Animal or Human Bites in Children

Animal or Human Bites in Children - Prevention of Infection

Publication: 30/08/2010

Next review: 13/12/2024

Clinical Guideline

CURRENT

ID: 1617

Approved By: Improving Antimicrobial Prescribing Group

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 TREATMENT AND PREVENTION OF INFECTION FOLLOWING ANIMAL OR HUMAN BITES IN CHILDREN

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

Diagnostics
Management
Prophylaxis or treatment
Prevention of transmission of associated infections
Empirical treatment
Review by 72
Background and safeguarding information
Footnotes

DIAGNOSTICS

For patients admitted with an animal or human bite the following diagnostic tests should be taken to confirm management plans:

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).

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.

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.

MANAGEMENT

Immediate irrigation with copious amounts (at least 250ml) of sodium chloride 0.9% or sterile water. Visible contamination should be removed with forceps or scrubbing.
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.
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.
Offer analgesia as appropriate (paracetamol or ibuprofen).

PROPHYLAXIS OR TREATMENT

Infected bite	Give antimicrobial treatment for a duration of 5 days
Non-infected bite	Give antimicrobial prophylaxis only if indicated below for a duration of 3 days
Type of bite	Bite has not broken the skin	Bite has broken the skin but not drawn blood	Bite has broken the skin and drawn blood
Human	Do not give antibiotics	Advise antibiotics if it is in a high-risk area¹ or person at high risk²	Give antibiotics
Cat		Consider antibiotics if the wound could be deep	Give antibiotics
Dog or other traditional pet		Do not give antibiotics	Give antibiotics if it has caused considerable, deep tissue damage

PREVENTION OF TRANSMISSION OF ASSOCIATED INFECTIONS

All bites
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.
In human bites: If the bite has not broken the skin there is no risk of blood-borne virus transmission If the bite has broken the skin, offer testing for Hepatitis B, Hepatitis C and HIV.
Hepatitis B	In human bites consider risk of transmission
HIV	In human bites consider risk of transmission
Animal Bites
Rabies: animal bites	There is no risk from bites acquired in the United Kingdom. Bites acquired overseas require a risk assessment. For bites that have originated outside of the UK, information can be sought from Public Health England's guidance on Rabies risks by country and Public Health England's Rabies and Immunoglobulin Service, PHE Colindale (tel. 020 8327 6204).
Rabies: bats	Advice should be sought from PHE, Virus Reference Department (VRD), Colindale, London (Tel: 020 8327 6017).

EMPIRICAL TREATMENT

Empirical options following an animal or human bite
Duration: Prophylaxis = 3 days Treatment = 5 days³
Choice for children under 1 month4	Co-Amoxiclav 0.25ml/kg of the 125/31 suspension PO 8-hourly
1st line for children ages 1 month and over	Co-Amoxiclav Dose (as below)PO 8-hourly Child 1 month–11 months: 0.25 mL/kg of 125/31 suspension Child 1–5 years: 5 mL or 0.25 mL/kg of 125/31 suspension Child 6–11 years: 5 mL or 0.15 mL/kg of 250/62 suspension Child 12–17 years: one 250/125 strength tablet (increase to 500/125 strength tablet in severe infection⁵) NB: Absolute dose is convenient to give with lower risk of calculation error. Recommend using mg/Kg dosing in extremes of bodyweight for age.
Alternative 1st line for children under 1 month if penicillin allergy or co-amoxiclav unsuitable	Refer to microbiology
Alternative 1st line for children under 12 years if penicillin allergy or co-amoxiclav unsuitable	Co-trimoxazole ⁷ Dose (as below) PO 12-hourly 6 weeks-5 months: 24mg/kg or 120mg 6 months-5 years: 24mg/kg or 240mg 6 years-11 years: 24mg/kg or 480mg Consider adding Metronidazole if anaerobic cover is indicated. NB: Absolute dose is convenient to give with lower risk of calculation error. Recommend using mg/Kg dosing in extremes of bodyweight for age.
Alternative 1st line for children aged 12 years and over if penicillin allergy or co-amoxiclav unsuitable	Doxycycline PO 200mg on day one then 100mg daily (increase to 100mg twice daily in severe infection5) AND Metronidazole PO 400mg 8-hourly
Alternative 1st line in pregnancy if penicillin allergy or co-amoxiclav unsuitable	Metronidazole PO 400mg 8-hourly AND Azithromycin PO Weight 26-36kg: 300mg daily Weight 36-45kg: 400mg daily Weight ≥46kg: 500mg once daily
1st choice IV antibiotics (if unable to take orally or severely unwell) and under 1 month	Refer to microbiology
1st choice IV antibiotics (if unable to take orally or severely unwell) and >1 month	Co-Amoxiclav IV 30mg/kg 1-2 months: 12-hourly 3 months-17 years: 8-hourly (max 1.2g)
	Oral switch: Co-Amoxiclav see 1st line oral for dosage and frequency
Alternative 1st choice IV antibiotics for penicillin allergy or co-amoxiclav unsuitable and able to tolerate cephalosporins.	Cefuroxime IV 1 month-17 years 20mg/kg (max 750mg per dose) 8-hourly⁶ AND Metronidazole 1 month: loading dose of 15mg/kg then 7.5mg/kg 8-hourly 2 months-17 years: 7.5mg/kg (max 500mg per dose) 8-hourly
	Oral switch: If 1 month-12 years give: Co-trimoxazole Dose (as below) PO 12-hourly 6 weeks-5 months: 24mg/kg or 120mg 6 months-5 years: 24mg/kg or 240mg 6 years-11 years: 24mg/kg or 480mg NB: Absolute dose is convenient to give with lower risk of calculation error. Recommend using mg/Kg dosing in extremes of bodyweight for age. If 12-17 years give: Doxycycline PO 100mg daily (increase to 100mg twice daily in severe infection⁵) AND Metronidazole PO 400mg 8-hourly
Alternative 1st line IV antibiotic if cephalosporin unsuitable	Co-trimoxazole Dose (as below) IV 12-hourly 6 weeks-17 years: 18mg/kg (can increase to 27mg/kg in severe infection5 to a maximum of 1.44g per dose).
	Oral switch: If 1 month-12 years give: Co-trimoxazole Dose (as below) PO 12-hourly 6 weeks-5 months: 24mg/kg or 120mg 6 months-5 years: 24mg/kg or 240mg 6 years-11 years: 24mg/kg or 480mg NB: Absolute dose is convenient to give with lower risk of calculation error. Recommend using mg/Kg dosing in extremes of bodyweight for age. If 12-17 years give: Doxycycline PO 100mg daily (increase to 100mg twice daily in severe infection⁵) AND Metronidazole PO 400mg 8-hourly

REVIEW BY 72

NICE recommends that IV antibiotics given for treatment of bites should be reviewed within 48 hours and switched to an oral antibiotic if possible.

Please contact Microbiology if the patient is not responding to the recommended antimicrobial regimens.

BACKGROUND AND SAFEGUARDING INFORMATION

A bite is an injury sustained by a human or animal tooth. They can cause lacerations, punctures, crush or degloving injuries: the most common injury being puncture wounds. Domestic Animals are responsible for approximately 90% of all bite injuries. Initial wound care is key to managing these, over the use of prophylactic antibiotics. Each year in the UK, a quarter of a million people will attend a minor injuries or A+E department with a dog bite injury. Children are more commonly affected than adults by dog bites. The younger child is more likely to sustain these injuries to the face, neck and head. These wounds should prompt consideration of a referral to the Maxillofacial surgeon for any closure.

After domesticated animals, human bites are the next most common animal bite. In the context of children, adult human bites should prompt consideration for safeguarding concerns. The RCPCH are conducting a systemic review of bites in children and this will be published on their website in late 2021. In the context of animal bites consider the supervision of the child at the time of the incident, previous injuries and the significance of the injuries sustained in relation to safeguarding concerns.

Advice for keeping children safe around dogs can be accessed here.
https://www.rspca.org.uk/adviceandwelfare/pets/dogs/company/children/safe. In the context of a dog bite this information should be given to the care giver.

There are types of illegal or banned dogs that should be reported to the police as per the Dangerous Dog Act. Information regarding this can be found on the West Yorkshire Police website.

If you believe the dog to be a dangerous dog and the dog has attacked/injured someone in a public OR private place you can report this to the police via the West Yorkshire police website or via 101. https://www.gov.uk/control-dog-public gives information regarding controlling dogs and how to report a suspected dangerous dog.

FOOTNOTES

High risk areas include the hands, feet, face, genitals, skin overlying cartilaginous structures or an area of poor circulation.
People at high risk include those at risk of serious wound infection because of a co-morbidity (such as diabetes, immunosuppression, asplenia, or decompensated liver disease).
Duration may need to be extended to 7 days if there is significant tissue destruction or the bite has penetrated bone, joint, tendon or vascular structures
In this scenario, NICE advises to contact an infection specialist. Local decision: use co-amoxiclav.
Severe infection defined as: evidence of spreading cellulitis, tissue damage or child systematically unwell.
Cefuroxime dose can be increased to 50-60mg/kg (max 1.5g per dose) 6-8-hourly if infection is severe
Off-label use

Provenance

Record:	1617
Objective:
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

NICE: Human and animal bites: antimicrobial prescribing. NICE guideline [NG184] Published date: 04 November 2020 https://www.nice.org.uk/guidance/ng184/resources/visual-summary-pdf-8897023117
NICE: CKS Bites - human and animals. Last revised: October 2020

NHS Digital. Provisional Monthly HES for admitted patient care, outpatients and Accident and Emergency Data April 2014 to February 2015: Topic of interest: admissions caused by dogs and other mammals [online], 2015. Available: https://files.digital.nhs.uk/pdf/h/6/animal_bites_m12_1415.pdf [Accessed MAY 2021].
Kennedy, S.A., Stoll, L.E. and Lauder, A.S. (2015) Human and other mammalian bite injuries of the hand: evaluation and management. Journal of the American Academy of Orthopaedic Surgeons 23(1), 47-57
Morgan, P. and Palmer, J. (2007) Dog bites. BMJ 334(7590), 413-417
Edens, M.A., Michel, J.A. and Jones, N. (2016) Mammalian bites in the emergency department: recommendations for wound closure, antibiotics, and postexposure prophylaxis. Emergency Medicine Practice 18(4), 1-20
Ellis, R. and Ellis, C. (2014) Dog and cat bites. American Family Physician 90(4), 239-243
Public Health Wales (2016) Managing human bite injuries. Guidance for health protection teams. Public Health Wales. http://www.wales.nhs.uk [Free Full-text]

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 2.0

Related information

Not supplied

Equity and Diversity

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.