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

2. 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

3. 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 – 800-1600 Tiger – 800-1600 Lion –60-200 Lion –60-200 Leopard—30-125 Leopard—30-125 Hippopotamus 200-300 Hippopotamus 200-300

8. Human Bites Open Mouth Clenched Fist

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

10. Dog/Cat Bites Cat Bite Pit Bull Bite

11. 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;217-220 CDC, US, 2001. MMWR 2003;52:605-610

12. 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

13. 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

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

15. 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

16. 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

17. Antibiotic Selection Amoxicillin/Clavulanate Amoxicillin/Clavulanate Azithromycin Azithromycin Cipro Cipro

18. 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

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

20. Bees/Wasps Bumble bee Paper wasp Honey bee Yellow jacket

21. 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

22. Flea Bites

23. Chiggers

24. Tick Line Up

25. Eyrthema Chronica Migrans

26. 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

27. 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

28. 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)

29. 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)

30. Spiders

31. 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

32. Spiders-Brown Recluse

33. Brown Recluse Bite

35. Harmless Daddy Long Legs House Spider

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

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

38. Scabies

39. 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

40. 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