Chapter 712 - Animal and Human Bites from Kliegman: Nelson Textbook of Pediatric...

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Kliegman: Nelson Textbook of Pediatrics, 18th ed.

Copyright 2007 Saunders, An Imprint of Elsevier

Chapter 712 Animal and Human Bites

Charles M. Ginsburg

With approximately 100 million dogs and cats in the United States, an estimated 3.54.7
million individuals are bitten annually. More than 400,000 of these individuals seek medical
care in hospital emergency departments and free-standing emergency centers in the U.S.
each year. It has been estimated that more bite-injured individuals seek medical attention in
medical offices and primary care clinics than in emergency facilities.
EPIDEMIOLOGY.

During the past 3 decades, there have been approximately 20 deaths per year in the U.S. from
dog-inflicted injuries; 65% of these occurred in children <11 yr of age. The breed of dog
involved in attacks on children varies; Table 712-1 depicts the risk index by breed from 1 study
of 341 dog bites. Rottweilers, pit bulls, and German shepherds accounted for >50% of all fatal
bite-related injuries. Unaltered male dogs account for approximately 75% of attacks; nursing
dams often inflict injury to humans when children attempt to handle one of their puppies.
TABLE 712-1 -- Risk of Dog Bites in the U. S. Among Children by Dog Breed
DOG BREED

NO. DOG BITES (%) DOG POPULATION (%) RISK INDEX

German shepherd 105 (34)

12

2.83

Doberman

8 (3)

1.1

2.71

Spitz

5 (2)

1.1

1.81

Pekingese

10 (3)

1.9

1.56

Dachshund

22 (7)

5.2

1.35

Schnauzer

5 (2)

1.5

1.33

Collie

10 (3)

2.3

1.30

Hound dog

15 (5)

3.9

1.29

Poodle

10 (3)

3.1

0.98

Rottweiler

3 (1)

1.1

0.92

Beagle

3 (1)

1.2

0.80

Terrier

15 (5)

8.1

0.61

Bernese dog

3 (1)

1.7

0.58

Labrador retriever 11 (4)

8.2

0.49

Cross-breed

39 (13)

28

0.46

Spaniel

5 (2)

6.5

0.31

Shi tzu

1 (0.3)

1.2

0.26

Maltese
0 (0.0)
1.1
0.00
From Schalamon J, Ainoedhofer H, Singer G, et al: Analysis of dog bites in children who are
younger than 17 years. Pediatrics 2006;117:e374e379.
*

Data about the distribution of the dog population were collected from the local community dog
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register. The risk index was calculated by dividing the representation of a dog breed among
the total dog population by the representation of this breed among all evaluated dog bites.

The majority of dog-related attacks occur in children between the ages of 611 yr of age. Boys
are attacked more often than girls (1.5:1). Approximately of the attacks occur around the
home, 75% of the biting animals are known by the child, and almost 50% of the attacks are said
to be unprovoked. Similar statistics apply to Canada, where 70% of all bites were sustained by
children between 214 yr; 65% of the dogs involved in the biting were part of the family or
extended family and occurred in someone's home.
Of the approximately 450,000 reported cat bites per year occurring in the U.S., nearly all are
inflicted by known household animals. Because rat bites and gerbil bites are not reportable
conditions, little is known about the epidemiology of these injuries and the incidence of
infection after rodent-inflicted bites or scratches.
Few data exist on the incidence and demographics of human bite injuries in pediatric patients;
however, preschool- and early school-aged children appear to be at greatest risk of sustaining
an injury from a bite by a human. Human bites are a common cause of injury in daycare
centers in the U.S., although in some series the proportion of human bites is highest among
adolescents. In adolescents, fist-to-mouth (tooth) injuries are associated with fights.
CLINICAL MANIFESTATIONS.

Dog biterelated injuries can be divided into three, almost equal categories: abrasions;
puncture wounds; and lacerations, with or without an associated avulsion of tissue. Dog bites
may be crush injuries. The most common type of injury from cat and rat bites is a puncture
wound. Cat bites often penetrate to deep tissue. Human bite injuries are of two types: an
occlusion injury that is incurred when the upper and lower teeth come together on a body part
and, in older children and young adults, a clenched-fist injury that occurs when the injured fist,
usually on the dominant hand, comes in contact with the tooth of another individual.
DIAGNOSIS.

Management of the bite victim should begin with a thorough history and physical examination.
Careful attention should be paid to the circumstances surrounding the bite (e.g., type of animal,
domestic or sylvatic, provoked or unprovoked, location of the attack); a history of drug allergies; and
the immunization status of the child (tetanus) and animal (rabies). During physical examination,
meticulous attention should be paid to the type, size, and depth of the injury; the presence of foreign
material in the wound; the status of underlying structures; and, in instances where the bite is on an
extremity, the range of motion of the affected area. A diagram of the injury
(s) should be recorded in the patient's medical record. A radiograph of the affected part should
be obtained if there is likelihood that a bone or joint could have been penetrated or fractured or
if foreign material is present. The possibility of a fracture or penetrating injury of the skull should
be considered in individuals, particularly infants, who have sustained dog bite injuries to the
face and head.
COMPLICATIONS.

Infection is the most common complication of bite injuries, regardless of the species of biting
animal. The decision to obtain material for culture from a wound depends on the species of the
biting animal, the length of time that has elapsed since the injury, the depth of the wound, the
presence of foreign material contaminating the wound, and whether there is evidence of infection.
Although potentially pathogenic bacteria have been isolated from up to 80% of dog bite wounds that
are brought to medical attention within 8 hr after the bite, the infection rate for wounds receiving
medical attention in <8 hr is small (2.520%). Thus, unless they are deep and extensive, dog bite
wounds that are less than 8 hr old do not need to be cultured unless there is
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Chapter 712 - Animal and Human Bites from Kliegman: Nelson Textbook of Pediatric... Page 3 of 8

evidence of contamination or early signs of infection, or the patient is immunocompromised.

Species of Capnocytophaga canimorsus, uncommon pathogens in bite-inflicted injuries, have
been isolated from nearly 5% of infected wounds in immunocompromised patients. The
infection rate in cat bite wounds that receive early medical attention is at least 50%; therefore,
it is prudent to obtain material for culture from all but the most trivial cat-inflicted wounds and all
other animal bite wounds that are not brought to medical attention within 8 hr, regardless of
species of the biting animal.
The rate of infection after rodent bite injuries is not known. Most of the oral flora of rats is
similar to that of other mammals; however, approximately 50% and 25% of rats harbor strains
of Streptobacillus moniliformis and Spirillum minus, respectively, in their oral flora. Each of
these agents has the potential to cause infection (see Chapter 712.1 ).
All human bite wounds, regardless of the mechanism of injury, should be regarded as carrying
high risk for infection and cultured. Because of the large incidence of anaerobic infection after
bite wounds, it is important to obtain material for anaerobic as well as aerobic cultures.
Common causes of soft tissue bacterial infections after dog, cat, or human bites are noted
in Table 712-2 . High-risk bites for infection include hand, foot, or genital wounds,
penetration of bone or tendons, human or cat bites, delay in treatment >24 hr, presence of
foreign material, immunosuppression (asplenia), and crush or deep puncture wounds.
TABLE 712-2 -- Microorganisms Associated With Mammalian Bite Wound Infections
COMMON

UNCOMMON

DOGS
Mixed infection

Acinetobacter spp.

Pasteurella multocida

Aeromonas hydrophila

Staphylococcus aureus

, , streptococci

Staphylococcus epidermidis Bacteroides spp.

Brucella canis
Capnocytophaga canimorsus (formerly DF-2)
Enterobacter cloacae
Enterococcus spp.
Escherichia coli
Klebsiella spp.
Moraxella spp.
Peptococcus spp.
Peptostreptococcus spp.
Pseudomonas spp.
CATS
P. multocida Acinetobacter spp.
S. aureus

Bacteroides spp.

Corynebacterium spp.
E. cloacae
Fusobacterium spp.
Streptococcus spp.
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S. epidermidis
HUMANS
, , streptococci

Enterococcus spp.

Bacteroides spp.

Eubacterium spp.

Corynebacterium spp.

Klebsiella pneumoniae

Eikenella corrodens

Neisseria spp.

Fusobacterium spp.

Peptococcus spp.

Mixed infection

Pseudomonas spp.

Peptostreptococcus spp.

Veillonella spp.

S. aureus
TREATMENT ( TABLE 712-3 ).

After the appropriate material has been obtained for culture, the wound should be anesthetized,
cleaned, and vigorously irrigated with copious amounts of normal saline. Irrigation with antibioticcontaining solutions provides no advantage over irrigation with saline alone and may cause local
irritation of the tissues. Puncture wounds should be thoroughly cleansed and gently irrigated with a
catheter or blunt-tipped needle; high-pressure irrigation should not be employed. Avulsed or
devitalized tissue should be debrided and any fluctuant areas incised and drained.

TABLE 712-3 -- Prophylactic Management of Human or Animal Bite Wounds to

Prevent Infection
CATEGORY OF MANAGEMENT MANAGEMENT
Cleansing

Sponge away visible dirt. Irrigate with a copious volume of

sterile saline solution by high-pressure syringe irrigation. [*]
Do not irrigate puncture wounds. Standard precautions should
be used.

Wound culture

No for fresh wounds, unless signs of infection exist.

Yes for wounds more than 812 h old and wounds that appear
infected. []
Radiographs Indicated for penetrating injuries overlying bones or joints, for
suspected fracture, or to assess foreign body inoculation.
Remove
g:
Dbridement
devitalized
1 Extensive
wounds
Operative dbridement and exploration
tissue.
(devitalized tissue)
Yes
2 Involvement of the
if
metacarpophalangea
one
l joint (closed fist
of
injury)
the
follo
3 Cranial bites by large
win
animal

Wound closure

Yes for selected fresh, nonpuncture bite wounds (see text)

Assess tetanus immunization

status

Yes

Assess risk of rabies from animal

bites

Yes

Assess risk of hepatitis B virus

Yes

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infection from human bites

Assess risk of human
immunodeficiency virus from
human bites

Yes

Initiate antimicrobial therapy

Yes for:
Moderate or severe bite wounds, especially if edema or
crush injury is present
Puncture wounds, especially if penetration of bone,
tendon sheath, or joint has occurred

Facial bites

Hand and foot bites

Genital area bites

Wounds in immunocompromised and asplenic people

Wounds with signs of infection
Follow-up

Inspect wound for signs of infection within 48 h

From American Academy of Pediatrics. Bite wounds. In: Pickering LK, Baker CJ, Long SS,
McMillan JA, eds.Red Book: 2006 Report of the Committee on Infectious Disease. 27th ed. EIK
Grove Village, IL, AAP, 2006:pp 191195.

1*

Use of 18-gauge needle with a large-volume syringe is effective. Antimicrobial or anti-infective solutions offer no advantage

and may increase tissue irritation.

Both aerobic and anaerobic bacterial culture should be performed.

Much controversy and few data exist to determine whether bite wounds should undergo primary
closure or delayed primary closure (35 days) or should be allowed to heal by secondary
intention. Factors to be considered are the type, size, and depth of the wound; the anatomic
location; the presence of infection; the time interval from the injury; and the potential for
cosmetic disfigurement. Surgical consultation should be obtained for all patients with deep or
extensive wounds; wounds involving the face or bones and joints; and infected wounds that
require open drainage. Although there is general agreement that infected wounds and those
that are >24 hr of age should not be sutured, there is disagreement and varying clinical
experience about the efficacy and safety of closing wounds that are <8 hr of age with no
evidence of infection. Because all hand wounds are at high risk for infection, particularly if
there has been disruption of the tendons or penetration of the bones, delayed primary closure
is recommended for all but the most trivial bite wounds of the hands. Facial lacerations are at
smaller risk for secondary infection because of the more luxuriant blood supply to this region.
Many plastic surgeons advocate primary closure of facial bite wounds that have been brought
to medical attention within 6 hr and have been thoroughly irrigated and debrided.
There are few studies that unequivocally demonstrate the efficacy of antimicrobial agents for
prophylaxis of bite injuries. There is general consensus that antibiotics should be administered
to all victims of human bites and all but the most trivial of dog, cat, and rat bite injuries,
regardless of whether there is evidence of infection. The bacteriology of bite wound infections
is primarily a reflection of the oral flora of the biting animal and, to a lesser extent, a reflection
of the skin flora of the victim (see Table 712-2 ). Because each of the multitudes of aerobic and
anaerobic bacterial species that colonize the oral cavity of the biting animal has the potential to
invade local tissue, multiply, and cause tissue destruction, most bite wound infections are
polymicrobial. Evidence suggests that as many as five different species may be isolated from
infected dog bite wounds.
Despite the large degree of homology in the bacterial flora of the oral cavity among humans,
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dogs, and cats, important differences exist between the biting species, and this is reflected in the
type of wound infections that occur. The predominant bacterial species isolated from infected dog
bite wounds are Staphylococcus aureus (2030%), Pasteurella multocida (2030%),
Staphylococcus intermedius (25%), and C. canimorsus; approximately one half of dog bite
wound infections contain mixed anaerobes. Similar species are isolated from infected cat bite
wounds; however, P. multocida is the predominant species in at least 50% of cat bite wound
infections. At least 50% of rats harbor strains of Streptobacillus moniliformis in their oropharynx,
and approximately 25% harbor S. minor, an aerobic gram-negative organism. In human bite
wounds, non-typable strains of Haemophilus influenzae, Eikenella corrodens, S. aureus, hemolytic streptococci, and -lactamaseproducing aerobes (about 50%) are the predominant
species. Clenched fist injuries are particularly prone to infection by Eikenella spp. (25%) and
anaerobic bacteria (50%).
The choice between an oral and parenteral antimicrobial agent should be based on the severity of
the wound, the presence and degree of overt infection, signs of systemic toxicity, and the patient's
immune status. Amoxicillin-clavulanate is an excellent choice for empirical oral therapy for human
and animal bite wounds because of its activity against most of the strains of bacteria that have been
isolated from infected bite injuries. Similarly, ticarcillin-clavulanate or ampicillin and sulbactam are
preferred for patients who require empirical parenteral therapy. Procaine penicillin remains the drug
of choice for prophylaxis and treatment of rat-inflicted injuries. First-generation cephalosporins have
limited activity against P. multocida and E. corrodens and, therefore, should not be used for
prophylaxis or empirical initial therapy of bite wound infections. The therapeutic alternatives for
penicillin-allergic patients are limited, because the traditional alternative agents are generally
inactive against one or more of the multiple pathogens that cause bite wound infections. Although
erythromycin is commonly recommended as an alternative agent for penicillin-allergic patients who
have suffered dog and cat bites, it has incomplete activity against strains of P. multocida and S.
moniliformis and is not effective against E. corrodens. Similarly, clindamycin and the combination
trimethoprim-sulfamethoxazole have limited activity against strains of P. multocida and anaerobic
bacteria, respectively. Azithromycin and the ketolide antibiotics may be considered because they
have activity against aerobic and anaerobic bacteria that are present in infected bite wounds.
Tetracycline is the drug of choice for penicillin-allergic patients who have sustained rat bite injuries.
Although tetanus occurs only rarely after human or animal bite injuries, it is important to obtain a
careful immunization history and to provide tetanus toxoid to all patients who are incompletely
immunized or those in whom it has been longer than 10 yr since their last immunization. The need
for postexposure rabies vaccine in victims of dog and cat bites depends on whether the biting
animal is known to have been vaccinated and, most importantly, on local experience with rabid
animals in the community (see Chapter 271 ). The local health department should be consulted for
advice in all instances where the vaccination status of the biting animal is unknown and if there is
known endemic rabies in the community. Postexposure prophylaxis for hepatitis B should be
considered in the rare instance in which an individual has sustained a human bite from an
individual who is at high risk for hepatitis B (see Chapter 355 ).

All but the most trivial bite wounds of the hand should be immobilized in position of function for
3 5 days, and patients with bite wounds of an extremity should be instructed to keep the
affected extremity elevated for 2436 hr or until the edema has resolved. All bite wound victims
should be re-evaluated within 2436 hr after the injury.
PREVENTION.

It is possible to reduce the risk of injury with anticipatory guidance. Parents should be routinely
counseled during prenatal visits and routine health maintenance examinations about the risks of
having potentially biting pets in the household. All patients should be cautioned against harboring
exotic animals for pets. Additionally, parents should be made aware of the proclivity of certain
breeds of dogs to inflict serious injuries and the protective instincts of nursing dams. All young
children should be closely supervised, particularly when in the presence of animals and, from a
very early age, taught to respect animals and to be aware of their potential to inflict injury (Tables
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Chapter 712 - Animal and Human Bites from Kliegman: Nelson Textbook of Pediatric... Page 7 of 8

712-4 and 712-5 [4] [5]).

TABLE 712-4 -- Code of Behavior When Handling a Dog
DOGSHUMANS
dog, let it sniff
you.
be
Do not run
dog.
past dogs.
ha
Remain calm
vio
if a dog
Do not try to
approaches.
r.
outrun a
contact.
dence. eye
Avoid
interpreted as
Direct contact
may be
direct eye aggression.
ng anythi
If
together) and attacked and cover the
do ng
ears with the
attac protect neck while
gs that is
lying,
hands. Do not
ked, and face with
bit near.
keep
move.
stan arms and
e
face
d still hands.
Do not try to
at
down
stop 2 fighting
(feet Stand up. If
dogs.
a
a
rin
a
i
dencies).
b
g
nf
6 Never
c
o
a
d
a
leave
h
u
do
o
nt
infants or
i
t
g.
young
g
or
children
l
to
4 Sp
alone with
d
a
o
d
en
any dog.
r
dl
d
i
d
7 Properly
er
tim
s
o
socializ
p
.
e
g
u
e and
wit
5 Sp
f
p
train
ay/
h a
e
a
ne
p
any dog
do
a
n
ute
y
entering
g
r
r
d
the
bef
virt
f
,
i
ore
househ
ual
u
n
bu
old.
ly
l
i
t
yin
all
Teach
f
o
do
g
the dog
o
gs
or
submiss
r
s
(thi
t
ad
ive
o
s
h
opt
behavio
fre
a
,
e
ing
rs (e.g.,
qu
p
it.
ent
rolling
p
d
h
Us
ly
over to
r
e
o
re
e
expose
e
l
du
m
ca
h
a
abdome
ce
e
uti
e
y
n and
s
on
n
ag
relinquis
o
wh
gr
s
a
hing
f
en
es
i
c
food
bri
siv
v
q
without
a
e
ngi
e
u
growling
ten
n
ng
i

Dogs sniff as a means of communication.

Dogs like to chase moving objects.

Dogs run faster than humans.

Screaming may incite predatory
The order of precedence needs in
to be Do not hug or kiss a dog. evi
Dogs tend to attack
extremities, face, and
neck.
Lying on the
ground provokes
attacks.
From Schalamon J, ori
st,
Ainoedhofer H,
or
Singer G, et al:
res
Analysis of dog
po
bites in children
who are younger nsi
ble
than 17 years.
bre
Pediatrics
ed
2006;117:e374
er)
e379.
to
det
er
mi
TABLE 712-5 -ne
Measures for
Preventing Dog sui
Bites
tab
le
bre
1 Realist
ed
ically
s
evalua
of
te
do
enviro
gs
nment
for
and
co
lifestyl
nsi
e and
der
consult
ati
with a
on.
profes
sional
Do
(e.g.,
gs
veterin
wit
arian,
h
animal
his
behavi
tori

F
i
g
h
t
i
es
of
ag
gr
es
si
on
ar
e
in
ap
pr
op
ria
te
in
ho
us
eh
ol
ds
wit
h
ch
ild
re
n.

3 Be
se
ns
itiv
e
to
cu
es
th
at

Before
petting a

).

8 Imm
ediat
ely
seek
profe
ssion
al
advic
e
(e.g.,
from
veteri
naria

ns,
ani
ma
l
be
ha
vio
rist
s,
or
res
po
nsi
ble

br
ee
de
rs)
if
th
e
do
g
de
ve
lo
ps
ag

g
r
e
s
s
i
v
e

d
e
s
i
r
a
b
l
e

vi
or
s.

9 Do

wr
es
tli
ng
).

y
ar
ou
nd
do
gs
an
d
rev
ie
w
re
gul
arl
y:

not
play10 Te
agg
ac
ress
h

ive
ch
gam
ild
o
es
re
r
b
with
n
e
your
ba
u
h
dog
sic
n
a
(e.g
sa
.,
fet
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Nev
er
appr
oac
h an
unfa
mili
ar
dog.
Nev
er
run
from
a
dog
and
scre
am.

Chapter 712 - Animal and Human Bites from Kliegman: Nelson Textbook of Pediatric... Page 8 of 8
e still like a tree).

R
e
m
a
i
n
m
o
t
i
o
n
l
e
s
s
w
h
e
n
a
p
p
r
o
a
c
h
e
d
b
y
a
n
u
n
f
a
m
i
l
i
a
r
d
o
g
(
e
.
g
.
,


If knocked over by
a dog, roll into a
ball and lie still
(e.g.,be still like a
log).

Never play with a

dog unless
supervised by an
adult.

Immediately report
stray dogs or dogs
displaying unusual

behavior to an
adult.

Do not pet a MMWR 1997;46: 463467.

dog without
allowing it to
see and sniff

Reduction of human bite

you first.
Avoid direct
injuries, particularly in daycare
eye contact
centers and schools, can be
with a dog.
If bitten,
immediately achieved by good surveillance

report the
of the children and adequate
Do not disturb
bite to an
supervisory personnel-to-child
a dog who is
adult.
sleeping,
ratios.
eating, or
Fromfor
Centers for Disease
caring
puppies.
Control and Prevention:
Copyright 2008 Elsevier Inc. All rights
Dog biterelated fatalities
United States, 1995 1996.
reserved. - www.mdconsult.com

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