Animal or Human Bites in Children - Prevention of Infection

Publication: 30/08/2010  
Last review: 04/09/2017  
Next review: 01/09/2020  
Clinical Guideline
CURRENT 
ID: 1617 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for the Prevention of Infection Following Animal or Human Bites (including antimicrobial prophylaxis) in Children

Summary
Animal or Human Bites in Children

Diagnostic criteria

Guidelines apply to any mammalian bite (including human)

Investigations

No microbiology investigations required if no signs of infection.
X-ray: if suspicion of bony injury or penetrating joint injury or suspicion of retained radio-opaque foreign body (e.g. tooth).

Management

  • Immediate irrigation with copious amounts of sodium chloride 0.9% or water.
  • If cellulitis is already present see Guidelines for cellulitis and necrotizing fasciitis for antimicrobial and treatment recommendations.
  • If NOT infected give antimicrobial prophylaxis only for high-risk wounds.
  • Recommended prophylaxis for high-risk wounds: Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav  for 3 days, stop if no evidence of infection at 3 day review.
    • Child 1 month–11 months: 0.25 mL/kg of 125/31 suspension three times a day (8-hourly);
    • Child 1–5 years: 5 mL of 125/31 suspension three times a day (8-hourly) or 0.25 mL/kg of 125/31 suspension three times a day (8-hourly);
    • Child 6–11 years: 5 mL of 250/62 suspension three times a day (8-hourly) or 0.15 mL/kg of 250/62 suspension three times a day (8-hourly);
    • Child 12–17 years: one 250/125 strength tablet three times a day (8-hourly)

Specialist referral
Consider referral to hand / plastic surgeons (upper limb bite) / orthopaedic surgeons (lower limb bite) if extensive wound or complex structures involved or if cosmetic concerns e.g. facial wounds. If there is doubt consult with a senior Emergency Department Clinician

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Background

Two hundred thousand dog bites have been reported to occur in Britain each year (Smith et al., 2003). 0.5-1% of Emergency department visits are due to animal bites (Smith et al., 2003). Bites may become infected or transmit infectious agents (e.g. rabies, hepatitis B, HIV). About 9% of dog bites become infected (Smith et al., 2003) but a meta-analysis of trials revealed only one study that showed a significant benefit for antimicrobial prophylaxis – there is general agreement that routine antimicrobial prophylaxis is not required and that initial wound care is key.

Bite wounds generally contain polymicrobial flora that reflects the microbiology of the skin of the victim, the oral flora of the biter and the environment. The predominant cause of bites wound infection varies with the type of animal but broad antimicrobial cover is generally required because of the polymicrobial nature of infections. Important bacterial causes include: Pasteurella, Staphylococcus aureus, Staphylococcus intermedius, Streptococci, Capnocytophaga canimorsus and anaerobes.

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Clinical Diagnosis

If cellulitis is already present see Guidelines for cellulitis and necrotizing fasciitis for antimicrobial and treatment recommendations

History
Initial clinical assessment should include documenting the timing, nature and location of the bite, the animal involved and where the bite took place. Documentation should include any initial treatment, subsequent potential contamination. In addition any immunosuppression and known allergies to antimicrobials should be established. Standard procedures should be followed relating to protection of children and vulnerable adults.
NB patients may not volunteer that a human bite has occurred – specific questioning may be required to elicit this history.

Check tetanus vaccination status. In human bites check Hepatitis B vaccination status.

Examination
The depth of the wound should be assessed.

The wound and adjacent structures should be examined for signs of infection, foreign bodies (e.g. teeth especially in deep or crush wounds) damage to blood vessels, nerves, tendons, joints, or bones and lymphadenopathy.

Categorise wound risk according to box 1.

Wound is HIGH RISK if the dermis has been penetrated and any of the following are present

Human bites

Open fracture secondary to bite

Puncture wound (deep injury with small skin wound, e.g. cat bites)

Tendons, joint, bone, vessels involved

Hands, face, feet, genitals involved

Delayed presentation >8 hours

Diabetes

Splenectomy and functional hyposplenism

Immunocompromise

Box 1. Categorisation of high-risk wounds (based on (Dendle & Looke, 2008; Moore, 1997))

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Investigation

If there is no clinical evidence of infection at the time of presentation no microbiological investigations are required.

X-ray if bite is over a joint, wound is to/through periosteum, unable to determine depth of wound (as well as speciality referral), suspected foreign body (including tooth fragments) and suspicion of retained radio-opaque foreign body.

Rarely tooth fragments may remain in bite wounds, particularly when high forces such as punch injuries or some dog bite injury occur. In the presence of deep or extensive bite injuries soft tissue x-rays may be required to exclude retained foreign body.

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Treatment
Non-Antimicrobial Treatment

Wound Management

  • Recommendation: Immediate irrigation with copious amounts (at least 250ml) of sodium chloride 0.9% or water (Dendle & Looke, 2008; Smith et al., 2003). Visible contamination should be removed with forceps or scrubbing.[Evidence level B].
  • Recommendation: If debridement is likely to result in a significant tissue deficit which will compromise wound closure or cosmetic outcome referral should be made to plastic surgery.
  • Recommendation: Primary wound closure should not routinely performed except for bite wounds on the face. Rigorous cleansing and appropriate debridement must occur prior to any primary closure. Delayed primary closure should be considered at review at 48-72 hours. The presence of cellulitis or other obvious wound infection is a contraindication to delayed primary closure at that time.[Evidence level D].

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Empirical Antimicrobial Treatment

Antibacterial prophylaxis

Recommendation: Routine antimicrobial prophylaxis is not recommended for dog bites (Cummings, 1994; Smith et al., 2003). [Evidence level A].

Recommendation: There is general agreement that antimicrobial prophylaxis should be confined to high risk wounds (Cummings, 1994; Dendle & Looke, 2008; Smith et al., 2003)
[Evidence level C] link to box 1.

For prophylaxis in the penicillin allergic patient, there is no evidence though doxycycline has traditionally been used in many countries. The microbiological data from animal bites suggest second generation fluoroquinolones and Azithromycin electronic Medicines Compendium information on Azithromycin have good activity against most of the common pathogens. Azithromycin electronic Medicines Compendium information on Azithromycin is not effective against Staphylococcus intermedis (but this is uncommon). Azithromycin electronic Medicines Compendium information on Azithromycin has better activity against Pasteurella and Eikenella than clarithromycin and erythromycin. Azithromycin electronic Medicines Compendium information on Azithromycin also seems to have good tissue penetration, is a once daily regimen and is well tolerated. Compliance with a combination of Metronidazole electronic Medicines Compendium information on Metronidazole and Doxycycline electronic Medicines Compendium information on Doxycycline likely to be less compared with the simpler regimen of once daily Azithromycin electronic Medicines Compendium information on Azithromycin – which also has a better safety profile.

Recommended prophylaxis for high-risk wounds: Co-amoxiclav  for 3 days, stop if no evidence of infection at 3 day review.

  • Child 1 month–11 months: 0.25 mL/kg of 125/31 suspension three times a day (8-hourly);
  • Child 1–5 years: 5 mL of 125/31 suspension three times a day (8-hourly) or 0.25 mL/kg of 125/31 suspension three times a day (8-hourly);
  • Child 6–11 years: 5 mL of 250/62 suspension three times a day (8-hourly) or 0.15 mL/kg of 250/62 suspension three times a day (8-hourly);
  • Child 12–17 years: one 250/125 strength tablet three times a day (8-hourly)

[Evidence level D]

Recommended prophylaxis for high-risk wounds AND genuine penicillin allergy: Azithromycin electronic Medicines Compendium information on Azithromycin  once daily for 3 days.

  •   Child over 6 months: 10 mg/kg once daily (max. 500 mg daily)
    or
  • Body-weight 15–25 kg: 200 mg once daily
  • Body-weight 26–35 kg: 300 mg once daily
  • Body-weight 36–45 kg: 400 mg once daily
  • Body-weight over 46 kg: 500 mg once daily

[Evidence level D]

If uncommon or unusual animals are involved seek expert advice (Microbiology/Infectious Diseases).

Prevention of Tetanus
A tetanus toxoid booster should be administered for patients whose immunization schedule is not up to date, or whose immune status is unknown, and further doses given to complete the five-dose schedule.

Link to guidance for tetanus prophylaxis and management of tetanus prone wounds (LTHT Internal Only)
Link to notes for use of tetanus guidance (LTHT Internal Only)

In human bites consider hepatitis B transmission risk
Link to Hepatitis B PGD (LTHT Internal Only)

In human bites consider HIV transmission risk
Link to Infection control needle stick policy (LTHT Internal Only)
Link to infection control needle stick/splash/bite injury flow chart (LTHT Internal Only)

Rabies: animal bites
There is no risk from bites acquired in the United Kingdom. Bites acquired overseas require a risk assessment. Always seek advice from infectious diseases for patients with animal bites acquired from overseas.

Rabies: bats
Advice should be sought from HPA, Virus Reference Department, Colindale, London (Tel: 0208 2004400).

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Provenance

Record: 1617
Objective:

Aims

  • To standardise the initial management of animal and human bites in children.

Objectives

  • To guide the initial management of patients presenting with animal and human bites to reduce the likelihood of subsequent complications – particularly infection.
  • To provide evidence-based recommendations for appropriate antimicrobial prophylaxis of animal and human bites
  • To recommend appropriate dose, route of administration and duration of antimicrobial agents.
  • To advise in the event of antimicrobial allergy.
  • To set out criteria for referral for surgery or specialist input.
Clinical condition:

Infected Animal/Human Bites

Target patient group: Paediatrics
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Pharmacists
Adapted from:

Evidence base

Cummings, P. (1994). Antibiotics to prevent infection in patients with dog bite wounds: a meta-analysis of randomized trials. Ann Emerg Med 23, 535-540.

Dendle, C. & Looke, D. (2008). Review article: Animal bites: an update for management with a focus on infections. Emerg Med Australas 20, 458-467.

Goldstein, E. J. C., Citron, D. M., Gerardo, S. H., Hudspeth, M, & Merriam, C.V. (1998). Activities of HMR 3004 (RU 64004) and HMR 3647 (RU 66647) Compared to Those of Erythromycin, Azithromycin, Clarithromycin, Roxithromycin, and Eight Other Antimicrobial Agents against Unusual Aerobic and Anaerobic Human and Animal Bite Pathogens Isolated from Skin and Soft Tissue Infections in Humans Antimicrob. Agents Chemother. 42: 1127-1132.

Griego, R. D., Rosen, T., Orengo, I. F. & Wolf J. E. (1995). Dog, cat and human bites: a review. J Am Acad Dermatol 33, 1019-1029.

Health Protection Agency North West (2007). Guidelines for the management of human bite injuries.

Medeiros, I. & Saconato, H. (2001). Antibiotic prophylaxis for mammalian bites. Cochrane Database Syst Rev (2), CD001738.

Moore, F. (1997). "I've just been bitten by a dog". Bmj 314, 88-90.

Morgan, M. & Palmer, J. (2007). Dog bites. British Medical Journal 334, 413-417.

NHS Clinical Knowledge summaries. Bites - human and animal. http://cks.library.nhs.uk/bites_human_and_animal Assessed 12th November 2008.

Smith, M. R., Walker, A. & Brenchley, J. (2003). Barking up the wrong tree? A survey of dog bite wound management. Emerg Med J 20, 253-255.

Smith, P. F., Meadowcroft, A. M. & May D. B. (2000). Treating mammalian bite wounds. Journal of Clinical Pharmacy and Therapeutics 25, 85-99.

Talan, D. A., Citron, D. C., Abrahamian, F. M., Moran, G. J., & Goldstein, E. J. C. (1999). Bacteriologic analysis of infected dog and cat bites. New England Journal of Medicine 340, 85-92.

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Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

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