECTIVES: Evidence and consensus on best practices on the management of human bite injuries is lacking. Our objective was to identify factors that are associated with delay to emergency department (ED) presentation, antibiotic usage and patient admission. METHODS: We present a retrospective chart review of adults treated for human bites. Multivariable logistic regression models used demographic characteristics and bite circumstances and characteristics as factors associated with ED presentation more than 24 hours after the bite, antibiotic usage and hospital admission. RESULTS: Of the 388 patients evaluated for a human bite, 66.5% were bitten during an altercation; 23.8% presented more than 24 hours after the bite; 50.3% were bitten on the hands or fingers, 23.5% on an extremity and 17.8% on the head or neck. Only 7.7% of all patients sustained closed-fist injuries; the majority had occlusional or other kinds of bites. The majority of patients (77.3%) received antibiotics and 11.1% were admitted to hospital. Patients who had greater odds of presenting more than 24 hours after the bite were black (odds ratio [OR] 1.79, 95% confidence interval [CI] 1.02-3.13), Hispanic (OR 2.68, 95% CI 1.22-5.89) and those who had a non-occupational bite (OR 3.87, 95% CI, 1.68-8.90). Patients had a greater chance of receiving antibiotics if they were bitten during an altercation (OR 1.87, 95% CI, 1.09-3.20) and were bitten on the hands or fingers (OR 2.23, 95% CI 1.31-3.80). Patients had a greater chance of being admitted to the hospital if they were bitten during an altercation (OR 4.91, 95% CI 1.65-14.64), bitten on the hands or fingers (OR 5.26, 95% CI, 1.74-15.87) and if they presented >or= 24 hours after the bite. CONCLUSION: Most patients presented to the ED within 24 hours of their injury and received antibiotics. The circumstances surrounding the bite appeared to be associated with delay to ED presentation, receipt of antibiotics and admission to the hospital. There are ethnic background differences in delay to ED presentation. ED clinicians in our study favour antibiotic usage and admission based on the body location of the bite, despite little evidence to support these practices.

[Bite wound infections]. / Infeksjoner ved bitt.

BACKGROUND: The lifetime risk of experiencing a bite wound, human or animal, is approximately 50%, and bite wounds account for approximately 1% of all visits to emergency departments. The majority of bite wounds are inflicted by dogs and cats. MATERIAL AND METHODS: A review of the literature on the diagnosis and treatment of bite wound infections is presented. RESULTS: The most common pathogens associated with bite wounds are Streptococcus species, Staphylococcus species, Pasteurella multocida, Capnocytophaga canimorsus and anaerobic bacteria. Sporadically other pathogens are isolated from bite wounds. Human bites differ from animal bites by higher prevalence of Staphylococcus aureus and Eikenella corrodens. INTERPRETATION: It is important to be aware of the possibility of complicating infections following bite wounds, particularly after cat bites. Phenoxymethyl penicillin should be the drug of choice in treatment of infections associated with cat and dog bites. However, in case of slow recovery or no improvement, simultaneous lymphadenopathy or pneumonia, S. aureus or Francisella tularensis should be suspected; ciprofloxacin is recommended. For human bite infections the recommend treatment is phenoxymethyl penicillin in combination with penicillinase-stable penicillin.

Clinical presentation and bacteriologic analysis of infected human bites in patients presenting to emergency departments.

Previous studies of infected human bites have been limited by small numbers of patients and suboptimal microbiologic methodology. We conducted a multicenter prospective study of 50 patients with infected human bites. Seventy percent of the patients and assailants were young adult men. Fifty-six percent of injuries were clenched-fist injuries and 44% were occlusional bites. Most injuries were to the hands. Fifty-four percent of patients were hospitalized. The median number of isolates per wound culture was 4 (3 aerobes and 1 anaerobe); aerobes and anaerobes were isolated from 54% of wounds, aerobes alone were isolated from 44%, and anaerobes alone were isolated from 2%. Isolates included Streptococcus anginosus (52%), Staphylococcus aureus (30%), Eikenella corrodens (30%), Fusobacterium nucleatum (32%), and Prevotella melaninogenica (22%). Candida species were found in 8%. Fusobacterium, Peptostreptococcus, and Candida species were isolated more frequently from occlusional bites than from clenched-fist injuries. Many strains of Prevotella and S. aureus were beta-lactamase producers. Amoxicillin-clavulanic acid and moxifloxacin demonstrated excellent in vitro activity against common isolates.

Comparative in vitro activity of ertapenem and 11 other antimicrobial agents against aerobic and anaerobic pathogens isolated from skin and soft tissue animal and human bite wound infections.

We studied the comparative in vitro activity of ertapenem, a new carbapenem, against 240 aerobic and 180 anaerobic recent clinical bite isolates using an agar dilution method and an inoculum of 10(4) cfu/spot for aerobes and 10(5) cfu/spot for anaerobes. Ertapenem inhibited 410/420 (98%) of the isolates tested at < or = 4 mg/L with only 4/5 Campylobacter gracilis and 1/3 Campylobacter rectus strains requiring . or = 16 mg/L for inhibition. Ertapenem was only moderately active (MIC 8 mg/L) against 4/6 Enterococcus faecalis and 1/11 Staphylococcus epidermidis strains. All Pasteurella multocida, Pasteurella septica, Pasteurella canis, Pasteurella dagmatis, Moraxella spp. and EF-4 isolates were inhibited at < or = 0.015 mg/L. MIC(90)s for other aerobic genera and species were as follows: Corynebacterium spp., 4 mg/L; Staphylococcus aureus, 0.25 mg/L; Staphylococcus epidermidis, 4 mg/L; other coagulasenegative staphylococci, 0.25 mg/L; Streptococcus milleri group, 0.5 mg/L; Eikenella corrodens, 0.03 mg/L; and Bergeyella zoohelcum, 0.5 mg/L. For anaerobes the range of MICs and MIC(90)s were: Prevotella ssp., < or = 0.015-0.5, 0.125 mg/L; Porphyromonas spp., < or = 0.015-0.03, 0.015 mg/L; Fusobacterium spp., 0.015-0.125, 0.03 mg/L; Bacteroides tectum, 0.03-0.125, 0.125 mg/L; and Peptostreptococcus spp., 0.01-2, 1 mg/L. Ertapenem showed excellent potency against the full range of animal and human bite wound pathogens.

Treating mammalian bite wounds.

The incidence of dog, cat and human bites has been increasing steadily and represents an important cause of morbidity and mortality in the United States. Approximately half of all Americans will suffer a bite wound during their lifetime, and the annual medical costs of managing these injuries has been estimated to be over $100 million. Possible complications may include disfigurement, dismemberment and infection. Effective management requires rapid medical evaluation and may necessitate surgical intervention and prophylactic antibiotic therapy. As bite wounds are microbiologically diverse and most often polymicrobial in nature, selection of an appropriate antibiotic regimen requires knowledge of common pathogens. Close clinical follow-up is recommended to minimize the risk of late complications.

Trovafloxacin compared with levofloxacin, ofloxacin, ciprofloxacin, azithromycin and clarithromycin against unusual aerobic and anaerobic human and animal bite-wound pathogens.

The activity of trovafloxacin and five other oral agents against 250 aerobic and 137 anaerobic strains isolated from human and animal bite wounds was determined by an agar dilution method. Trovafloxacin was active against all aerobic and fastidious facultative isolates at < or = 0.5 mg/L and all anaerobes at < or = 2 mg/L (Bacteroides tectum, Porphyromonas salivosa and Prevotella heparinolytica, < or = 0.25 mg/L; Porphyromonas spp., < or = 0.5 mg/L; Prevotella spp. and peptostreptococci, < or = 2.0 mg/L), except Fusobacterium nucleatum and other fusobacteria (MIC90 < or = 4 mg/L). Levofloxacin was generally one to two dilutions more active than ofloxacin, while ciprofloxacin was active against aerobes (MIC < or = 1 mg/L) but less active against anaerobic strains (MIC90 < or = 16 mg/L).

[Bite injuries in the head and neck area]. / Bissverletzungen im Kopf-Halsbereich.

In Germany about 8500 dog-bite injuries in the face occur every year; more than 50% of the victims are infants and schoolchildren. Besides dogs, other animals such as cats or horses may be responsible for these accidents. Even human bites are reported. The predominant areas are the nose and the auricles. The tissue defects may be superficial, but they can even cause amputations, including severe vascular and nerve or bony destruction. Systemic antibiotic therapy is needed when the wound is infected. The surgical approach to bite injuries includes local wound cleansing, careful excision of necrotic tissue and primary closure of the wound whenever possible. Regarding the importance of surgery in the head and neck area plastic-reconstructive techniques including autologous transplantations and various local or regional flaps should be used at the time the wound is first repaired.

Lesiones faciales por mordeduras de humanos y de animales / Facial injuries by human and animal bites

Se presenta una revisión de la literatura así como de la experiencia en el Hospital Central Dr. Ignacio Morones Prieto en el tratamiento de las mordeduras por humanos y por animales. El tratamiento temprano a base de la revisión quirúrgica y cierre primario, así como la antiobioticoterapia adecuada, dan el éxito buscado

Mordedura humana: apresentaçäo de um caso clínico com complicaçäo infecciosa / Human bite: report of a case with infectious complication

Os autores relatam um caso de mordedura humana complicada com infecçäo local regional. Destacam as conseqüências da mordedura, especialmente as referentes às complicaçöes infecciosas, e discutem a terapêutica e a profilaxia. A mordedura humana apesar da sua importância clínica tem sido pouco estudada, o que faz com que profissionais médicos dos Serviços de Emergência tenham dificuldade em prestar um atendimento adequado a esse tipo de paciente. A conduta correta é a lavagem mesticulosa da ferida com soro fisiológico a 0,9 por cento e a retirada do tecido desvitalizado. Se necessário, deve ser feita a vacina ou a antitoxina antitetânica. O uso de antibiótico profilático deve visar os principais agentes causadores de complicaçöes infecciosas, que säo os estreptococos, cocos anaeróbios, a Eikenella corrodens e o Staphylococcus aureus. Por isso recomenda-se o emprego da associaçäo amoxicilina + ácido clavulânico ou de tetraciclinas por três dias. Nos casos com lesäo extensa ou múltipla acometendo o tecido celular subcutâneo, indicamos o uso da penicilina G por via I.V. associada à oxacilina por três a cinco dias. Baseados nesta conduta terapêutica, os autores propöem evitar complicaçöes infecciosas como celulites, abscessos, mionecrose, osteomielite, artrite séptica e septicemias.

Conductas en infectología / Behavior in infectology

Excelente, conciso y actualizado texto sobre diagnóstico y tratamiento de Enfermedades Infecciosas y temas relacionados (por ej.: infecciones en el paciente con cáncer, fiebre de origen desconocido, uso racional de antibióticos en el hospital, infecciones vinculadas con catéteres vasculares, causas infecciosas de esterilidad, infecciones en pacientes con sistemas de derivación o shunt ventrículo-peritoneal, etc, etc). Infecciones del aparato respiratorio. Del aparato circulatorio. Del sistema nervioso. Del aparato digestivo. Del aparato genitourinario. Oculares. Osteoarticulares. De piel y partes blandas. Infecciones severas y su control. En pacientes inmunocomprometidos. Patología infecciosa prenatal y perinatal. Enfermedades exantematicas. Infecciones ganglionares y glandulares. Toma de muestras para bacteriología. Antibioticoterapia. Inmunoprofilaxis y quimioprofilaxis en condiciones especiales

Conductas en infectología / Behavior in infectology

Excelente, conciso y actualizado texto sobre diagnóstico y tratamiento de Enfermedades Infecciosas y temas relacionados (por ej.: infecciones en el paciente con cáncer, fiebre de origen desconocido, uso racional de antibióticos en el hospital, infecciones vinculadas con catéteres vasculares, causas infecciosas de esterilidad, infecciones en pacientes con sistemas de derivación o shunt ventrículo-peritoneal, etc, etc). Infecciones del aparato respiratorio. Del aparato circulatorio. Del sistema nervioso. Del aparato digestivo. Del aparato genitourinario. Oculares. Osteoarticulares. De piel y partes blandas. Infecciones severas y su control. En pacientes inmunocomprometidos. Patología infecciosa prenatal y perinatal. Enfermedades exantematicas. Infecciones ganglionares y glandulares. Toma de muestras para bacteriología. Antibioticoterapia. Inmunoprofilaxis y quimioprofilaxis en condiciones especiales