Expert Review of Anti-infective Therapy

ISSN: 1478-7210 (Print) 1744-8336 (Online) Journal homepage: http://www.tandfonline.com/loi/ierz20

Animal bite-associated infections: microbiology

and treatment

Nicole Thomas & Itzhak Brook

To cite this article: Nicole Thomas & Itzhak Brook (2011) Animal bite-associated infections:
microbiology and treatment, Expert Review of Anti-infective Therapy, 9:2, 215-226, DOI: 10.1586/
eri.10.162

To link to this article: http://dx.doi.org/10.1586/eri.10.162

Published online: 10 Jan 2014.

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Nicole Thomas1 and
Downloaded by [Australian Catholic University] at 11:12 08 October 2017
Itzhak Brook†2
1
USAF, Fellow Pediatric Infectious
Diseases, National Capitol Consortium
4301 Jones Bridge Road, Bethesda,
MD 20814, USA
2
Department of Pediatrics,
Georgetown University School of
Medicine, Washington, DC, USA
†
Author for correspondence:
Tel.: +1 202 744 8211
Fax: +1 612 233 0806
ib6@georgetown.edu ss
www.expert-reviews.com
Review
Animal bite-associated
infections: microbiology
and treatment
Expert Rev. Anti Infect. Ther. 9(1), 215–226 (2011)
Human and animal bites may lead to serious infection. The organisms involved tend to originate
from the oral cavity of the offending biter, as well as the environment where the injury occurred.
A variety of aerobic as well as anaerobic organisms have been isolated from bite wounds, with
infection ranging from localized cellulitis to systemic dissemination, leading to severe disease
ranging from abscess to bone and joint infection, to endocarditis and brain abscess. Immediate
wound management, including recognition of the most commonly associated infectious
pathogens, and judicious use of empiric antibiotics are crucial in providing the best care after
a bite. Here, we discuss the common animal bite associated infections, and provide the most
up to date information regarding their management.
Keywords : antibiotics • bite • cats • dogs • human
Adults and children frequently interact with drainage, but generally begin to improve within
animals, and are subsequently at risk of being 2 days of the bite. Further swelling, erythema,
bitten. Animal bites are a public health issue, red streaking (lymphangitis) and warmth as well
with up to 2% of the population being bitten as local lymphadenopathy are indicators of a pro-
each year. The majority of these are due to dogs, gressive infection. Fever is often a late finding,
with up to 4.7 million Americans sustaining as is purulent drainage.
injury and approximately 800,000 requiring The hand is the most likely site to develop infec-
some form of medical care each year [201] . In tion and long-term disability. It is reported that
addition to severe injury, there is a potential risk up to 40% of hand bites become infected [3] .This
of infection. This risk differs among various ani- is due to the complex anatomy and superficial
mal species, and is dependent on the type of bite location of the bones, joints and tendons.
as well as the pathogenicity of the animal’s oral Bite wounds may develop into deeper-seated
flora. Infecting organisms may also arise from infections, and may disseminate systemically.
human skin or the environment. In addition to bite location and depth, host
Multiple studies have evaluated the broad factors such as immunodeficiency or immuno-
range of pathogens isolated from various human compromised status, diabetes, peripheral vas-
and animal bite infections. In addition to well- cular disease and alcohol abuse may contribute
recognized aerobic organisms, improved methods to complications such as soft tissue or muscle
of collection and identification have increased abscesses, osteomyelitis, septic arthritis, teno­
the recovery of anaerobic organisms, and have synovitis, bacteremia/sepsis, endocarditis and
illustrated their importance in bite wound infec- even intracranial abscess [4,5] .
tions [1,2] . This article will discuss the pathogens
associated with human and animal bite wound Human bites
infection and their management. Although human bites are the third most com-
mon bite injury, after those inflicted by dogs
Clinical findings/infectious complications and cats, they are clinically very important.
Clinical signs for development of bite-associated These wounds can range in severity, with the
infection may be subtle, with increased pain mechanism of injury ranging from intentionally
and tenderness around the wound as the first inflicted bites to any injury due to contact with
indication. Injuries may initially have edema, the teeth. Examples include closed fist injury
erythema, ecchymosis and even serosanguinous during a fight, accidental bite due to collision
10.1586/ERI.10.162 ISSN 1478-7210 215
 Review Thomas & Brook
contact with resultant laceration, or injury to the nail bed with
resultant paronychia. Children who sustain a bite injury from an
adult (i.e., bite mark with intercanine distance >3 cm) should be
evaluated for abuse [6] . Puncture wounds from punching (i.e.,
clenched fist injury) may lead to fractures of the third meta-
carpal and/or neck of the fifth metacarpal. If not adequately
addressed, osteomyelitis or joint infection may develop and result
in loss of function [7] . Injury to the common extensor tendons
that cover the joint may separate, allowing bacterial entry into
the joint space. When the clenched fist is relaxed, the tendons
may carry bacteria deeper into the hand, extending infection to
other spaces [8] .
Human bites tend to have a higher complication and infection
rate than animal bites, with approximately 10–15% of human
bites becoming infected [9] . Infection usually emerges 1–2 days
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after the bite; however, this may be delayed with deeper infection.
Unfortunately, patients often present for care after infection has
become well established.
Human saliva can contain up to 109 organisms per ml, and
there may be as many as 190 different species of bacteria pres-
ent [202] . Commonly isolated aerobes include Streptococcus angi-
nosis, Staphlococcus aureus, coagulase-negative Staphylococcus
spp., Enterococcus spp. and Corynebacterium spp. [8] . S. aureus
is often associated with severe infections. Eikenella corrodens,
a capnophilic slow-growing Gram-negative rod, is often asso-
ciated with chronic infection and abscess formation, and has
been shown to have synergistic activity with a-Streptococcal
species in causing infection. Anaerobes that are often isolated
include Gram-negative bacilli including pigmented Prevotella,
Porphyromonas and Bacteroides spp., as well as Fusobacterium
(especially Fusobacterium nucleatum) and Gram-positive species
such as Peptostreptococcus [10] . Candida species have been isolated
from occlusional bites [8] .
Viruses associated with human bite wounds include hepatitis B
and C, as well as HIV. Hepatitis B antigen has been detected in
the saliva of up to 75% of patients with this infection [11] . If the
victim has not been vaccinated against hepatitis B, and the assail-
ant’s hepatitis B status is unknown, it is recommended that a vac-
cine series be administered immediately. If the biter is hepatitis B
positive, the vaccine series should be completed, and hepatitis B
immune globulin should be given as soon as possible, preferably
within 24 h after exposure [12] .
Although rare, there have been documented cases of HIV trans-
mission after human bite, usually in association with the presence
of bloody saliva [13] . The level of risk of HIV transmission can
be determined by the health status of both the assailant and the
victim, as well as the severity of the wound. HIV postexposure
prophylaxis may need to be considered in high-risk injuries, and
consultation with an HIV specialist regarding management is
recommended. According to the CDC, if the biter has blood in
the mouth, the biter should be tested for HIV, hepatitis B and
C, and syphilis [203] . The detection of any associated infection
requires referral to an infectious disease specialist. Other infec-
tions that have been rarely transmitted via human bite include
herpes simplex virus, TB, actinomycosis and tetanus [8] .
216
Dog bites
According to the American Pet Product Manufacturers Association
there are approximately 77.5 million dogs in the USA [204] , and
CDC records indicate that approximately 2% (4.5 million people)
of the population is bitten annually [14] . Children from the ages
of 5–9 years (especially boys) are at the highest risk of being bit-
ten, and most of these bites are from a household dog or a dog
that is known to the child [15] . Half of these bites are considered
unprovoked and the incidence seems to be higher in dogs who
have not been neutered [16] . Dog breeds more likely to bite include
the Pitt Bull, Rottweiler and German Shepherd, although any dog
is capable of biting [17] . Injuries to children are usually located on
the head, neck and face, because of the relationship of the dog’s
mouth to the child’s height, whereas adults are most likely bitten
on the hand or upper extremity [18] . On an international level,
the lack of standard reporting in many countries makes accurate
estimates of dog bite incidence difficult to determine.
Bite wound infections are usually polymicrobial, with a mix of
animal oral flora, recipient skin flora and environmental organ-
isms. The most common pathogens in dog bites are Pasteurella spp.
(both Pasteurella multocida and Pasteurella canis), Staphylococcus
and Streptococcus spp., and the fastidious Gram-negative rod
Capnocytophaga canimorsus (previously known as the CDC and
Prevention Group Dysgonic Fermenter-2).
Capnocytophaga has been identified as part of the normal oral
flora in anywhere from 16–41% of dogs [19–21] . Since this organ-
ism is fastidious, early notification of the microbiology laboratory
by the provider evaluating the bite victim is very helpful in cases
of possible exposure to the organism. C. canimorsus infection
usually affects older individuals, and may be especially debilitat-
ing for asplenic individuals, those with other forms of immuno­
compromise or those with a history of alcoholism, although this
bacteria has also been associated with severe disease in healthy
individuals [22] . In addition to wound infections and gangrene,
the organism has been associated with dissemination and associ-
ated sepsis, meningitis, endocarditis and ocular infection [23–26] .
Other organisms associated with dog bite infection include
anaerobes, which may be present in up to 75% of dog bite infec-
tions, especially those with abscess formation. The most fre-
quently isolated anaerobic pathogens include Porphyromonas [27] ,
Bacteroides and Fusobacterium spp. [28] . Of note, Corynebacterium
auriscanis was recently isolated from a localized dog bite infection
in an immunocompetent host [29] .
Most C. canimorsus isolates are sensitive to penicillin (PCN),
extended-spectrum PCNs such as amoxicillin/clavulante, and
third-generation cephalosporins, as well as carbapenems. For
PCN-allergic patients, alternatives include a fluoroquinolone or
doxycycline [30] .
The dog is the most common transmitter of rabies to humans
worldwide, with greater than 95% of reported cases being due
to these animals [31] . In the USA, however, animal control and
vaccination programs have effectively eliminated domestic dogs
as reservoirs of rabies [32] . In the USA, recommendations for post-
exposure prophylaxis depend on the health of the dog. If the
animal is healthy and available for 10 days of observation, then
Expert Rev. Anti Infect. Ther. 9(2), (2011)
 Animal bite-associated infections: microbiology & treatment
prophylaxis is only required if the dog develops any sign of rabies
(along with testing the dog). If the animal is rabid or suspected of
being rabid, the animal should be euthanized and tested for rabies,
and postexposure initiated. Immunization may be discontinued if
the immunoflourescent test result for the animal is negative [33] .
The WHO recommends, in addition to local cleaning of the
wound (15 min with either soap and water, or a virucidal anti­
septic), postexposure guidelines based on the category of exposure
to the suspect rabid animal. If there are only minor scratches
or abrasions without bleeding, then immediate vaccination and
treatment of the wound are recommended, whereas if any further
injury occurs, if licks on broken skin, or contamination of mucous
membranes with saliva from licks occurs, then administration
of rabies immunoglobulin is added to the regimen [205] . Other
factors that the WHO recommends considering include the likeli-
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hood of the animal being rabid, the clinical features of the animal,
and its availability for monitoring and lab testing. In developing
countries, they do not recommend that the vaccination status of
the suspected animal be used to determine whether to initiate
prophylaxis or not.
Cat bites
Cats are responsible for approximately 10–20% of animal bites
in the USA. These occur more frequently in adult women and
are often associated with handling the animal [3,34] . Bite location
is most commonly on the face and upper extremities, with the
injury usually consisting of a deep puncture wound with only a
small opening. Although these bites are not as damaging as those
inflicted by dogs, wounds are often more difficult to debride and
disinfect, and the mechanism of injury is more commonly asso-
ciated with infection as well as soft tissue abscess and osteomy-
elitis [35] . It is reported that anywhere from 20–80% of cat bites
may become infected [36] .
As with other bite-associated infections, those due to cats are
polymicrobial, with a mix of aerobes and anaerobes. Common
aerobic pathogens in cat bites include Streptococcus species (includ-
ing Streptococcus pyogenes), Staphylococcus species, especially
S. aureus and Moraxella.
Pasteurella multocida, a small (0.2–2.0 µm) facultatively anaero-
bic, Gram-negative, nonmotile, non-spore-forming, pleomorphic
coccobacillus is the most common organism isolated in cat bites.
Pasteurella is part of the natural oral flora of domestic cats, with
up to a 90% carriage rate [37] . Infection with P. multocida gener-
ally presents as a rapidly spreading cellulitis, usually occurring
within 24 h of the bite. If untreated, complications range from
pneumonia to osteomyelitis, brain abscess or endocarditis [38] .
Bartonella henslae, the organism associated with ‘cat scratch
fever’, may be transmitted by a cat bite or scratch (usually by a kit-
ten). Disease is usually self-limited, but may present with lymph­
adenitis, osteomyelitis or prolonged fever. Bacillary angiomato-
sis (cutaneous nodules due to Bartonella species) may develop
in patients with AIDS. Associated anaerobes, like those seen
in dog bite infection, include Fusobacterium, bacteroides and
porphyromonas species. Rare diseases that have been reported
from cat bites include ulceroglandular tularemia [39,40] , human
www.expert-reviews.com
Review
plague [41] and sporotrichosis [42,43] . Owing to the concern for
serious infection, especially with Pasteurella, empiric antibiotics
are recommended for all cat bites (see Table 1).
Nonhuman primate bites
Monkey bites are not common in the USA. They can, however,
present in returned travelers and zoo or lab workers. The bites
inflicted by the nonhuman primates can be severe, and infection
is common. The bacteriology of simian bite wounds is diverse
and includes a-hemolytic and other Streptococci, Enterococcus
spp., Staphylococcus epidermidis, Enterobacteriaceae, Bacteroides,
Fusobacterium spp. and Eikenella corrodens have also been iso-
lated [44] . In addition to the risk of a polymicrobial bacterial infec-
tion, similar to that seen after human bites, the transmission of
viral infections is also possible.
Monkeys may transmit rabies, and prophylaxis should be
given if the bite occurred in a rabies-endemic area. Simian her-
pes virus B (also called Cercopithecine herpes virus 1, herpes B,
monkey B virus or herpes virus B) may also be transmitted via
the bites of macaque monkeys [45] . Infections with this virus can
lead to rapidly fatal encephalomyelitis. It is not known whether
postexposure prophylaxis is beneficial, however 14 days of oral
valacyclovir is recommended if an individual is scratched or
bitten by a macaque [46] .
Rodent bites
Infection occurs in up to 10% of rodent (i.e., rats, mice, guinea
pigs, hamsters) bites. The most commonly associated disease is rat
bite fever. This is due to either Spirillum minus or Streptobaccilus
moniliformis, a fastidious organism that is difficult to isolate in
culture. Symptoms include fever, rash and arthritis that remit
and relapse without therapy [47] . This triad of symptoms may
sometimes be incorrectly diagnosed as rheumatoid arthritis, thus
delaying appropriate treatment [48] .
In the classic presentation, the arthritis is believed to be immune
mediated, however it has recently been shown that S. moniliformis
may also be associated with actual infective arthritis, especially in
patients with underlying joint abnormalities [49] .
Serious complications such as endocarditis may also occur,
and mortality may be as high as 53% [50] . Most cases are due to
rat bites, but other rodents have been implicated [51] . Effective
antibiotic therapy for rat bite fever includes PCN or doxycycline.
Other bacteria found in rat bite wounds include Staphylococcus,
Leptospira, Pasteurella, Corynebacterium and Fusobacterium spp. [52,53].
Bat bites
Bat bites are most commonly associated with rabies infection,
however there are 11 known species of the Lyssavirus genus.
European bat lyssavirus-1 and -2 infections have been detected
in humans in the UK and across Europe, with the most north-
ern case reported in Finland [54,206] . In Australia, there have
been two cases of encephalitis from Australian bat lyssavirus [36]
and in Africa there have been cases of bat-transmitted infection
due to the Duvenhage virus [55,206] . The symptoms of these
viruses are similar to those of rabies, and are treated in the same
217
 Review Thomas & Brook

Table 1. Microbiology and antimicrobial therapy of bite infections.

Animal Organism Empiric antibiotic therapy
Human Eikenella corrodens Oral
Viridans Streptococci Amoxicillin/clavulanate (Augmentin®, GlaxoSmithKline,
Staphylococus aureus Brentford, UK)
Coagulase-negative Staphylococus OR
Corynebacterium Moxifloxacin (only suitable for patients >18 years of age)
Bacteroides Intravenous
Peptostreptococcus Ampicillin/sulbactam
Hepatitis B/C OR
HIV Piperacillin/tazobactam
OR
Cefoxitan
OR
Ertapenem
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PCN allergic
Moxifloxacin (only suitable for patients >18 years of age);
Doxycycline (only suitable for patients >8 years of age)
OR
Metronidazole or clindamycin
PLUS
Trimethoprim/sulphamethoxazole
OR
Another fluoroquinolone (ciprofloxacin/levofloxacin)
Dog S. aureus/intermedius Same as human
Pasteurella canis/multocida
Capnocytophaga canimorsus
Streptococcus spp.
Moraxella spp.
Clostridium spp.
Bacteroides
Fusarium
Cat Pasteurella multocida Same as human
Streptococcus spp. (especially S. pyogenes)
S. aureus
Moraxella spp.
Fusobacterium
Bacteroides
Porphyromonas
Nonhuman primates Mixed flora (aerobic/anaerobic) Same as human +
Streptococcus spp. Valacyclovir
Neisseriae spp.
Haemophilus influenzae
Enterobacteriaceae
Simian Herpes B
Rodents Streptobacillus moniliformis Same as human
Spirillum minus
Salmonella spp.
Staphylococcus
Leptospira
Pasteurella
Corynebacterium
Fusobacterium
PCN: Penicillin.
Data taken from [28].

218 Expert Rev. Anti Infect. Ther. 9(2), (2011)

 Animal bite-associated infections: microbiology & treatment Review

Table 1. Microbiology and antimicrobial therapy of bite infections (cont.).

Animal Organism Empiric antibiotic therapy
Ungulates Polymicrobial Same as human
Actinobacillus spp.
Pasteurella spp.
Staphylococcus spp.
Viridans Streptococci (Streptococcus equi)
Reptiles Aeromonas hydrophila Ceftazadime + PCN + metronidazole
(i.e., crocodiles/ Pseudomonas OR
alligators) Proteus vulgaris Ceftriaxone + doxycycline + metronidazole
Enterobacter
Citrobacter
Burkholderia
Serratia spp.
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Mixed anaerobes
Marine organisms Vibrio spp. Doxycycline
fish Mycobacterium marinum OR
Erysipilothrix rhusiopathiae Ciprofloxaxin
Aeromonas hydrophila OR
Third-generation cephalosporin
OR
Extended-spectrum penicillin
PCN: Penicillin.
Data taken from [28].

manner, although only the Australian bat lyssavirus is prevent-
able by available rabies vaccines and rabies immune globulin
(RIG) [206] . If a known bat bite occurs, effective postexposure
prophylaxis with rabies immunization, as well as RIG is a neces-
sity. Since the injury inflicted by a bat may be small, and may
go unnoticed, or the circumstance of contact may preclude
accurate recall (i.e., bat in the room while people slept, or bat
in the room of an unsupervised child, or mentally disabled or
intoxicated person), it is important to give prophylaxis even
in these circumstances unless prompt testing of the bat can
exclude rabies virus infection [33] .
Ungulate bites
Of the ungulates in the USA, pigs are the most likely to bite,
whereas horses, cows, sheep and deer are more likely to injure via
kicking or crushing. Pig bites are often severe with a high incidence
of infection that is often polymicrobial with organisms includ-
ing Staphylococcus and Streptococcus spp. (including Streptococcus
suis), Haemophilus influenzae, Pasteurella, Actinobacillus and
Flavobacterium species [56–58] .
In 2005 there were an estimated 9.2 million horses in the
USA [207] . Of all horse-related injuries, only approximately 4%
are related to bites [59] . As with other animal bites, injury may
range from superficial trauma (nips), to amputation of digits.
The oral flora of horses has been shown to contain up to 270
bacterial isolates, 98 of which are anaerobes [60] . Of the organisms
associated with human infection, the Gram-negative coccobacilli
Actinobacilli (especially Actinobacillus lignieresii) are common cul-
prits. As mentioned previously, these are also part of the normal
flora of pigs. Clinically, the majority of cases present with an
abscess around the bite wound.
Other organisms associated with horse bite infections include
S. aureus, Steptococcus equi (as well as other Viridans Streptococci),
Neisseria spp. and Pasteurella spp. including P. multocida [61] .
Anaerobes, as with other mammal bites include Fusobacterium
spp., including the recently identified Fusobacterium equi-
num [62,63] , as well as Bacteroides and Prevotella spp. [64] . Of note,
horses may become infected with rabies, although there have been
no cases of rabies transmission from horse to human [65] .
As with most mammalian bites, amoxicillin/clavulanic acid
(augmentin) is a reasonable empiric antibiotic in an individual
bitten by an ungulate. Doxycycline may be used in individuals
greater than 8 years of age, or metronidazole/clindamycin plus
ciprofloxacin, or trimethoprim/sulfamethoxazole may be used in
PCN-allergic patients.
Bear bites
As the remote bear habitat is encroached by human development,
there has been an increase in bear encounters, with a resultant
increase in attacks. The oral flora of bears generally reflects their diet,
which is high in plant matter, and occasional meat or carrion [66] .
Organisms that have been most commonly isolated from the oral
cavities of black bears include Streptococcus spp., Staphylococcus spp.,
E. coli and Enterobacter spp. [67–69] . With regards to actual wound
infections from bear bites, there are few reports. Kunimoto et al.
reported on a hunter who, among other injuries, was bitten on the
head by a grizzly bear. The patient was originally given empiric
antibiotics (cefazolin and metronidazole), and cultures were
obtained 12 h after the attack, but there was still polymicrobial
growth, including Serratia spp., Aeromonas hydrophila, Bacillus cereus
and Enterococcus spp. No anaerobes were identified [70] . Another
case report of bear bite wound infection was reported in a man

www.expert-reviews.com 219
 Review Thomas & Brook
who sustained several bites from a brown bear. The infected thigh
wound grew Mycobacterium fortuitum as well as Streptococcus sanguis,
Neisseria sicca and Bacillus spp. [71] . Liu et al. reported on a 4-year-old
who developed a chronic osteomyelitis after being bitten by a bear
in captivity. The wound grew Prevotella oralis, Streptococcus viridans
and Propionibacteria acnes [72] . Although there are no specific recom-
mendations regarding empiric therapy after bear bite, Floyd et al.
recommended coverage for Gram positives with either a PCN or
first-generation cephalosporin, and further modification based on
culture results [67] . However, based on the few case reports of actual
bear bite infection, it would seem reasonable to also include broader
coverage for Gram-negative organisms.
Reptile bites
Bites from crocodiles or alligators are usually fatal. If the victim
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survives, there is a high risk of infection. There are reports of infec-
tions with Burkholderia pseudomallei, which are usually due to con-
tamination from the environment [73,74] . Multiple microorganisms,
especially aerobic Gram negatives, have been isolated from wounds
after alligator attacks. A study of the oral flora of alligators showed
Aeromonas (most common), Proteus, Pseudomonas and Citrobacter
species to be the predominant aerobic isolates. Anaerobic flora
were variable with the most common species being Clostridium,
Bacteroides, Fusobacterium and Peptococcus [75,36] .
In light of these identified organisms, it is believed that the flora
of the crocodile/alligator mouth might actually consist of the flora
of the feces of the previous prey [75] . Owing to the high risk of poly-
microbial infection in survivors, broad-spectrum empiric antibiotics
are recommended (see Table 1).
Both elapids (coral snakes) and crotalids (vipers, rattlesnakes, cop-
perheads) have venom that elicit antimicrobial activity [76] . Elapid
bites rarely become infected; however, infection after envenomation
by those from the crotalids have been due to a range of organisms,
including S. aureus and E. coli [77,78] . Shek, who studied the oral flo-
ral of the Chinese cobra, found over 50 species of bacteria, including
Morganella, Aeromonas, Proteus and Clostridia species, in addition
to S. aureus, Enterococcus and coagulase-negative Staphylococci [79] .
Similar to the alligator, it is believed that the flora is fecal in origin,
as the live prey may defecate in the snake’s mouth as it is being
ingested [80] .
The use of prophylactic antibiotics after snakebite is controversial,
and generally not recommended [81–85] . Shek et al. however, recom-
mended broad empiric therapy (with levofloxacin and amoxicillin/
clavulanate), especially if there is evidence of wound necrosis [79] .
Salmonella species are a common pathogen associated with lizard
contact. Most lizards generally do not bite, but there are a few reports
of infection after bites, ranging from cellulitis with S. marcesens after
an iguana bite [86,87] , to septic arthritis due to Pseudomonas aerugi-
nosa after injury from a monitor lizard [88] .
Marine organism bites
Sharks are the most reported marine animal to bite humans, although
there have been reports of bites from fish such as barracuda and eels.
Infecting organisms are usually specific to the marine environment,
and therapy should be tailored to the organism. There is a paucity
220
of published data on shark bite injuries, but Lentz et al. published
a report on 96 episodes of shark attack. The most common organ-
isms associated with these bites were Vibrio spp. (especially Vibrio
vulnificus, Vibrio parahaemolyticus and Vibrio alginolyticus) and con-
tamination often led to soft tissue infection and necrosis [89] . Buck
et al. looked at cultures of great white shark teeth and, in addition, to
the Vibrio species, Pseudomonas spp., Staphylococcus, Citrobacter and
Micrococcus species were isolated [90] . Unfortunately, they did not
culture for anaerobic organisms. Owing to infection potential, early
treatment has been indicated for all shark bites, even when minor.
Barracuda bites are associated with a shearing type injury, whereas
eels cause severe lacerations or puncture wounds [91,92] . The risk
of infection from eel injuries is unclear. Erickson et al. reported
three superficial wounds that all healed uneventfully without sec-
ondary infection. However, each patient received prophylactic
antibiotics at the initial presentation [93] . Regardless of whether
prophylactic antibiotics are given, any early signs of invasive wound
infection should be treated promptly. Ciprofloxacin, cefuroxime,
tetracycline or trimethoprim/sulfamethoxazole are often chosen
for these wounds due to the concern for infection with Vibrio and
Pseudomonas species [94] .
Management
Most of the management guidelines for the treatment of bite infec-
tions are based on expert opinion. The goals of therapy are to prevent
or treat infection, as well as minimize soft tissue damage. In general,
a number of therapies may be undertaken for all bite wounds.
Smaller wounds should be flushed with large amounts of cool
clean water. A mild soap may be gently used to cleanse the area, and
may have some prophylactic effects against rabies [15] . The WHO
recommends thorough flushing and washing of bite wounds for a
minimum of 15 min with soap and water, detergent or povidone
iodine [205] . Soaking the injury is not recommended as this may
introduce infection into the wound [95] . Alcohol or peroxide is
also not recommended because of the potential for further tissue
injury [15] . Application of an ice pack may aid in pain relief and
decrease swelling.
Professional medical care should start with obtaining the history
of the injury to include timing, and details about the biter (i.e.,
human vs animal, domestic vs wild, vaccination status of the biter
and availability of animal to be quarantined). Rabies risk should be
determined with an inquiry into unusual behavior of the animal,
and whether or not the attack was provoked. History of the patient’s
health should include medications and allergies, past medical history
and risk factors for infection.
Examination should determine the type of wound (i.e., laceration,
puncture, contusion or crush-avulsion), depth of wound and pos-
sible involvement of underlying structures (e.g., tendons, joints or
bones). Range of motion of joints near and involved with the injury
should be evaluated, as well as examination for signs of infection.
Radiological studies are often obtained after any ‘mauling’ inju-
ries, any extensive wounds, as well as on closed-fist injuries and other
bites to the hand. In addition to identifying fractures, radiographs
may reveal air in a joint, or may be used to determine if a piece of
broken tooth or a foreign body is in the wound. Radiographs are
Expert Rev. Anti Infect. Ther. 9(2), (2011)
 Animal bite-associated infections: microbiology & treatment
also used to look for evidence of osteomyelitis in a chronic wound
infection. If there is evidence of purulence in the wound, aerobic
and anaerobic cultures should be obtained.
Meticulous cleaning with saline irrigation should occur, as the
wound should always be considered contaminated. Saline lavage
with a 30‑ml syringe and 18-gauge intravenous catheter is recom-
mended, with volumes up to 150 ml for wounds less than 3 cm [95] .
When necessary, foreign body removal and debridement of dirt
and nonviable tissue can occur after irrigation is complete.
Aside from bite wounds to the face, there is little evidence and
agreement as to whether or not to close a bite wound. Primary
closure of neck and face wounds (even cat and human bites) with
avoidance of buried sutures, and usage of prophylactic antibiotics,
is reasonable because of the excellent vascular supply [96] . Most
authors do not recommend wound closure, although those who
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propose that wounds may be primarily closed, indicate that the
decision depends on the species of the biter, size and location
of the wound and the time between injury and presentation for
medical attention. In general, if one chooses to suture a wound,
it must be done within 8 h of the bite [95.97] . Garbutt and Jenner
performed a review that looked at 74 papers on management
of bite wounds, with the specific question of whether primary
closure of animal bites increases wound infection rates [98] . They
found one study that they felt adequately addressed the ques-
tion. The study completed by Maimaris and Quitoc looked at
96 patients with 169 dog bite lacerations, who were randomized
to primary closure, or leaving the wound open (puncture wounds
were excluded) [97] . the
����������������������������������������������
study concluded that there was no signifi-
cant difference in infection rates between the two groups except
in those wounds occurring to the hands. It was then proposed
that dog bite wounds to the hand should be left open, but that
nonpuncture wounds elsewhere may be safely treated by primary
closure after thorough cleaning.
Cat bites are generally not sutured unless on the face or scalp.
Nonsutured wounds should be bandaged with bulky dressings.
Facial bites usually heal well and have adequate cosmesis if adequate
irrigation and debridement occur prior to primary repair [99,18] .
Tetanus and rabies prophylaxis are very important considerations
when managing a bite wound. Every patient with a bite injury
that seeks medical care should have their tetanus status checked,
with appropriate immunization as needed. Tetanus booster should
be given if the victim received a primary series, but no booster
within the last 5 years. If tetanus status is unknown, or if the
vaccine series was not completed, then both tetanus vaccine and
tetanus immune globulin (in the arm opposite the vaccine) should
be administered [100] .
If the bite is from an animal capable of transmitting rabies, it
is important to determine the animal’s vaccine status. If it the
animal has received the rabies vaccine and it can be quarantined
for 10 days, then rabies prophylaxis is not necessary. If the status
is unknown, then postexposure prophylaxis should be initiated
immediately. The regimen consists of one dose of RIG, with up
to 50% of the dose being injected around the wound and the
remainder being given intramuscularly. In March of 2010, the
CDC changed the postexposure rabies vaccine recommendation
www.expert-reviews.com
Review
from five to four doses (first dose in the arm opposite the dose
of RIG), with immunization administration on days 0, 3, 7 and
14 [208] .
There is much debate on whether or not to use prophylactic
antibiotics. In general, if the wound is not infected then there is
no need for antibiotic prophylaxis, unless the wound is deemed
moderate to severe, or if the bite injury is considered a high risk
for infection. These risks include: extremes of age, immunocom-
promise (especially asplenics), comorbid factors such as chronic
disease (i.e., diabetes), usage of certain medications, the type of
animal inflicting the bite (i.e., cats or sharks), the number/type of
pathogen inoculated in the bite, and the size and location of the
wound [101] . Deep puncture wounds beyond the epidermal layer,
crush injury, bites to hands, feet, genitalia or over joint surfaces
are considered especially high risk [102] . In general, empiric therapy
is usually an oral medication covering the most likely pathogens
(see Table 1) for 3–5 days.
Empiric choice of antibiotics for an actual wound infection will
depend on the predicted inciting organisms. Human bites must
cover both anaerobes and aerobes, with special attention to E. cor-
rodens, which is resistant to first-generation cephalosporins. For
cat bites, it is important to cover for Pasteurella spp., whereas dog
bites require coverage for both Pasteurella and Capnocytophaga spp.
Other mammalian bite infections have common oral flora includ-
ing staphylococcus and streptococcus species. If infection can be man-
aged on an outpatient basis, usage of oral amoxicillin/clavulanate or
moxifloxacin (in patients >18 years of age) is effective. Moxifloxacin
has been shown to have excellent in vitro activity against Pasteurella
and Eikenella spp., as well as other organisms found in bite wounds
[103] , including a number of anaerobes [54,104–106] . Although there
have not been studies specifically looking at the use of moxifloxacin
against bite-associated infections, this once‑a-day drug could be
considered as a potential addition to the antbiotic regimen arma-
mentarium. Merriam et al. recently showed adequate in vitro activity
of azithromycin to 98% of 296 strains of oral anaerobes, including
all fusobacteria and b‑lactamase-producing strains of Prevotella spp.,
as well as E. corrodens [106] . Although promising, the use of azithro-
mycin has not yet been established as an alternate oral treatment of
human bites.
If parenteral therapy is required, choices include ampicillin/
sulbactam, ticarcillin/clavulanic acid, or piperacillin/tazobactam.
Appropriate alternative regimens include cefoxitan, cefotetan or a
carbapenem such as ertapenem [107,108] . If an extended-spectrum
cephalosporin (cefotaxime or ceftriaxone) is chosen, then clinda-
mycin should be added to cover anaerobes. PCN-allergic patients
requiring intravenous therapy may be treated with doxycycline or
a fluoroquinolone with clindamycin. Of note, tigecycline has an
indication for skin and soft tissue infections, and although not for-
mally studied, may be an intravenous alternative for a patient who
is highly PCN allergic.
For mammalian bites, PCN-allergic patients should receive doxy-
cycline (children >8 years of age), moxifloxacin (if >18 years of age),
or a choice of metronidazole or clindamycin (for anaerobes), plus
either trimethoprim/sulfamethoxazole or the other flouroquinolones
such as ciprofloxaxin. Of note, antibiotics used for other skin and
221
 Review Thomas & Brook

soft tissue infections, such as antistaphylococcal PCNs, the first-
generation cephalosporins and erythromycin are not active against
Pasteurella and Eikenella species [109] .
Reptiles, especially alligators, must include coverage for Aeromonas
spp. Third-generation cephalosporins are very effective against these
organisms [110] , whereas with marine animals, coverage for Vibrio
species with a tetracycline or fluoroquinolone is necessary.
The decision to use parenteral versus oral antibiotics as well as
length of therapy will depend on location and extent of infection.
Soft tissue infections usually only require 7–14 days of therapy after
appropriate wound care is accomplished, whereas septic arthritis or
osteomyelitis may require longer treatment regimens, with courses
from 3 to 6 weeks. Ultimately, duration and route of antibiotic
should be individualized, based on the infected site, culture and
sensitivity results, and response to therapy.
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In addition, antimicrobial susceptibility may also vary in the
wound. Microbiological cultures and collaboration between the
microbiology laboratory and clinicians are therefore required.
Improved methods of collection, transportation and cultiva-
tion have increased the rate of recovery of anaerobes, and have
highlighted their importance in bite wound infections. However,
there is still a need to continue to educate medical providers about
the importance of obtaining anaerobic cultures as well as how to
properly collect and transport them to the microbiology laboratory.
There is still much to be learned about bite infections. As new and
improved techniques for identification and susceptibility testing of
bacterial pathogens are developed it is hopeful that the care of wound
infection will improve and the rate of complications will decline.
Five-year view

Finally, adequate follow-up and education are crucial. Patients Performance of controlled studies that will assess the optimal
should be taught wound care as well as the signs of infection. A antimicrobial therapy of bite wound infections in the face of
follow-up wound check should take place in 24–48 h (sooner if there antimicrobial resistance will be conducted over the next 5 years.
are signs of infection). Also, if indicated, the bite should be reported Development of improved laboratory testing to rapidly deter-
to local health or law enforcement agencies. mine the identity and antimicrobial susceptibility of organisms
associated with bite wounds, especially anaerobic pathogens should
Conclusion also be achieved in the coming years. Also in the future, contin-
Humans frequently sustain bites that often result in infection caused ued effort to provide worldwide vaccination against tetanus and
by the biter’s oral flora as well as environmental bacteria. It is impor- further emphasis on education to promote the prevention of bites,
tant for providers to be familiar with the evaluation and treatment and the need for immediate medical assessment after being bitten,
of bite wounds, recognize which are most likely to become infected will be priorities.
and, if indicated, which antibiotics are most effective.
Financial & competing interests disclosure
Expert commentary The authors have no relevant affiliations or financial involvement with any
Bite wounds are ubiquitous throughout the world. The majority organization or entity with a financial interest in or financial conflict with the
of bites are mild, with home care being the predominant means of subject matter or materials discussed in the manuscript. This includes employ-
treatment. Unfortunately, failure to adequately clean bite wounds, ment, consultancies, honoraria, stock ownership or options, expert testimony,
along with delayed medical care, often leads to infection. The grants or patents received or pending, or royalties.
majority of bites are still from dogs, although, as humans continue No writing assistance was utilized in the production of this manuscript.
to move into the remote territories of wild
animals such as bears and sharks, encounters Key issues
and often attacks by these animals become • Bite wounds may develop into deep-seated infections, and may disseminate
more frequent. systemically. Host factors (especially immune status of the patient) may contribute to
As we continue to improve methods in complications ranging from cellulitis and osteomyelitis to life-threatening infections
trauma care, survival from major animal such as endocarditis or intracranial abscess.
attacks has increased. This has resulted in • Bite wound infections are generally polymicrobial due to aerobic and anaerobic
a higher rate of infection (along with the organisms. Therapy should provide coverage for both types of pathogens.
evaluation of the oral microbiology of bit- • Many animal species carry a unique bacterial and viral oral flora that requires specific
ing animals), but has also given scientists the empirical therapy. Examples include Eikenella in humans, herpes B virus in monkeys,
Pasteurella in cats and dogs, Capnocytophaga in dogs, Actinobacillus in pigs and
opportunity to better prevent and, if needed,
horses, and Aeromonas in alligators.
treat infected bite wounds.
• Amoxicillin/clavulanate is considered the standard oral agent to empirically treat
This article underscores the importance mammalian bite wound infections. Moxifloxacin may be considered as an effective
of assessing the microbiology of wounds by single-drug regimen in individuals over 18 years of age (especially if they are penicillin
obtaining cultures when treating animal allergic).
bites. Owing to the unique oral flora of each • Rabies prophylaxis is an important consideration in all individuals who are bitten by a
biting animal or human, atypical infections mammal capable of spreading the virus. New CDC guidelines have decreased the
can arise at bite wounds. Unexpected envi- number of rabies postexposure vaccine injections from five to four doses.
ronmental organisms (i.e., from soil, dust • Thorough cleaning with debridement (if necessary), and evaluation to include
or water) can also enter the wound, adding determination of tetanus vaccine status and radiologic studies are crucial components
to the complexity of the infecting flora. of bite wound management.

222 Expert Rev. Anti Infect. Ther. 9(2), (2011)


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Pasteurella multocida, and therefore
should not be used as empiric therapy for
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225
 Review Thomas & Brook
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Expert Rev. Anti Infect. Ther. 9(2), (2011)