Bites Michael A. Renzi, DO, FACP Advocare Heights Primary Care

Epidemiology 1% of ED visits 1% of ED visits 80-90% are from dogs 80-90% are from dogs 5-15% are from cats 5-15% are from cats

Human Deaths from Animal Attacks Humans – 200,000(US-3,400) Humans – 200,000(US-3,400) Snake – 60,000 Snake – 60,000 Crocodile– 1000 Crocodile– 1000 Tiger – Tiger – Lion – Lion – Leopard— Leopard— Hippopotamus Hippopotamus

Human Bites Open Mouth Clenched Fist

Microbiology 80% S. aureus 80% S. aureus Mouth Anaerobes Mouth Anaerobes Group A β-hemolytic Strep Group A β-hemolytic Strep Eikenella Eikenella

Dog/Cat Bites Cat Bite Pit Bull Bite

Dogs, Man’s BFF? 4.7 million bits annually 4.7 million bits annually 750,000 visits 750,000 visits 66% of bites are not reported 66% of bites are not reported 59 per 10,000 incidence 59 per 10,000 incidence 250 per 10,000 in India 250 per 10,000 in India 96% percent of rabies cases 96% percent of rabies cases Chhabra M. Humna rabies in Delhi, Indian Journal of Peds, 2004; 71; CDC, US, MMWR 2003;52:

Cat Bites 400,000 bits annually 400,000 bits annually Mostly female cats Mostly female cats Mostly female victims Mostly female victims Smith Treating Mammalian bite wounds, J Clinical Pharm, 2000; 25:85-99

Microbiology Pasteurella multocida –60% Pasteurella multocida –60% S. aureus S. aureus Cynocatophagia Cynocatophagia Anaerobes Anaerobes The average dog has 64 different bacterial isolates in mouth The average dog has 64 different bacterial isolates in mouth

Marine Bites Shark, fish, eel Shark, fish, eel Vibrio(cirrhotics) Vibrio(cirrhotics) Aeromonas(GNR) Aeromonas(GNR)

Evaluation Provoked or unprovoked? Provoked or unprovoked? Penicillin allergy Penicillin allergy Tetanus status Tetanus status Evaluate for injury below the skin Evaluate for injury below the skin

Treatment Aggressive debridement and wound lavage Aggressive debridement and wound lavage Closure of lacerations within 24 hours Closure of lacerations within 24 hours May avoid antibiotics in superficial dermis non-extremity wounds(scalp) May avoid antibiotics in superficial dermis non-extremity wounds(scalp) All hand bites get prophylactic antibiotics All hand bites get prophylactic antibiotics ABX may be warranted in immuno- compromised hosts ABX may be warranted in immuno- compromised hosts

Antibiotic Selection Amoxicillin/Clavulanate Amoxicillin/Clavulanate Azithromycin Azithromycin Cipro Cipro

Rabies Prophylaxis Live captured animal is best Live captured animal is best Need the head Need the head Keep it in the frig until it can be analyzed Keep it in the frig until it can be analyzed Unprovoked aggression Unprovoked aggression Lack of fear of humans Lack of fear of humans Daylight attacks Daylight attacks

Which Animals? Racoons Racoons Skunks Skunks Bats Bats Foxes Foxes Cats Cats Dogs Dogs Cattle Cattle Horses Horses

Bees/Wasps Bumble bee Paper wasp Honey bee Yellow jacket

Bee Stings Local edema Local edema Prednisone—for local edema Prednisone—for local edema H1 blockade –for urticaria H1 blockade –for urticaria Epinephrine-laryngeal edema Epinephrine-laryngeal edema

Flea Bites

Chiggers

Tick Line Up

Eyrthema Chronica Migrans

Evidence for the Evidence Grade A—Good evidence to support use Grade A—Good evidence to support use Grade B—Moderate Evidence Grade B—Moderate Evidence Grade C—Poor Evidence Grade C—Poor Evidence Grade D—Moderate Evidence Against use Grade D—Moderate Evidence Against use Grade E—Good Evidence Against use Grade E—Good Evidence Against use

Quality of the Evidence I—One positive randomized controlled trial I—One positive randomized controlled trial II—One well designed trial II—One well designed trial Without randomization Without randomization Cohort Cohort Case controlled Case controlled III—Evidence and opinions from authorities based on clinical experience or expert committes III—Evidence and opinions from authorities based on clinical experience or expert committes

Prophylaxis Routine use of antibiotics or serologic testing after tic bite(E-1, D-III) Routine use of antibiotics or serologic testing after tic bite(E-1, D-III) Remove attached tic ASAP(A-III) Remove attached tic ASAP(A-III) Treatment with ticks attached longer than 48 hours (C-III) Treatment with ticks attached longer than 48 hours (C-III)

Who to Treat All Patients with ECM(A-I) All Patients with ECM(A-I) All patients who develop a rash or high fever (>100F) within 30 days of bite (A-II) All patients who develop a rash or high fever (>100F) within 30 days of bite (A-II) Erlichiciosis or Babesiosis Erlichiciosis or Babesiosis All patients with positive ELISA(A-1) All patients with positive ELISA(A-1)

Spiders

Some Basics Offending critter rarely recovered Offending critter rarely recovered Bite thin-skinned areas Bite thin-skinned areas Areas where clothing presses tightly Areas where clothing presses tightly Appearance of the wound does not help with diagnosis Appearance of the wound does not help with diagnosis

Spiders-Brown Recluse

Brown Recluse Bite

Harmless Daddy Long Legs House Spider

Black widow Found in every state in US Usually warmer climates Highly venomous Have them bring in the spider

Yellow Sac Bites feel like bee sting Serum Sickness Eschar not always present

Scabies

Nice People Get Scabies Without treatment, infection may last indefinitely Without treatment, infection may last indefinitely Nocturnal itching is hallmark of scabies Nocturnal itching is hallmark of scabies 4-6 weeks between infestation and symptoms 4-6 weeks between infestation and symptoms

Treatment Permethrin (A) Permethrin (A) Launder clothing and sheets Launder clothing and sheets Launder the kids, spouse Launder the kids, spouse Zoloft may be necessary Zoloft may be necessary