Treatment

Management of bite wounds is the same as for any other wound: good wound care in the form of adequate irrigation and debridement of nonviable tissue as needed (Table 16-19). Bite wounds in general do not require primary closure, but after adequate irrigation and debridement, wounds may be approximated and closed by delayed primary or secondary intention. An exception to this rule may include bite wounds to the face. General wound management measures such as tetanus toxoid administration should also be employed. Bite wounds involving the hands should be evaluated by a hand surgeon, given the risk of adjacent tendon sheath, bone, or joint involvement and the dire consequences if such structures are involved.

The transmission of rabies through the bites of domestic pets in the United States and developed countries is rare. In fact, the dog strain of rabies is considered eliminated in the U.S. dog population, and cat bites are often managed through observation of the animal, without the immediate need for rabies postexposure treatment (PET). However, wild mammal exposure, especially bat, skunk, or raccoon, often warrants PET, which involves thorough cleaning of the bite wound, ideally with povidone-iodine solution, along with rabies immune globulin given at the wound site and rabies vaccine given on days 0, 3, 7, and 14.

Bite wounds should be considered contaminated wounds from presentation, given the oral microbial flora of humans and animals, and most patients should probably receive antibiotics early. Empiric antibiotics are used to eradicate oral flora inoculated from the mouth of the biter, whether human or animal, into the wound. All moderate to severe animal bite wounds, or wounds that have an associated crush injury or that are close to a bone or joint, should be considered contaminated with potential pathogens, and these patients should receive 3 to 5 days of "prophylactic" antimicrobial therapy. Gram stains with culture of bite wounds are specific but not sensitive indicators of bacterial growth. Nonetheless, Gram stain can be used to help guide initial empiric antibiotic therapy.

Amoxicillin-clavulanic acid (amoxicillin-clavulanate; Augmentin) or penicillin plus a penicillinase-resistant penicillin are normally first-line agents for empiric therapy directed at bite wounds. First-generation cephalosporins (e.g., cephalexin) are not effective as monotherapy because of resistance of some anaerobic bacteria and E. corrodens. A 5- to 10-day course of antibiotics is usually adequate for infections limited to the soft tissue, and a minimum of 3 weeks of therapy is required for infections involving joints or bones. Close follow-up is required in all bites to ensure adequate healing.

Of special consideration in human bite wounds is the potential for spread of viral pathogens, most notably hepatitis

B virus (HBV) and HIV, if the source person is positive. HBV exposure in this setting should be handled in the same manner as other exposures, with administration of HBIG and HBV vaccination. With regard to HIV, CDC guidelines for managing nonoccupational HIV exposure recommend handling each case individually in consultation with an infectious diseases specialist.

KEY TREATMENT

Use of antibiotic prophylactic after bites of the hand reduces the incidence of infection (Medeiros and Saconato, 2005) (SOR: B). Antibiotic prophylaxis after bites by humans reduces incidence of infection (SOR: C).

BONE AND JOINT INFECTIONS

Anthony Zeimet Key Points

• The diagnosis of osteomyelitis is based on radiographic findings (plain radiograph or MRI) showing bony destruction along with histologic analysis and culture results.

• Chronic osteomyelitis is not an emergency, and antibiotics can be safely withheld until an etiologic diagnosis is established.

• Diabetic foot infections require a careful evaluation to assess perfusion and vascular supply, and corrective measures should be undertaken to reestablish adequate perfusion if necessary.

• In diabetic foot ulcers, if one can probe to bone, the patient most likely has osteomyelitis.

• Orthopedic hardware infections are best managed in conjunction with an infectious diseases specialist and orthopedic surgeon.

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