Animal or Human Bites in Adults - Prevention of Infection
|Publication: 01/07/2009 --|
|Last review: 27/04/2018|
|Next review: 27/04/2021|
|Approved By: Improving Antimicrobial Prescribing Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2018|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
Guideline for the Prevention of Infection Following Animal or Human Bites (including antimicrobial prophylaxis) in Adults
Animal or Human Bites in Adults - Prevention of Infection
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.
If cellulitis is already present see Guidelines for cellulitis and necrotizing fasciitis for antimicrobial and treatment recommendations
Check tetanus vaccination status. In human bites check Hepatitis B vaccination status.
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.
Box 1. Categorisation of high-risk wounds (based on (Dendle & Looke, 2008; Moore, 1997))
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 have good activity against most of the common pathogens. Azithromycin is not effective against Staphylococcus intermedis (but this is uncommon). Azithromycin has better activity against Pasteurella and Eikenella than Clarithromycin and Erythromycin . Azithromycin also seems to have good tissue penetration, is a once daily regimen and is well tolerated. Compliance with a combination of Metronidazole and Doxycycline likely to be less compared with the more simple regimen of once daily Azithromycin – which also has a better safety profile.
Recommended prophylaxis for high risk wounds: Co-Amoxiclav (Amoxicillin-Clavulanate) 625mg three times daily for 3 days, stop if no evidence of infection at 3 day review.
Recommended prophylaxis for high risk wounds and genuine penicillin allergy: Azithromycin 500mg daily for 3 days.
If uncommon or unusual animals are involved seek expert advice (Microbiology/Infectious Diseases).
Prevention of Tetanus
In human bites consider hepatitis B transmission risk
In human bites consider HIV transmission risk
Rabies: animal bites
|Please contact Microbiology if the patient is not responding to the recommended antimicrobial regimens.|
|Clinical condition:||Animal or human bites in adults|
|Target patient group:||Adult|
|Target professional group(s):||Pharmacists
Secondary Care Doctors
Secondary Care Nurses
- 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.
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
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