Morning Report

Morning Report: 8/1/2013

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Today’s Morning Report is presented by Dr. Bradby!

 

Human Bite Wounds

Overview

–       10-15% of human bite wounds become infected

–       Most injuries occur in the hands

–       Saliva contains as many as 100 million organisms per mL and up to 190 different species!

–       HIV is unlikely to be transmitted through these bites

–       Goals of therapy:  minimize possible soft tissue deformity and prevent/treat infection

 

Pathophysiology

–       2 types:  clenched fist injuries (closed fist strikes teeth of another individual) and occlusive bites (bite with sufficient force to violate the integrity of the skin)

–       Commonly isolated bacteria:  Eikenella corrodens, Staph, Strep, Corynebacterium

  • Staph aureus is isolated in up to 30% of infected human bite wounds w/ the highest complication rates
  • E. corrodens – slow growing gram negative bacillus – assoc with chronic infection and abscess formation
  • Commonly isolated anaerobes: Bacteriodes and Peptostreptococcus

–       Must consider the potential for transmission of systemic infections – ex:  Hep B – the antigen is detectable in the saliva of 75% of infected patients.

 

History/Physical

–       Things you must ask:

  • Tetanus Immunization status
  • Time delay from injury to presentation
  • Underlying disease (diabetes, immunosuppressive disorders)
  • Mechanism of injury
  • Signs of infection:  Pain, Fever, Erythema, Swelling, Discharge/Odor

–       Document injuries well – assault cases might go to court

–       Wound Characteristics:  location, size, shape, type (puncture, laceration, avulsion, crush), depth of penetration, drainage, foreign body, loss of tissue, tenderness, involvement of other structures, NV status, lymphadenopathy

 

Treatment

–       Tetanus

–       Irrigate!  Irrigate!  Irrigate!

–       Consider x-rays (fight bites, possible boxer’s fractures, etc)

–       Closure:  do not close hand wounds/puncture wounds/infected wounds more than 12 hours old (heal by secondary intention); head/neck wounds may be closed if less than 12 hours old for cosmesis.

  • All of these patients must get abx prophylaxis
  • Avoid layered closure
  • Goal:  provide wound edge approximation, but still allow for drainage

–       Consider consults as needed – ex. OMFS/ENT if wounds are to the face/ear

–       Antibiotics for 3-5 days:

  • Augmentin or Unasyn
    • Keflex does NOT cover Eikenella
  • Bactrim or a Quinolone (ex. Levofloxacin or Moxifloxacin) + Clindamycin – for the PCN allergic

–       Consider:  Hep B vaccine + HBIG, HIV prophylaxis, though they are low risk for transmission.

–       Admission should be considered for those who are already showing signs of infection from the bite at presentation.

 

References:

  • Baddour, LM.  Soft Tissue Infections in Human Bites.  In:  Uptodate, Baron, E (Ed), UpToDate, Waltham, MA, 2013.
  • Barrett, J. (2012, September 20). Human Bites.  Emedicine.  Retrieved July 15, 2013, from http://emedicine.medscape.com/article/218901-overview.
The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.
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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital
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