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Acta chir belg, 2006, 106, 692-695

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 medical help is sought. The objective of this study is to define the complications resulting from cat and dog bites that lead
to 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 retrospectively
analysed, 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 within
24 hours after the bite. In 11 of these patients (44.0%), primary closure of the wound was performed after thorough rinsing and evaluation of the dead space. All these patients were given prophylactic antibiotics. In none of these did the
wounds need to be reopened afterwards. Nine patients (26.5%) did not present to the ED until after the day they were
bitten. In all these patients, the bite wounds were located on the hand (n = 6) or forearm (n = 3). They all consulted
because of complications. The main symptoms were limited and there was painful mobilisation of fingers and wrist, and
swelling and redness in the area of the bite wound. Their wounds were thoroughly explored and in 6 of these nine
late-presenting patients, a tendon lesion or a purulent flexor tenosynovitis was diagnosed. These six patients needed
admission for further management. The mean admission duration was 6 days (range 4 to 10 days). None of the
admitted 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 presented early, the importance of possible late complications should not be overlooked. Patients that present with the symptoms of tissue infection due to a cat or dog bite should be examined adequately and may need admission. Due to aggressive treatment, we had no serious or disabling complications in our population after discharge.

Introduction
Cat and dog bites are the most common domestic animal
bites in Belgium. Although they mostly cause minor
lesions, for which no medical help is sought, they can
lead to severe wound infection with systemic complications and long-term disability if not treated properly. The
objective of this study was to define the possible complications resulting from cat and dog bites in humans.
The need for hospital admission and surgical treatment
was analysed. This analysis resulted in updated guidelines 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 presented with bite wounds from either cat or dog. The
patient files were reviewed. The collected information
included age, sex, date, location of the bite wounds, time
delay (measured in days) between the bite and presenta-

tion at the emergency department, treatment in the emergency department, use of imaging techniques, admission
duration, laboratory values on admission, antibiotherapy
and possible extensive surgical treatment.
Results
In 2004, thirty-four patients bitten by cats or dogs presented to our ED. The male/female ratio was 2/1.4 and
the mean age thirty-six years (range three to eighty-two
years of age). Only 4.9% of the patients were children
(< eighteen years of age). The body parts most affected
were the hands and the arms, which were involved in
64.7% of all cases (N = 22).
73.5% of all patients (N = 25) consulted within twenty-four hours after the bite. They had all been bitten by
dogs. All the bite wounds were carefully evaluated,
debrided and thoroughly rinsed, first with sodium chloride solution followed by a povidone-iodine solution
(Isobetadine) using high-pressure irrigation by means
of a twenty millilitre syringe and a sixteen gauge
catheter under local anaesthesia. Fourteen of these

Cat and Dog Bites

693

patients (56.0%) were given a renewal of their tetanus


prophylaxis, while the others were still covered by their
previous vaccinations. The risk of rabies should always
be evaluated (3, 19) but is quite small in Belgian domestic animals, so there was no need for rabies-postexposure-prophylaxis (RPEP) treatment. In 11 of the
early-consulting patients (44.0%), primary closure or
approximation of the wound edges was performed after
careful evaluation of the remaining dead space. The
other fourteen patients presented with superficial abrasions or puncture wounds, which were thoroughly rinsed
but did not need suturing. All the primarily sutured
patients were given prophylactic antibiotics by mouth.
In none of them did the wounds need to be reopened
afterwards. The first-line antibiotic of choice is amoxicillin-clavulanate (Augmentin) (3), which was given in
seventeen (68.0%) of the early presenting patients, in a
dose 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 mean
patient delay between the time of the bite and presentation at the ED was 7.4 days (range 2 to 21 days). The
cat/dog bite ratio in these late presenting patients was 4
to 5, although all patients bitten by a cat who were
included in our study were part of this late group. In all
these late-presenting patients, the bite wounds were
located on the hand (N = 6) or the forearm (N = 3). Two
of these nine patients had already been treated by their
general practitioner (GP) by means of primary closure
without adequate wound evaluation and rinsing.
All the late-presenting patients presented because of
complications. The main symptoms were limited and
painful mobilisation of the fingers and wrist and
swelling and redness in the area of the bite wound. Their
wounds were thoroughly explored and in six of these
nine late-presenting patients (66.7%), a purulent
tenosynovitis was diagnosed on examination, which
showed 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 management, because of the risk of further spread of the infection and loss of the finger due to increasing pressure in
the tendon sheath (8). The data concerning these admitted patients can be seen in Table I. More admitted
female patients were bitten by a cat (66.66%), while two
out of three admitted male patients were bitten by a dog.
Two of the three patients admitted with a cat bite had
previously been treated by their GP by means of primary suturing without thorough rinsing. The patient delay
time between the bite and admission was remarkably
longer 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 the
case of a cat bite. The laboratory values (c-reactive protein (CRP) and white cell count (WCC)) of these
patients on admission were looked up, but showed no
significant changes.
After admission, the treatment consisted of a medical
part and a surgical part. All the admitted patients
received intravenous antibiotics. 83.33% (N = 5) were
given the combination of clindamycin (Dalacin C) 3 
300 mg a day and levofloxacin (Tavanic) 2  500 mg a
day. The other 16.67% (N = 1) received intravenous
amoxicillin-clavulanate (Augmentin) in a 3  1 g daily
dose. After four to six days, the intravenous treatment
was replaced in all patients by the same antibiotics by
mouth. After ultrasound imaging, which showed inflammation and abcedation of the tissue surrounding the
affected tendon, three patients needed further intensive
surgical treatment. During surgery, the affected tendon
sheath was opened, debrided and thoroughly irrigated.
A culture was taken from all the wounds of the late
presenting patients, but in only two cases, were bacteria
grown. One culture showed MRSA (methicillin resistant
Staphylococcus aureus), the other, Prevotella buccae,
both pathogens commonly found in the oral cavity of
cats (1). Both bacteria were found to be sensitive to the
antibiotics 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
Female
Male
Female
Male
Female
Male

Age (years)

Delay (days)

Cat or dog

Bite location

Primarily sutured
(G.P.)

CRP
(mg/100 ml)

WCC
( 1000/mm2)

56
16
58
73
38
57

3
3
5
7
8
14

cat
cat
cat
dog
dog
dog

Hand
Forearm
Forearm
Hand
Hand
Forearm

Yes
No
Yes
No
No
No

< 0,4
< 0,4
1,7
1,1
0,7
1,3

12,1
11
5,5
6
12,2
6,8

694

T. E. J. Philipsen et al.

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

further outpatient treatment after discharge, by means of


antibiotics administered by mouth and intensive hand
mobilisation therapy by a physiotherapist. We saw no
signs of limited mobility or disability during long-term
follow-up after discharge.
Discussion
Though often causing only minor lesions, cat and dog
bites can cause serious complications and even lead to
permanent disability if not treated properly at the ED or
by the general practitioner (GP).
In this study, only 4.9% of the patients were children
(< eighteen years old). Literature states however that
victims of cat and dog bites are mostly children (3, 4, 5),
because this kind of injury is often triggered by an interaction with the child (17). The incidence of pet bites in
children is possibly much higher than the 4.9% shown in
this 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 and
surgical treatment, we defined our updated guidelines

for the treatment of cat and dog bites in humans, based


on the time delay between the bite and the start of the
treatment (Fig. 1).
If presented early, within twenty-four hours after the
bite, the wounds should be carefully evaluated, debrided
and thoroughly rinsed, preferably with a solution of
sodium chloride and povidone-iodine using high-pressure irrigation by means of a syringe and catheter under
local anaesthesia. The tetanus immunization status
should be routinely checked and, if necessary, renewed (3, 6). After careful evaluation of the dead space, the
wound, no matter in what body region, can be closed
primarily if necessary. This is in contradiction to the
guidelines formerly used, which stated that bite wounds
should be left open for secondary healing (9), especially
wounds on the hand (20), and primary closure should
only be considered for bites in which the concerns about
cosmetic outcome outweigh the risk of infection, such as
facial lacerations by dog bites (15, 18). In case of primary closure, a treatment with broad-spectrum antibiotics should be started to reduce the incidence of infection in high risk wounds, especially those on the
hands (1, 5, 10, 15, 20). The chosen antibiotic should

Cat and Dog Bites


cover most pathogens commonly found in the oral cavity of cats and dogs, such as amoxicillin-clavulanate,
covering beta-lactamase-producing aerobic and anaerobic species (15), and should be given for one week.
Puncture wounds or superficial abrasions do not need
closure after thorough wound care and no prophylactic
antibiotics should be started (11).
If the patient presents more then twenty-four hours
after the bite, especially if the bite wounds are located on
the hand and/or caused by a cat, the infection risk is high
and thorough investigation is necessary (3, 20). In our
study, all patients with cat bites presented more than
twenty-four hours after the bite. All injuries caused by
cats involved the hand or forearm, known as the two
most common locations for cat bites and scratches (19).
In these late presenting bite wounds on the hand, one
should always consider the presence of purulent or pyogenic tenosynovitis. If positive on examination, as
shown by the four signs described by KANAVEL (7), the
patient should be admitted and intravenous antibiotics
should be started to prevent tendon necrosis or the further spread of infection (2). The antibiotics given should
cover beta-lactamase-producing aerobic and anaerobic
species, and should be adjusted based on the pathogens
present in the wound, if necessary. The antibiotics
should be given intravenously for at least five days. On
admission, an ultrasound of the affected tendon should
be performed, to evaluate the necessity for further surgical intervention. In case of abcedation, immediate
drainage with debridement and irrigation of the affected
tendon sheath should be performed, to improve the prognosis (9, 12, 13, 14). After discharge, the same antibiotics should be continued by mouth for at least one week
and intensive hand mobilisation therapy should be started as soon as possible (2), in order to avoid long term
limited mobility and permanent disability.

695
3. LEWIS K. T., STILES M. Management of cat and dog bites. Am Fam
Physician, 1995 Aug, 52 (2) : 479-85, 489-90.
4. FLEISHER G. R. The management of bite wounds. N Engl J Med,
1999 Jan 14, 340 (2) : 138-40.
5. MEDEIROS I., SACONATO H. Antibiotic prophylaxis for mammalian
bites. Cochrane Database Syst Rev, 2001, (2) : CD001738.
Review.
6. LUCHANSKY M. A., BERGMAN M. A., DJALDETTI R. B., HERTZEL A.
Cat bite in an old patient : is it a simple injury ? EJEM, 10 (2) :
130-132.
7. KANAVEL A. B. Infections of the hand. In : A guide to the surgical
treatment of acute and chronic suppurative processes in the fingers, hand, and forearm. 7th ed Philadelphia : Lea & Febiger,
1943 : 241-2.
8. SCHNALL S. B., VU-ROSE T., HOLTOM P. D., DOYLE B.,
STEVANOVIC M. Tissue pressures in pyogenic flexor tenosynovitis
of the finger. JBJS, 1996, 78-B : 793-5.
9. WONGWORAWAT M. D., SCHNALL S. B. Hand infections. Current
treatment options in infectious diseases, 2002, 4 : 295-301.
10. CUMMINGS P. Antibiotics to prevent infection in patients with dog
bite wounds : a meta-analysis of randomized trials. Ann Emerg
Med, 1994 Mar, 23 (3) : 535-40.
11. DIRE D. J. Cat bite wounds. Risk factors for infection. Ann emerg
med, 1991 Sep, 20 (9) : 973-9.
12. BOLES S. D., SCHMIDT C. C. Pyogenic flexor tenosynovitis. Hand
Clin, 1998 Nov, 14 (4) : 567-78.
13. LILLE S., HAYAKAWA T., NEUMEISTER M. W., BROWN R. E.,
ZOOK E. G., MURRAY K. Continuous postoperative catheter irrigation is not necessary for the treatment of suppurative flexor
tenosynovitis. J Hand Surg (Br), 2000 Jun, 25 (3) : 304-7.
14. MONSTREY S. J., VAN DER WERKEN C., KAUER J. M., GORIS R. J.
Tendon sheath infections of the hand. Neth J Surg, 1985 Dec,
37 (6) : 174-8.
15. CORREIRA K. Managing dog, cat, and human bite wounds. JAAPA,
2003 Apr, 16 (4) : 28-32,34,37.
16. KAHN A., ROBERT E., PIETTE D., DE KEUSTER T., LAMOUREUX J.,
LEVQUE A. Prevalence of dog bites in children : a telephone
survey. Eur J Pediatr, 2004, 163 : 424.
17. KEUSTER T. D., LAMOUREUX J., KAHN A. Epidemiology of dog
bites : A Belgian experience of canine behaviour and public health
concerns. Vet J, 2005 Jun, in press, corrected proof.
18. CHAUDRY M. A., MACNAMARA A. F., CLARK S. Is the management
of dog bite wounds evidence based ? A postal survey and review
of 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 treated
in emergency departments in a major Italian city. Emerg Med J,
2005, 22 : 260-262.
20. GARBUTT F., JENNER R. Wound closure in animal bites. Emerg
Med J, 2004, 21 : 589-590.

References
1. MELLOR D. J., BHANDARI S., KERR K., BODENHAM A. R. Mans best
friend : life-threatening sepsis after minor dog bite. BMJ, 1997 Jan
11, 314 (7074) : 129-30.
2. MITNOVETSKI S., KIMBLE F. Cat bites of the hand. ANZ J Surg,
74 (10), 859-862.

Philipsen T. E. J.
J.B.Stessensstraat 2
B-2440 Geel, Belgium
E-mail : tine.philipsen@telenet.be