Animal Bite Infections

Animal Bite Infections

 

Definition

The most common problem following an animal bite is simple infection. The saliva of dogs, cats, ferrets, and rabbits is known to contain a wide variety of bacteria. According to one recent study, bacteria or other pathogens show up in about 85 percent of bites. When an animal bites, it can then transmit pathogens into the wound. These microorganisms may grow within the wound and cause an 2infection. The consequences of infection range from mild discomfort to life-threatening complications.

Description

Two to 4.5 million animal bites occur each year in the United States; about 1% of these bites require hospitalization. Animal bites result in 334,000 emergency room visits per year, which represents approximately 1% of all emergency hospital visits, at an annual cost of $100 million dollars in health care expenses and lost income. Children are the most frequent victims of dog bites, with 5-9 year-old boys having the highest incidence. Men are more often bitten by dogs than are women (3:1), whereas women are more often bitten by cats (3:1).
Dog bites make up 80-85% of all reported incidents. Cats account for about 10% of reported bites, and other animals (including hamsters, ferrets, rabbits, horses, raccoons, bats, skunks, and monkeys) make up the remaining 5-10%. Cat bites become infected more frequently than dog bites. A dog's mouth is rich in bacteria, but only 15-20% of dog bites become infected. In contrast, approximately 30-50% of cat bites become infected.
Many factors contribute to the infection rates, including the type of wound inflicted, the location of the wound, pre-existing health conditions in the bitten person, the extent of delay before treatment, patient compliance and the presence of a foreign body in the wound. Dogs usually inflict crush injuries because they have rounded teeth and strong jaws; thus, the bite of an adult dog can exert up to 200 pounds per square inch of pressure. This pressure usually results in a crushing injury, causing damage to such deep structures as bones, blood vessels, tendons, muscles, and nerves. The canine teeth in a dog's mouth are also sharp and strong, often inflicting lacerations. Cats, with their needle-like incisors and carnassial teeth, typically cause puncture wounds. Puncture wounds appear innocuous on the surface, but the underlying injury goes deep. Cat teeth essentially inject bacteria into the bite, and the deep, narrow wound is difficult to clean. Persons with impaired immunocompetence—for example, individuals with HIV infection—are especially vulnerable to infection from cat bites. Lastly, bites or stings from marine creatures (sharks, rays, eels, etc.) require immediate medical attention as these bites may contain disease organisms unique to the ocean environment as well as causing severe loss of blood.
The bacterial species most commonly found in bite wounds include Pasteurella multocida, Staphylococcus aureus, Pseudomonas sp, and Streptococcus sp. P. multocida, the root cause of pasteurellosis, is especially prominent in cat bite infections. Other infectious diseases from animal bites include cat-scratch disease, tetanus and rabies.
Doctors are increasingly aware of the importance of checking animal bite wounds for anaerobic organisms, which are microbes that can live and multiply in the absence of air or oxygen. A study published in 2003 reported that about two-thirds of animal bite wounds contain anaerobes. These organisms can produce such complications as septic arthritis, tenosynovitis, meningitis, and infections of the lymphatic system.

Key terms

Anaerobic — Referring to an organism that can live in the absence of air or oxygen. About two-thirds of animal bites are found to contain anaerobic disease-producing organisms.
Canines — The two sharp teeth located next to the front incisor teeth in mammals that are used to grip and tear.
Carnassials — The last upper premolar teeth in the mouths of cats and other carnivores, adapted to shear or puncture food. Carnassial teeth often cause puncture wounds when a cat bites a human.
Culture — A laboratory procedure in which a sample from a wound, the blood or other body fluid is taken from an infected person. The sample is placed in conditions under which bacteria can grow. If bacteria grow, identification tests are done to determine the bacteria species causing the infection.
Immunocompetence — An individual's ability to fight off infection.
Microorganisms — Microscopic organisms, such as bacteria, viruses, algae and fungi.
Pasteurellosis — A bacterial infection caused by Pasteurella multocida. Pasteurellosis is characterized by inflammation around the wound site and may be accompanied by bacteria in the bloodstream and infection in tissues and organs.
Pathogen — Any disease-producing microorganism.
Postexposure prophylaxis (PEP) — Any treatment given after exposure to a disease to try to prevent the disease from occurring. In the case of rabies, PEP involves a series of vaccines given to an individual who has been bitten by an unknown animal or one that is potentially infected with the rabies virus.
Tenosynovitis — Inflammation of the sheath of tissue that surrounds a tendon. Tenosynovitis is a common complication of animal bites containing anaerobic bacteria.
Zoonosis (plural, zoonoses) — Any disease of animals that can be transmitted to humans. Rabies is an example of a zoonosis.
With regard to the most common types of domestic pets, it is useful to note that biting and other aggressive behavior has different causes in dogs and cats. To some extent these differences are rooted in divergent evolutionary pathways, but they have also been influenced by human interference through selective breeding. Dogs were first domesticated by humans as early as 10,000 B.C. for hunting and as guard or attack dogs. Many species travel in packs or groups in the wild, and many human fatalities resulting from dog bites involve a large group of dogs attacking one or two persons. In addition, dogs typically relate to humans according to a hierarchical model of dominance and submission, and many of the techniques of dog training are intended to teach the dog to respect human authority. Certain breeds of dogs are much more likely to attack humans than others; those most often involved in fatal attacks are pit bulls, Rottweilers, German shepherds, huskies, and mastiffs. According to the Centers for Disease Control (CDC), there are between 15 and 20 fatal dog attacks on humans in the United States each year. There are several assessment or evaluation scales that veterinarians or animal trainers can use to score individual or mixed-breed dogs for dominant or aggressive behavior.
Unlike dogs, cats were not domesticated until about 3000 B.C., and were important to ancient civilizations as rodent catchers and household companions rather than as protectors or hunters of wild game. Biologists classify cats as solitary predators rather than as pack or herd animals; as a result, cats do not relate to humans as authority figures in the same way that dogs do, and they do not form groups that attack humans when threatened or provoked. In addition, domestic cats have been selectively bred for appearance rather than for fierceness or aggression. Most cat bites are the result of fear on the cat's part (as when being placed in a carrier for a trip to the vet) or a phenomenon known as petting-induced aggression. Petting-induced aggression is a behavior in which a cat that has been apparently enjoying contact with a human suddenly turns on the human and bites. This behavior appears to be more common in cats that had no contact with humans during their first seven weeks of life. In other cats, this type of aggression appears to be related to a hypersensitive nervous system; petting or cuddling that was pleasurable to the cat for a few seconds or minutes becomes irritating, and the cat bites as a way of indicating that it has had enough. In older cats, petting-induced aggression is often a sign that the cat feels pain from touching or pressure on arthritic joints in its neck or back.

Causes and symptoms

The most common sign of infection from an animal bite is inflammation. The skin around the wound is red and feels warm, and the wound may exude pus. Nearby lymph glands may be swollen. Complications can arise if the infection is not treated and spreads into deeper structures or into the bloodstream. If the bite is deep or occurs on the hand or at a joint, complications are more likely.
Live disease-causing bacteria within the bloodstream and tissues cause complications far from the wound site. Such complications include meningitis, brain abscesses, pneumonia and lung abscesses, and heart infections, among others. These complications can be fatal. Deep bites or bites near joints can damage joints and bones, causing inflammation of the bone and bone marrow or septic arthritis.
Cat-scratch disease is caused by Bartonella henselae, a bacterium that is carried in cat saliva; infection may be transmitted by a bite or scratch. Approximately 22,000 cases are reported each year in the United States; worldwide, nine out of every 100,000 individuals become infected. More than 80% of reported cases occur in persons under the age of 21. The disease is not normally severe in individuals with healthy immune systems. Symptoms may become serious, however, in immunocompromised individuals, such as those with acquired immune deficiency syndrome (AIDS) or those undergoing chemotherapy. Common symptoms include an inflamed sore in the area of the bite or scratch, swollen lymph nodes, fever, fatigue, and rash.
Rabies is caused by a virus that is transmitted through the bite of an animal that is already infected. It is classified as a zoonosis, which is a term that refers to any disease of animals that can be transmitted to humans. More than 90% of animal rabies cases occur in such wild animals as skunks, bats, and raccoons, with such domestic animals as dogs and cats accounting for fewer than 10% of cases. The World Health Organization (WHO) estimates that between 35,000 and 50,000 individuals worldwide die each year as a result of rabies. The highest incidence of rabies occurs in Asia where, in 1997, over 33,000 deaths were noted, most occurring in India. Rabies is nowadays rare in the United States, as a result of good animal control practices. Onset is delayed, usually weeks to months after the person has been bitten. Early symptoms of rabies include fever, headache, and flu-like symptoms. These progress to anxiety, hallucinations, muscle spasms, partial paralysis, fear of water (hydrophobia), and other neurological symptoms as the virus spreads to the central nervous system. Medical treatment must be sought soon after exposure because death invariably follows once the infection becomes established.
Most deaths from rabies in the United States result from bat bites; the most recent victim was a 66-year-old man in California who died in September 2003 after failing to report a bat bite.

Diagnosis

A medical examination involves taking the history of the injury and assessing the wound type and damage. Tetanus immunization and general health status are checked. An x ray may be ordered to assess bone damage and to check for foreign objects in the wound. Wound cultures are done for infected bites if the victim is at high risk for complications or if the infection does not respond to treatment. Evaluation of possible exposure to rabies is also important. A biting animal suspected of having rabies is usually apprehended, tested, and observed for a period of time for evidence of pre-existing infection.

Treatment

Treatment depends on the wound type, its site, and risk factors for infection. All wounds are cleaned and disinfected as thoroughly as possible. Bites to the head and face usually receive sutures, as do severe lacerations elsewhere. Puncture wounds are left open. If abscess formation occurs, the physician may perform an incision so as to drain the abscess.
If infection occurs, antibiotics are prescribed. Antibiotics may also be used for infection prevention. Since a single bite wound may contain many different types of bacteria, no single antibiotic is always effective. Commonly prescribed antibiotics are penicillin or a combination of amoxicillin and clavulanate potassium. Aztreonam has been reported to be effective in treating infections caused by P. multocida.
Because rabies is caused by a virus, antibiotics are not effective. In addition, as of 2003, there is no known cure for the disease once symptoms become apparent. It is therefore recommended that individuals with a high risk of contracting the disease (veterinarians, animal handlers, some laboratory workers) receive preexposure vaccination. Individuals bitten by an unknown or potentially rapid animal should receive postexposure vaccination, also called postexposure prophylaxis (PEP). The PEP regimen consists of one dose of vaccine given at the initial visit as well as one dose of human immune globulin. Additional doses of vaccine are given on days 3, 7, 14, and 28.

Prognosis

Once a bacterial infection is halted, the bite victim usually recovers fully. There is no known cure for rabies once symptoms become evident and death is almost certain. WHO reports that 114 rabies deaths occurred in the Americas in 1997, with only four deaths occurring that year in the United States, thus emphasizing the importance of good animal control practice and postexposure prophylaxis.

Prevention

Preventing bites obviously prevents subsequent infections. With regard to domestic pets, parents should inform themselves about the aggression level and other characteristics of a particular breed before bringing a purebred pet dog into the family, and consider having a specific dog evaluated by a veterinarian or animal behaviorist before adopting it. In addition, parents should make sure that the dog has been neutered or spayed, since intact dogs of either sex are more likely to bite than those that have been altered. Cat bites can often be prevented by learning about a cat's body language and recognizing the signs of petting-induced aggression. These include dilating pupils, a low growl, stiffening of the body, twitching of the tail, and flattening the ears backward against the head.
Children under 12 years of age are at a higher risk for bites due to their small size and their inexperience with animals; therefore, they should be supervised with animals and taught to act appropriately around them. In particular, children should be taught not to tease a dog by pulling its fur or tail; to leave a dog alone while it is eating; and to avoid running or screaming in the presence of a dog, as the animal is more likely to chase a moving object. Direct eye contact with a threatening dog should be avoided, as the dog may interpret that as aggression. It is best to stand still if at all possible, with feet together and arms against the chest; most dogs will lose interest in an object that is not moving, and will eventually go away.
A wild animal that is unusually aggressive or behaving strangely (e.g. a raccoon or bat that is active during the daytime or is physically uncoordinated) should be avoided and reported to the local animal control authorities; it may be infected with the rabies virus. Wild animals should not be taken in as pets, and garbage or pet food that might attract wild animals should not be left outside the home or camp site. People should also avoid trying to break up fights between animals and should as a rule approach unknown cats and dogs very cautiously, especially on their territory. Finally, animals should not be trained to fight.
Domestic pets should be vaccinated against rabies; people should consult a veterinarian for advice about the frequency of booster vaccinations for the area in which they live. In addition, people who are traveling to countries where rabies is endemic should consider vaccination before leaving the United States.

Resources

Books

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Central Nervous System Viral Diseases: Rabies (Hydrophobia)." Section 13, Chapter 162 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 1999.
Beers, Mark H., MD, and Robert Berkow, MD., editors. "Infections of Bones and Joints." Section 5, Chapter 54 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 1999.
Dodman, Nicholas H., DVM. If Only They Could Speak: Stories About Pets and Their People. New York and London: W. W. Norton and Company, 2002. Contains several useful appendices about aggression in various dog breeds and a sample assessment form for evaluating a dog's potential for biting.
Garvey, Michael S., DVM, Ann E. Hohenhaus, DVM, Katherine A. Houpt, VMD, PhD, et al. The Veterinarians' Guide to Your Cat's Symptoms. New York: Villard, 1999.

Periodicals

Brook, I. "Microbiology and Management of Human and Animal Bite Wound Infections." Primary Care 30 (March 2003): 25-39.
Fooks, A. R., N. Johnson, S. M. Brookes, et al. "Risk Factors Associated with Travel to Rabies Endemic Countries." Journal of Applied Microbiology 94, Supplement (2003): 31S-36S.
Garcia Triana, M., M. A. Fernandez Echevarria, R. L. Alvaro, et al. "Pasteurella multocida Tenosynovitis of the Hand: Sonographic Findings." Journal of Clinical Ultrasound 31 (March-April 2003): 159-162.
"Human Death Associated with Bat Rabies—California, 2003." Morbidity and Mortality Weekly Report 53 (January 23, 2004): 33-35.
Le Moal, G., C. Landron, G. Grollier, et al. "Meningitis Due to Capnocytophaga canimorsus After Receipt of a Dog Bite: Case Report and Review of the Literature." Clinical Infectious Diseases 36 (February 1, 2003): 42-46.
Messenger, S. L., J. S. Smith, L. A. Orciari, et al. "Emerging Pattern of Rabies Deaths and Increased Viral Infectivity." Emerging Infectious Diseases 9 (February 2003): 151-154.
Perkins, R. A., and S. S. Morgan. "Poisoning, Envenomation, and Trauma from Marine Creatures." American Family Physician 69 (February 15, 2004): 885-890.
Sacks, Jeffrey J., MD, MPH, Leslie Sinclair, DVM, Julie Gilchrist, MD, et al. "Special Report: Breeds of Dogs Involved in Fatal Human Attacks in the United States Between 1979 and 1998." Journal of the American Veterinary Medical Association 217 (September 15, 2000): 836-840.
Weiss, R. A. "Cross-Species Infections." Current Topics in Microbiology and Immunology 278 (2003): 47-71.
Winner, J. S., C. A. Gentry, L. J. Machado, and P. Cornea. "Aztreonam Treatment of Pasteurella multocida Cellulitis and Bacteremia." Annals of Pharmacotherapy 37 (March 2003): 392-394.

Organizations

American Academy of Emergency Medicine (AAEM). 555 East Wells Street, Suite 1100, Milwaukee, WI 53202. (800) 884-2236. Fax: (414) 276-3349. http://www.aaem.org.
American Veterinary Medical Association (AVMA). 1931 North Meacham Road, Suite 100, Schaumburg, IL 60173-4360. http://www.avma.org.
Centers for Disease Control and Prevention. 1600 Clifton Rd., NE, Atlanta, GA 30333. (800) 311-3435, (404) 639-3311. http://www.cdc.gov.

Other

National Association of State Public Health Veterinarians, Inc. "Compendium of Animal Rabies Prevention and Control, 2003." Morbidity and Mortality Weekly Report Recommendations and Reports 52 (March 21, 2003) (RR-5): 1-6.
"Rabies Situation and Trends." Paris: World Health Organization. 2001. http://www.who.int/emc/diseases/zoo/rabies.html.