Cat & Dog Bites

8/10/2019 Cat & Dog Bites

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Acta chir belg, 2006, 106, 692-695

Introduction

Cat and dog bites are the most common domestic animalbites in Belgium. Although they mostly cause minorlesions, for which no medical help is sought, they canlead to severe wound infection with systemic complica-tions and long-term disability if not treated properly. Theobjective of this study was to define the possible com-plications resulting from cat and dog bites in humans.The need for hospital admission and surgical treatmentwas analysed. This analysis resulted in updated guide-lines for the treatment of cat and dog bites.

Material and methods

We retrospectively analysed the emergency department(ED) data of our hospital (AZ St. Dimpna, Geel,Belgium) for the year 2004, seeking patients that pre-sented with bite wounds from either cat or dog. Thepatient files were reviewed. The collected information

included age, sex, date, location of the bite wounds, timedelay (measured in days) between the bite and presenta-

tion at the emergency department, treatment in the emer-gency department, use of imaging techniques, admissionduration, laboratory values on admission, antibiotherapyand possible extensive surgical treatment.

Results

In 2004, thirty-four patients bitten by cats or dogs pre-sented to our ED. The male/female ratio was 2/1.4 andthe mean age thirty-six years (range three to eighty-twoyears of age). Only 4.9% of the patients were children(< eighteen years of age). The body parts most affectedwere the hands and the arms, which were involved in64.7% of all cases (N = 22).

73.5% of all patients (N = 25) consulted within twen-ty-four hours after the bite. They had all been bitten bydogs. All the bite wounds were carefully evaluated,debrided and thoroughly rinsed, first with sodium chlo-ride solution followed by a povidone-iodine solution(Isobetadine®) using high-pressure irrigation by means

of a twenty millilitre syringe and a sixteen gaugecatheter under local anaesthesia. Fourteen of these

Cat And Dog Bites. What To Do ?

Guidelines for the treatment of cat and dog bites in humans

T. E. J. Philipsen, C. Molderez, T. Gys

Dept. of surgery, AZ St. Dimpna, Geel, Belgium.

Key words. Cat bite ; dog bite ; tenosynovitis ; hand trauma.

Abstract. Introduction : Domestic animal bites are quite common, but mostly cause minor lesions, for which no med-ical help is sought. The objective of this study is to define the complications resulting from cat and dog bites that leadto hospital admission. This analysis led to updated guidelines for the treatment of dog and cat bites in humans.Patients and methods : The emergency department (ED) data of our hospital for the year 2004 were retrospectivelyanalysed, seeking patients that presented with bite wounds from either cat or dog. The patient files were reviewed. Results : 34 patients, bitten by cats or dogs, presented to our ED in 2004. 73.5% of them (n = 25) consulted within24 hours after the bite. In 11 of these patients (44.0%), primary closure of the wound was performed after thorough rins-ing and evaluation of the dead space. All these patients were given prophylactic antibiotics. In none of these did thewounds need to be reopened afterwards. Nine patients (26.5%) did not present to the ED until after the day they werebitten. In all these patients, the bite wounds were located on the hand (n = 6) or forearm (n = 3). They all consultedbecause of complications. The main symptoms were limited and there was painful mobilisation of fingers and wrist, andswelling and redness in the area of the bite wound. Their wounds were thoroughly explored and in 6 of these ninelate-presenting patients, a tendon lesion or a purulent flexor tenosynovitis was diagnosed. These six patients neededadmission for further management. The mean admission duration was 6 days (range 4 to 10 days). None of theadmitted patients showed any signs of limited mobility or disability during follow-up after discharge.Conclusion : While cat and dog bites often cause minor lesions that can be treated by thorough wound care if present-ed early, the importance of possible late complications should not be overlooked. Patients that present with the symp-

toms of tissue infection due to a cat or dog bite should be examined adequately and may need admission. Due to aggres-sive treatment, we had no serious or disabling complications in our population after discharge.



Cat and Dog Bites 693

patients (56.0%) were given a renewal of their tetanusprophylaxis, while the others were still covered by theirprevious vaccinations. The risk of rabies should always

be evaluated (3, 19) but is quite small in Belgian domes-tic animals, so there was no need for rabies-post-exposure-prophylaxis (RPEP) treatment. In 11 of theearly-consulting patients (44.0%), primary closure orapproximation of the wound edges was performed aftercareful evaluation of the remaining dead space. Theother fourteen patients presented with superficial abra-sions or puncture wounds, which were thoroughly rinsedbut did not need suturing. All the primarily suturedpatients were given prophylactic antibiotics by mouth.In none of them did the wounds need to be reopenedafterwards. The first-line antibiotic of choice is amoxi-cillin-clavulanate (Augmentin®) (3), which was given inseventeen (68.0%) of the early presenting patients, in adose ranging from 2 500 milligram a day to 2

875 milligram a day.Nine patients (26.5%) did not present to the ED until

after the day on which they were bitten. The meanpatient delay between the time of the bite and presenta-tion at the ED was 7.4 days (range 2 to 21 days). Thecat/dog bite ratio in these late presenting patients was 4to 5, although all patients bitten by a cat who wereincluded in our study were part of this late group. In allthese late-presenting patients, the bite wounds werelocated on the hand (N = 6) or the forearm (N = 3). Two

of these nine patients had already been treated by theirgeneral practitioner (GP) by means of primary closurewithout adequate wound evaluation and rinsing.

All the late-presenting patients presented because of complications. The main symptoms were limited andpainful mobilisation of the fingers and wrist andswelling and redness in the area of the bite wound. Theirwounds were thoroughly explored and in six of thesenine late-presenting patients (66.7%), a purulenttenosynovitis was diagnosed on examination, whichshowed the four typical signs as described by KANAVEL :a uniform swelling of the digit, digit held in partial

flexion, pain with passive extension of the finger and

tenderness along the course of the tendon sheath (7).These six patients needed admission for further manage-ment, because of the risk of further spread of the infec-

tion and loss of the finger due to increasing pressure inthe tendon sheath (8). The data concerning these admit-ted patients can be seen in Table I. More admittedfemale patients were bitten by a cat (66.66%), while twoout of three admitted male patients were bitten by a dog.Two of the three patients admitted with a cat bite hadpreviously been treated by their GP by means of prima-ry suturing without thorough rinsing. The patient delaytime between the bite and admission was remarkablylonger in patients bitten by a dog, with a mean delay of 9.66 days in the case of a dog bite, and 3.66 days in thecase of a cat bite. The laboratory values (c-reactive pro-tein (CRP) and white cell count (WCC)) of thesepatients on admission were looked up, but showed nosignificant changes.

After admission, the treatment consisted of a medicalpart and a surgical part. All the admitted patientsreceived intravenous antibiotics. 83.33% (N = 5) weregiven the combination of clindamycin (Dalacin C®) 3

300 mg a day and levofloxacin (Tavanic®) 2 500 mg aday. The other 16.67% (N = 1) received intravenousamoxicillin-clavulanate (Augmentin®) in a 3 1 g dailydose. After four to six days, the intravenous treatmentwas replaced in all patients by the same antibiotics bymouth. After ultrasound imaging, which showed inflam-

mation and abcedation of the tissue surrounding theaffected tendon, three patients needed further intensivesurgical treatment. During surgery, the affected tendonsheath was opened, debrided and thoroughly irrigated.

A culture was taken from all the wounds of the latepresenting patients, but in only two cases, were bacteriagrown. One culture showed MRSA (methicillin resistantStaphylococcus aureus), the other, Prevotella buccae,both pathogens commonly found in the oral cavity of cats (1). Both bacteria were found to be sensitive to theantibiotics the patients were given.

The mean admission duration was six days (range

four to ten days). All the admitted patients received

Table I

Data concerning the admitted patients

Sex Age (years) Delay (days) Cat or dog Bite location Primarily sutured CRP WCC(G.P.) (mg/100 ml) ( 1000/mm2)

Female 56 3 cat Hand Yes < 0,4 12,1Male 16 3 cat Forearm No < 0,4 11Female 58 5 cat Forearm Yes 1,7 5,5Male 73 7 dog Hand No 1,1 6

Female 38 8 dog Hand No 0,7 12,2Male 57 14 dog Forearm No 1,3 6,8



694 T. E. J. Philipsen et al.

further outpatient treatment after discharge, by means of antibiotics administered by mouth and intensive handmobilisation therapy by a physiotherapist. We saw nosigns of limited mobility or disability during long-termfollow-up after discharge.

Discussion

Though often causing only minor lesions, cat and dogbites can cause serious complications and even lead topermanent disability if not treated properly at the ED orby the general practitioner (GP).

In this study, only 4.9% of the patients were children(< eighteen years old). Literature states however thatvictims of cat and dog bites are mostly children (3, 4, 5),because this kind of injury is often triggered by an inter-action with the child (17). The incidence of pet bites inchildren is possibly much higher than the 4.9% shown inthis study due to under-reporting of these events (16,19).

By investigating the possible complications due to cat

and dog bites in humans and the need for admission andsurgical treatment, we defined our updated guidelines

for the treatment of cat and dog bites in humans, basedon the time delay between the bite and the start of thetreatment (Fig. 1).

If presented early, within twenty-four hours after thebite, the wounds should be carefully evaluated, debridedand thoroughly rinsed, preferably with a solution of sodium chloride and povidone-iodine using high-pres-sure irrigation by means of a syringe and catheter underlocal anaesthesia. The tetanus immunization statusshould be routinely checked and, if necessary, renew-ed (3, 6). After careful evaluation of the dead space, thewound, no matter in what body region, can be closedprimarily if necessary. This is in contradiction to theguidelines formerly used, which stated that bite woundsshould be left open for secondary healing (9), especiallywounds on the hand (20), and primary closure shouldonly be considered for bites in which the concerns aboutcosmetic outcome outweigh the risk of infection, such asfacial lacerations by dog bites (15, 18). In case of pri-mary closure, a treatment with broad-spectrum antibi-otics should be started to reduce the incidence of infec-

tion in high risk wounds, especially those on thehands (1, 5, 10, 15, 20). The chosen antibiotic should

(1) Amoxicillin-Clavulanate by mouth 2 500 mg/d during 1 week(2) Clindamycin 3 300 mg/d + Levofloxacin 2 500 mg/d intravenously for 5 days(3) Clindamycin 3 300 mg/d + Levofloxacin 2 500 mg/d by mouth for 1 week.

Fig. 1Current guidelines for treatment of cat and dog bites in humans



Cat and Dog Bites 695

cover most pathogens commonly found in the oral cavi-ty of cats and dogs, such as amoxicillin-clavulanate,covering beta-lactamase-producing aerobic and anaero-

bic species (15), and should be given for one week.Puncture wounds or superficial abrasions do not needclosure after thorough wound care and no prophylacticantibiotics should be started (11).

If the patient presents more then twenty-four hoursafter the bite, especially if the bite wounds are located onthe hand and/or caused by a cat, the infection risk is highand thorough investigation is necessary (3, 20). In ourstudy, all patients with cat bites presented more thantwenty-four hours after the bite. All injuries caused bycats involved the hand or forearm, known as the twomost common locations for cat bites and scratches (19).

In these late presenting bite wounds on the hand, oneshould always consider the presence of purulent or pyo-genic tenosynovitis. If positive on examination, asshown by the four signs described by KANAVEL (7), thepatient should be admitted and intravenous antibioticsshould be started to prevent tendon necrosis or the fur-ther spread of infection (2). The antibiotics given shouldcover beta-lactamase-producing aerobic and anaerobicspecies, and should be adjusted based on the pathogenspresent in the wound, if necessary. The antibioticsshould be given intravenously for at least five days. Onadmission, an ultrasound of the affected tendon shouldbe performed, to evaluate the necessity for further surgi-

cal intervention. In case of abcedation, immediatedrainage with debridement and irrigation of the affectedtendon sheath should be performed, to improve the prog-nosis (9, 12, 13, 14). After discharge, the same antibi-otics should be continued by mouth for at least one weekand intensive hand mobilisation therapy should be start-ed as soon as possible (2), in order to avoid long termlimited mobility and permanent disability.

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survey. Eur J Pediatr , 2004, 163 : 424.17. KEUSTER T. D., LAMOUREUX J., KAHN A. Epidemiology of dogbites : A Belgian experience of canine behaviour and public healthconcerns. Vet J , 2005 Jun, in press, corrected proof.

18. CHAUDRY M. A., MACNAMARA A. F., CLARK S. Is the managementof dog bite wounds evidence based ? A postal survey and reviewof the literature. Eur J Emerg Med , 2004 Dec, 11 (6) : 313-7.

19. OSTANELLO F., GHERARDI A., CAPRIOLI A., LA PLACA L., PASSINI A.,PROSPERI S. Incidence of injuries caused by dogs and cats treatedin emergency departments in a major Italian city. Emerg Med J ,2005, 22 : 260-262.

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Philipsen T. E. J.J.B.Stessensstraat 2B-2440 Geel, BelgiumE-mail : [email protected]

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Cat & Dog Bites