Bites - Management of Infection Guidance for Primary Care

Publication: 30/09/2010  
Last review: 01/01/1900  
Next review: 01/04/2018  
Clinical Guideline
UNDER REVIEW 
ID: 2259 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2010  

 

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.

The European Medicines Agency’s Pharmacovigilance Risk Assessment Committee has recommended restricting the use of fluoroquinolone antibiotics following a review of disabling and potentially long-lasting side effects mainly involving muscles, tendons, bones and the nervous system. This includes a recommendation not to use them for mild or moderately severe infections unless other antibiotics cannot be used (MHRA advice November 2018).

Bites - human and animal

Illness

Comments

Preferred option

Alternative

Bite (Human)

Thorough irrigation is important 1C
Assess risk of tetanus, HIV, Hepatitis B and C1C
Antibiotic prophylaxis is advised 3B-

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav
625mg TDS 4C
7 days4,5,6C

Review at 24 and 48 hours7C

Clindamycin electronic Medicines Compendium information on Clindamycin
300–450mg QDS
AND
Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin
500mg BD
7 days

Review at 24 and 48 hours7C

Bite (Cat or dog)
CKS

Assess risk of tetanus, rabies 2C
Give antibiotic prophylaxis if 3 :

  • cat bite/puncture wound
  • bite to hand, foot, face, joint, tendon, ligament
  • immuno-compromise
  • diabetic
  • asplenic
  • cirrhotic

Principles of Treatment

  1. This guidance is based on the best available evidence but its application must be modified by professional judgement.
  2. A dose and duration of treatment is suggested. In severe or recurrent cases consider a larger dose or longer course
  3. Choices are given as Preferred option or Alternative for patients intolerant of the preferred option and 2nd Line for when an alternative is required because of treatment failure
  4. Only send microbiology specimens if there is a clinical suspicion of infection. Inappropriate specimens (e.g. routine ulcer swab or routine catheter specimen of urine) lead to inappropriate antibiotic prescribing.
  5. Prescribe an antibiotic only when there is likely to be a clear clinical benefit.
  6. Consider a no, or delayed, antibiotic strategy for acute self-limiting upper respiratory tract infections 1,A+
  7. Limit prescribing over the telephone to exceptional cases.
  8. Use simple generic antibiotics if possible. Avoid broad spectrum antibiotics (e.g. co-amoxiclav, quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase risk of Clostridium difficile, MRSA and resistant UTI's.
  9. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations).
  10. In pregnancy AVOID tetracyclines, aminoglycosides, quinolones, and high dose metronidazole. Short-term use of trimethoprim (unless low folate status or taking another folate antagonist such as antiepileptic or proguanil) or nitrofurantoin (at term, theoretical risk of neonatal haemolysis) is unlikely to cause problems to the foetus.
  11. We recommend clarithromycin as it has less side-effects than erythromycin, greater compliance as twice rather than four times daily & generic tablets are similar cost. In children erythromycin may be preferable as clarithromycin syrup is twice the cost.
  12. Where a ‘best guess’ therapy has failed or special circumstances exist, microbiological advice can be obtained from LTHT Microbiology (Mon-Fri 9am-5pm and Sat and Sun 9am-1pm: 0113 39 23962/28580; Otherwise via LTHT switchboard - ask for the On call Microbiology Registrar)

Note

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Letters indicate strength of evidence:
A+ = systematic review: D = informal opinion

Provenance

Record: 2259
Objective:
  • to provide a simple, empirical approach to the treatment of common infections
  • to promote the safe, effective and economic use of antibiotics
  • to minimise the emergence of bacterial resistance and reduce the incidence of Healthcare Associated Infections in the community
Clinical condition:

Bite

Target patient group:
Target professional group(s): Primary Care Doctors
Pharmacists
Adapted from:

This guidance was initially developed in 1999 by practitioners in South Devon, as part of the S&W Devon Joint Formulary Initiative, and Cheltenham & Tewkesbury Prescribing Group and modified by the PHLS South West Antibiotic Guidelines Project Team, PHLS Primary Care Co-ordinators and members of the Clinical Prescribing Sub-group of the Standing Medical Advisory Committee on Antibiotic Resistance. It was further modified following comments from Internet users. The guidance has been updated annually as significant research papers, systematic reviews and guidance have been published. The Health Protection Agency works closely with the authors of the Clinical Knowledge Summaries.


Evidence base

Grading of guidance recommendations

The strength of each recommendation is qualified by a letter in parenthesis.

Study design

Recommendation
grade

Good recent systematic review of studies

A+

One or more rigorous studies, not combined

A-

One or more prospective studies

B+

One or more retrospective studies

B-

Formal combination of expert opinion

C

Informal opinion, other information

D

Clinical Knowledge Summaries web http://www.prodigy.nhs.uk. BNF (No 55), SMAC report - The path of least resistance (1998), SDHCT Medical Directorate guidelines + GU medicine guidelines, Plymouth Management of Infection Guidelines project LRTI and URTI.

Bites (human or animal)

  1. Health Protection Agency. Guidelines for the management of human bite injuries. Guidance for healthcare professionals on dealing with injuries where teeth break the skin. Health Protection Agency North West 2007. www.hpa.org.uk (Accessed 26th January 2010). Gives guidance on initial wound assessment, wound care, and assessment of risk of tetanus and blood-borne viruses.
  2. CKS. Bites – human and animal. Clinical Knowledge Summaries. 2007.Expert opinion is that prophylaxis for animal bites is only required for animal bites to the hand, foot, and face; puncture wounds; all cat bites; wounds requiring surgical debridement; wounds involving joints, tendons, ligaments, or suspected fractures; wounds that have undergone primary closure; wounds to people who are at risk of serious wound infection (e.g. those who are diabetic, cirrhotic, asplenic, immunosuppressed, people with a prosthetic valve or a prosthetic joint).
  3. Medeiros I, Saconat H. Antibiotic prophylaxis for mammalian bites. Cochrane Database of Systematic Reviews, 2001 Issue 2 http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001738/pdf_fs.html (Accessed 26th January 2009) ]). Human bites: only one trial (n = 48) analyzed human bites, and the infection rate in the antibiotic group (0%) was significantly lower than the infection rate in the control group (47%); OR 0.02, 95% CI 0.00 to 0.33. Dog bites: pooled results from six RCTs (n = 463) found that the infection rate was not reduced after the use of prophylactic antibiotics (4%) compared with the control group (5.5%); OR 0.74, 95% CI 0.30 to 1.8).Cat bites: one small study (n = 11) reported a lower infection rate in the treatment group who received prophylactic antibiotics (0%) compared with the control group (67%)
  4. First-line antibiotic. The Health Protection Agency and the Association of Medical Microbiologists recommend co-amoxiclav for treatment or prophylaxis of human or animal bites because it is a broad-spectrum antibiotic that is effective against the most commonly isolated organisms from human bites (alpha- and beta-haemolytic streptococci, S. aureus, S. epidermis, corynebacteria, and E. corrodens) and animal bites ( such as Pasteurella [57% of dog bites and 75% of cat bites], streptococci, staphylococci, moraxella, neisseria, and anaerobes).
  5. First-line antibiotics in penicillin allergy for animal bites. The Health Protection Agency and the Association of Medical Microbiologists recommend metronidazole PLUS doxycycline for adults with penicillin allergy who require treatment or prophylaxis of an animal bite. Doxycycline has activity against pasturella species (the most common pathogen), staphylococci and streptococci. Metronidazole is included to cover anaerobes. Macrolides are not recommended for animal bites because they do not adequately cover pasturella.
  6. First-line antibiotics in penicillin allergy for human bites. The Health Protection Agency and the Association of Medical Microbiologists recommend metronidazole plus either doxycycline or clarithromycin for adults and children with penicillin allergy who require treatment or prophylaxis of a human bite. Both doxycycline and clarithromycin are active against staphylococci and streptococci (the most common pathogens). Metronidazole is included to cover anaerobes. Doxycycline, but not clarithromycin is active against Eikenella species, which is also a common pathogen isolated from human mouths.
  7. The Health Protection Agency and the Association of Medical Microbiologists recommend that people with penicillin allergy are reassessed at 24 and 48 hours after starting a course of antibiotic treatment because the recommended regimen covers the majority, but not all, of the likely pathogens from an animal or human bite.

Document history

LHP version 1.0

Related information

Not supplied