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Bites, Animal: Treatment & Medication
Updated: Jun 25, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Prehospital Care
- Obtaining the history of the bite event is of major importance, including home treatment of wounds, body parts involved, and other symptoms (see History).
- Rinse bite wounds, if possible, and cover with a sterile dressing. Tap water has been shown to be as effective for irrigation as sterile saline.12
- Encourage patients to seek prompt care.
Emergency Department Care
- Most bite wounds can be treated in the ED. Essentials of treatment are necessary inspection, debridement, irrigation, and closure, if indicated. Complete trauma evaluation occasionally is indicated.
- Carefully inspect bite wounds to identify deep injury and devitalized tissue. Obtaining an adequate inspection of a bite wound without it first being anesthetized is nearly impossible. Care should be taken to visualize the bottom of the wound and, if applicable, to examine the wound through a range of motion.
- Debridement is an effective means of preventing infection. Removing devitalized tissue, particulate matter, and clots prevents these from becoming a source of infection, much like any foreign body. Clean surgical wound edges result in smaller scars and promote faster healing.
- Irrigation is another important means of infection prevention. A 19-gauge blunt needle and a 35-mL syringe provide adequate pressure (7 psi) and volume to clean most bite wounds. In general, 100-200 mL of irrigation solution per inch of wound is required.12 Heavily contaminated bite wounds require more irrigation. Large dirty wounds may require irrigation in the operating room. Isotonic sodium chloride solution is a safe, available, effective, and inexpensive irrigating solution. Few of the numerous other solutions and mixtures of saline and antibiotics have any advantages over saline. If a shieldlike device is used, take care to prevent the irrigating solution from returning to the wound, which decreases the effectiveness of the irrigation.
- Primary closure may be considered in limited bite wounds that can be cleansed effectively (this excludes puncture wounds, ie, cat bites). Other wounds are best treated by delayed primary closure. Facial wounds, because of the excellent blood supply, are at low risk for infection, even if closed primarily, but the risk of superinfection must be discussed with the patient prior to closure. Bite wounds to the hands and lower extremities, with a delay in presentation, or in immunocompromised hosts, generally should be left open.7
- If a bite wound involves the hand, consider immobilizing in a bulky dressing or splint to limit use and promote elevation.
- Consider tetanus and rabies prophylaxis for all wounds. Antirabies treatment may be indicated for bites by dogs and cats whose rabies status can not be obtained, or in foxes, bats, raccoons, or skunks in the Americas (see Rabies for treatment and dosing information).
- Oehler et al have established a wound management strategy following animal bites to prevent severe complications that include the following steps:13
- Culture for aerobes and anaerobes if abscess, severe cellulitis, devitalized tissue, or sepsis is present.
- Use saline solution for wound irrigation.
- Debride necrotic tissue and remove any foreign bodies.
- If fracture or bone penetration, radiography is indicated (MRI or CT may also be indicated).
- Initiate prophylactic antibiotics in selected cases (based on type and specific animal involved).
- If methicillin-resistant Staphylococcus aureus (MRSA) is suspected, first-line antibiotics include trimethoprim-sulfamethoxazole, doxycycline, minocycline, and clindamycin.
- Hospitalization is indicated if fever, sepsis, spreading cellulitis, severe edema, crush injury, or loss of function is present. Also consider hospitalization for patients who are immunocompromised or are likely to be noncompliant.
- Administer tetanus booster (if none given in past year) or initiate primary series in nonvaccinated individuals.
- Assess the need for rabies vaccine and immunoglobulin.
For additional information, see Medscape's Wound Management Resource Center.
Consultations
- Extensive wounds, those involving tissue loss, or those involving complex structures may require plastic surgery consultation.
- If the skull is penetrated, neurosurgery consultation is indicated.
- Local public health authorities should be notified of all bites and may help with recommendations for rabies prophylaxis.
Medication
This is one of most controversial subjects in wound care. Remember that proper wound care (inspection, debridement, irrigation, closure, if indicated) reduces infection more than antibiotics. In general, low-risk wounds do not require prophylactic antibiotics. However, therapy is recommended for high-risk wounds (eg, cat bites that are a true puncture, bites to the hand, massive crush injury, late presentation, poor general health).14
The goal of initial therapy is to cover staphylococci, streptococci, anaerobes, and Pasteurella species. Prophylactic antibiotics may be given for a 3- to 5-day course. The first-line oral therapy is amoxicillin-clavulanate. For higher risk infections, a first dose of intravenous antibiotic may by given (ie, ampicillin-sulbactam, cefuroxime, ticarcillin-clavulanate, piperacillin-tazobactam, or a carbapenem). Other combinations of oral therapy include amoxicillin plus cephalexin (possible poor compliance due to complicated regimen), clindamycin plus a fluoroquinolone (adults), clindamycin plus sulfamethoxazole and trimethoprim (Bactrim) (children), and less effective azithromycin or doxycycline.15,6,7 If the wound is infected on presentation, a course of 10 days or longer is recommended.
For monkey bites, postexposure prophylaxis valacyclovir or acyclovir should be given for 14 days.
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Ampicillin and sulbactam (Unasyn)
Drug combination of beta-lactamase inhibitor with ampicillin. Interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms.
Adult
1.5 (1 g ampicillin + 0.5 g sulbactam) to 3 g (2 g ampicillin + 1 g sulbactam) IV/IM q6-8h; not to exceed 4 g/d sulbactam or 8 g/d ampicillin
Pediatric
<3 months: Not established
3 months to 12 years: 100-200 mg ampicillin/kg/d (150-300 mg Unasyn) IV divided q6h
>12 years: Administer as in adults; not to exceed 4 g/d sulbactam or 8 g/d ampicillin
Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
Imipenem and cilastatin (Primaxin)
For treatment of multiple organism infections in which other agents do not have wide-spectrum coverage or are contraindicated due to potential for toxicity.
Adult
Base initial dose on severity of infection, and administer in equally divided doses; dose may range from 250-500 mg q6h IV for a maximum of 3-4 g/d
Alternatively, 500-750 mg q12h IM or intra-abdominally
Pediatric
Infants >3 months and children
<12 years: 15-25 mg/kg/dose IV q6h
Fully susceptible organisms: Not to exceed 2 g/d
Infections with moderately susceptible organisms: Not to exceed 4 g/d
>12 years: Administer as in adults
Coadministration with cyclosporine may increase CNS side effects of both agents; coadministration with ganciclovir may result in generalized seizures
Documented hypersensitivity; known hypersensitivity to amide local anesthetics; children with CNS infections (increased seizure risk); children <30 kg with renal impairment (lack of data)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adjust dose in renal insufficiency (adult adjustments)
CrCl (mL/min) 80-50: 0.5 g q6-8h
CrCl 50-10: 0.5 g q8-12h
Hemodialysis (HD): 0.25-0.5 g after HD, then q12h
Adjust dose in renal insufficiency; avoid use in children <12 y with CNS infections
Caution with history of seizures, hypersensitivity to penicillins, cephalosporins, or other beta-lactam antibiotics
Ertapenem (Invanz)
Bactericidal activity results from inhibition of cell wall synthesis and is mediated through ertapenem binding to penicillin-binding proteins. Stable against hydrolysis by a variety of beta-lactamases including penicillinases, cephalosporinases, and extended-spectrum beta-lactamases. Hydrolyzed by metallo-beta-lactamases.
Adult
1 g IV qd infused over 30 min
CrCl <30 mL/min/1.73 m2: 500 mg IV qd
Pediatric
<3 months: Not established
3 months to 12 years: 15 mg/kg IV q12h; not to exceed 1 g/d
>12 years: Administer as in adults
Probenecid may reduce renal clearance of ertapenem and increase half-life but benefit is minimum and does not justify coadministration
Documented hypersensitivity to drug or amide-type anesthetics
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Pseudomembranous colitis may occur; seizures and CNS adverse reactions may occur; when using with lidocaine to administer intramuscularly, avoid inadvertent injection into blood vessel; decrease dose in renal failure; serious and occasionally fatal hypersensitivity reactions may occur with beta-lactams, caution with previous hypersensitivity reactions to penicillin, cephalosporins, other beta-lactams, or other allergens; do not mix or co-infuse in same IV line as other medications; do not mix with dextrose-containing diluents
Piperacillin and tazobactam sodium (Zosyn)
Antipseudomonal penicillin plus beta-lactamase inhibitor. Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active multiplication.
Adult
3/0.375 g (piperacillin 3 g and tazobactam 0.375 g) IV q6h
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Tetracyclines may decrease effects of piperacillin; high concentrations of piperacillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels; high-dose parenteral penicillins may result in increased risk of bleeding
Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis should not be treated with an oral penicillin during the acute stage
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT levels during therapy; exercise caution in patients with hepatic insufficiencies; perform urinalysis, and BUN and creatinine determinations during therapy and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions
Meropenem (Merrem IV)
Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell-wall synthesis. Effective against most gram-positive and gram-negative bacteria.
Has slightly increased activity against gram-negatives and slightly decreased activity against staphylococci and streptococci compared to imipenem.
Adult
1 g IV q8h
Pediatric
40 mg/kg IV q8h
Probenecid may inhibit renal excretion of meropenem, increasing meropenem levels
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Dosage adjustments (adult adjustments)
CrCl (mL/min) 10-50: 0.5-1 g q12h
CrCl <10: 0.5 g/d
HD: As for CrCl <10, with an extra 0.5 g after HD
Pseudomembranous colitis and thrombocytopenia may occur, requiring immediate discontinuation of medication
Amoxicillin and clavulanate (Augmentin)
Drug combination that extends antibiotic spectrum of penicillin to include bacteria normally resistant to beta-lactam antibiotics. Indicated for skin and skin structure infections caused by beta-lactamase–producing strains of Staphylococcus aureus.
Adult
500/125 mg PO tid or 875/125 mg PO bid
Pediatric
10-15 mg/kg PO tid (based on amoxicillin component)
Coadministration with warfarin or heparin increases risk of bleeding
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Give for a minimum of 10 d to eliminate organism and prevent sequelae (endocarditis, rheumatic fever); following treatment, perform cultures to confirm eradication of streptococci
Amoxicillin (Trimox, Biomox, Amoxil)
Alone, this drug is effective against Pasteurella species. However, not indicated for skin and skin structure infections caused by beta-lactamase–producing strains of Staphylococcus aureus. A second antibiotic such as cephalexin is needed for Staphylococcus infections.
Adult
250-500 mg PO tid
Pediatric
30-50 mg/kg/d PO divided tid; not to exceed 500 mg/dose
Reduces the efficacy of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; may enhance chance of candidiasis
Ticarcillin and clavulanate potassium (Timentin)
Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active growth. Antipseudomonal penicillin plus beta-lactamase inhibitor that provides coverage against most gram-positive organisms, most gram-negative organisms, and most anaerobes.
Adult
3.1 g IV q4-6h
Pediatric
<3 months: Not established
>3 months
<60 kg: 200-300 mg/kg/d IV divided q4-6h
>60 kg: 3.1 g IV q4-6h
Tetracyclines may decrease effects of ticarcillin; high concentrations of ticarcillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels
Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis should not be treated with oral penicillin during acute stage
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT levels during therapy; exercise caution in patients with hepatic insufficiencies; perform urinalysis, and BUN and creatinine determinations during therapy and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions
Cephalexin (Keflex, Biocef, Keftab)
First-generation cephalosporin that arrests bacterial growth by inhibiting bacterial cell wall synthesis. Bactericidal activity against rapidly growing organisms. Primary activity against skin flora.
Adult
250-500 mg PO qid
Pediatric
25-50 mg/kg/d PO divided qid; not to exceed 500 mg/dose
Coadministration with aminoglycosides increases nephrotoxic potential
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy
Sulfamethoxazole/trimethoprim (Bactrim, Bactrim DS, Septra, Septra DS)
Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.
Adult
400-800 mg SMX PO bid
Pediatric
30-60 mg/kg/d SMX PO divided bid; not to exceed 800 mg/dose
May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly persons; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Documented hypersensitivity; megaloblastic anemia due to folate deficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBCs frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, chronic alcoholism, advanced age, anticonvulsant therapy, malabsorption syndrome); hemolysis may occur in G-6-PD deficiency; patients with AIDS may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation
Clindamycin (Cleocin)
Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Adult
300 mg PO qid
Pediatric
10-25 mg/kg/d PO divided qid; not to exceed 600 mg/dose
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile
Ciprofloxacin (Cipro)
Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, S epidermidis, and most gram-negative organisms, but no activity against anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth.
Adult
500 mg PO bid
Pediatric
Not recommended
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Azithromycin (Zithromax)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Treats mild-to-moderate microbial infections
Adult
500 mg PO on day 1, then 250 mg PO qd for 4 d
Pediatric
10 mg/kg PO d 1; not to exceed 500 mg/dose, then 5 mg/kg PO qd for 4 d; not to exceed 250 mg/dose
May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Site reactions can occur with IV route; bacterial or fungal overgrowth may result from prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients
Doxycycline (Doryx, Vibramycin, Bio-Tab)
Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Adult
100 mg PO bid
Pediatric
<8 years: Not recommended
>8 years: 2-5 mg/kg/d PO in 1-2 divided doses; not to exceed 200 mg/d
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Cefuroxime (Ceftin, Kefurox, Zinacef)
Second-generation cephalosporin maintains gram-positive activity that first-generation cephalosporins have; adds activity against P mirabilis, H influenzae, E coli, K pneumoniae, and M catarrhalis. Condition of patient, severity of infection, and susceptibility of microorganism determine proper dose and route of administration.
Adult
500 mg PO bid
Pediatric
15-30 mg/kg/d PO divided bid; not to exceed 500 mg/dose
Disulfiramlike reactions may occur when alcohol is consumed within 72 h after taking cefuroxime; may increase hypoprothrombinemic effects of anticoagulants; may increase nephrotoxicity in patients receiving potent diuretics such as loop diuretics; coadministration with aminoglycosides increases nephrotoxic potential
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Reduce dosage by half if creatinine clearance is 10-30 mL/min, and by 3/4 if <10 mL/min (high doses may cause CNS toxicity); bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy
Antiviral agents
These agents inhibit viral replication.
Acyclovir (Zovirax)
Prodrug activated by phosphorylation by virus-specific thymidine kinase that inhibits viral replication. Herpes virus thymidine kinase (TK), but not host cells' TK, uses acyclovir as a purine nucleoside, converting it into acyclovir monophosphate, a nucleotide analogue. Guanylate kinase converts the monophosphate form into diphosphate and triphosphate analogues that inhibit viral DNA replication.
Has affinity for viral thymidine kinase and, once phosphorylated, causes DNA chain termination when acted on by DNA polymerase. Has activity against a number of herpesviruses, including herpes virus B. Primarily available in preparations for PO and IV use. Patients experience less pain and faster resolution of cutaneous lesions when used within 48 h from rash onset. May prevent recurrent outbreaks. Early initiation of therapy is imperative.
Adult
800 mg 5 times/d for 14 d
Pediatric
Not established
Concomitant use of probenecid or zidovudine prolongs half-life and increases CNS toxicity of acyclovir
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal failure or when using nephrotoxic drugs
Valacyclovir (Valtrex)
Hydrochloride salt of the L-valyl ester of acyclovir. Rapidly converted into acyclovir after prompt absorption from the gut via first-pass intestinal or hepatic metabolism. An alternative to acyclovir for prophylaxis (or possibly treatment).
Adult
1000 mg PO q8 h for 14 d
Pediatric
Not established
Probenecid, zidovudine, or cimetidine coadministration prolongs half-life and increases CNS toxicity of valacyclovir
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal failure (decrease dose) and coadministration of nephrotoxic drugs; associated with onset of hemolytic uremic syndrome
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| Differential Diagnoses & Workup: Bites, Animal |
 Treatment & Medication: Bites, Animal |
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References
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Further Reading
Keywords
animal bites, animal bite management, wound management, animal bite treatment, animal bite infection, bite wound, animal bite wound, dog bite, cat bite, pet bite, wild animal bite, bite wound infection, bite-related infection, mammal bites, rodent bites, ferret bites, rabbit bites, pit bull bite, cellulitis, rabies, septic arthritis, Staphylococcus, Streptococcus, Pasteurella, Bacteroides, Capnocytophaga canimorsus, Eikenella, Enterobacter, Proteus, Haemophilus, Klebsiella, Actinomyces, Fusobacterium, Peptostreptococcus, Clostridium, Wolinella, Propionibacterium, osteomyelitis
