Taking the Bite out of Dog ma

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1 Taking the Bite out of Dog ma Dr. Michael Woo MD, CCFP(EM), RDMS Director, Emergency Medicine Ultrasonography Associate Professor, Department of Emergency Medicine Ultrasound uottawa DEM 25 May 2013

2 ACKNOWLEDGEMENTS Dr. Philippe Rola

3 None DISCLOSURE

4 OBJECTIVES Review controversies with management of dog and cat bites Review the safety of cephalosporin antibiotics in penicillin "allergic" patients Review the utility of antibiotics for cutaneous abscesses

5 CASE 50 yo female gets cat bite

6 CAT BITES Types 56% punctures 25% abrasions 17% lacerations Location 2/3 upper arm/hand

7 BUGS CAT BITES P. multocida 57-75% Streptococcus 46% Staphylococcus 35% Anaerobes 65% Usually appear within 3-24 hours after bite

8 CASE 6 year old male present with a dog bite

9 DOG BITES Pediatrics 50-70% Head and Neck Adults Extremities

10 BUGS DOG BITES Polymicrobial P. canis Strep Staph Opportunistic Capnocytophaga canimorsus Medeiros IM, Saconato H. Antibiotic prophylaxis for mammalian bites. Cochrane Database of Systematic Reviews 2001, Issue 2 Art. No.:CD

12 BACK TO THE CASES. Bites are on the arm Does not look infected Presents at 6 hours? Presents at 26 hours? Does it matter cat or dog? Does the location of the bite matter?

13 PROPHYLACTIC ANTIBIOTICS? Yes Hand bites NNT=4 < 24 hours (Cats only) Primary closure Asplenic/Immunocompromised No > 24 hours Henton J, Jain A. Cochrane corner: antibiotic prophylaxis for mammalian bites (intervention review). J Hand Surg Eur. 2012; 37(8):804-6) Medeiros IM, Saconato H. Antibiotic prophylaxis for mammalian bites. Cochrane Database of Systematic Reviews 2001, Issue 2 Art. No.:CD

14 ANTIBIOTIC CHOICES Amoxicillin/Clavulinic Acid Clindamycin + (Cipro or Cotrimoxazole or Doxycycline) Cefuroxime

15 PRIMARY WOUND CLOSURE?

16 PRIMARY WOUND CLOSURE? Primary closure < 24 hours Facial lacerations Beware Hands Wounds > 10 hours Morgan M. Dog bites. BMJ. 2007; 334:413. Maimaris C, Quinton DN. Dog-bite lacerations: a controlled trial of primary wound closure. Arch Emerg Med. 1988; 5(3); Callaham M. Dog bite wounds. JAMA Nov 21; 244(20):2327-8

17 CASE 18 yo male dog bite to hand Allergic to penicillin What antibiotic?

18 10% of patients who are allergic to penicillin will have an adverse reaction to cephalosporins Dash CH. Penicillin allergy and the cephalosporins. J Antimicrob Chemother. 1975;1:Suppl:107-18

19 Incidence of true penicillin allergy is less than 10% Serious allergic reactions to cephalosporins is 0.02% History of penicillin allergy increases this 2-4 times Surtees SJ, Stockton MG, Gietzen TW. Allergy to penicillin: fable or fact? BMJ 1991;302: Kelkar PS and Li JTC. Cephalosporin allergy. N Engl J Med. 2001:345(11);

20 Anne S, Reisman RE. Risk of administering cephalosporin antibiotics to patients with histories of penicillin allergy. Ann Allergy Asthma Immunol 1995;74: Campagna JD et al. The use of cephalosporins in penicllin-allergic patients: a literature review. J Emerg Med. 2012; 42(5): Hebert ME et al. Ten percent of patients who are allergic to penicillin will have serious reactions if exposed to cephalosporins. West J Med. 2000; 172(5)341. History of true penicillin allergy Increases serious reaction 3 times regardless of antibiotic Cross reaction to 3 rd and 4 th generation cephalosporins approaches 0%

21 What antibiotic are you going to give?

22 CASE 18 yo male dog bite to hand Patient has now returned with an abscess.

23 ANTIBIOTICS POST I&D? No even in MRSA What we need more answers to Overlying cellulitis? Multiple co-morbidities Immunocompromised Hankin A, Everett WW. Are antibiotics necessary after incision and drainage of a cutaneous abscess? Ann Emerg Med (1);

24 BONUS! Is their a role for ultrasound guided needle aspiration in abscess management?

25 IS THIS DOGMA? Non blinded Treatment failure 74% vs. 20% for I&D MRSA did worse in both groups Gaspari RJ et al. A randomized controlled trial of incision and drainage versus ultrasonographically guided needle aspiration for skin abscesses and the effect of MRSA. Ann Emerg Med 2011; 47:

26 MORE QUESTIONS? How do you define treatment failure? Patient comfort? Are there some abscesses that might respond to USG Needle aspiration? Sonographic features Squish sign Septations Elastography? Antibiotics?

27 OBJECTIVES Review controversies with management of dog and cat bites Review the safety of cephalosporin antibiotics in penicillin "allergic" patients Review the utility of antibiotics for cutaneous abscesses

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