Management of :

Animal Bite, Tetanus,

and Gangreene
Sahudi Sp.B (K)KL
Gas
SMF Bedah RSUD Dr. Sutomo
Surabaya
 Animal Bite
A) Overview on common pathogens associated with bites
from specific animals

B) General principles on animal bite management

C) Consideration of prophylactic or therapeutic antibiotic

D) Consideration of Tetanus prophylaxis

E) Consideration of Rabies prophylaxis

F) Other animal bite & ID management

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(A) PATHOGENS ASSOCIATED WITH
BITES FROM SPECIFIC ANIMALS
Animal Pathogen
Any vertebrate *Clostridium tetani
Mammal * Rabies Lyssaviruse

Dog *Capnocytophaga canimorsus

Cat *Bartonella henselae
*Pasteurella multocida
*Francisella tularensis

Rat *Streptobacilus moniliformis

*Spirillum minus

Fresh-water species Aeromonas hydrophila

Mycobacterium marinum

Salt-water species Vibrio vulnificus

Mycobacterium marinum

Macaque( ) Herpesvirus simiae (B virus)

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(B) General principles on animal bite
management

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 History taking
Circumstances of the injury (provoked or
unprovoked)
Type of animal involved
Current location of the animals/ ownership/
vaccination status
Patients underlying medical conditions
Drug allergy
Tetanus immunization status

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Physical exam
Location/type/depth of wound
Range of motion, neurovascular function
Signs of infection
Lymph node
X-ray if wound near joint or bone

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Principle of wound management
Clean with 25% soap solution or dilute povidone-
iodine solution, followed by irrigation with copious
normal saline with syringe
Take culture after topical decontamination ( if
infection suspected)
Remove foreign bodies and necrotic tissue. Delayed
suturing is advised for contaminated, large or deep
wounds and hand wounds
Ortho/ surgical consultation as appropriate
Elevation and immobilization of wound

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Bacteria commonly isolated from Dog/Cat bite wounds
Often Polymicrobial

Aerobes: Anaerobes:
Streptococci species Actinomyces

Staph aureus and other Bacteroides

species
Fusobacterium
Pasteurella multocida

Moraxella species Peptostreptococcus

Corynebacterium Prevotella
species
Capnocytophaga species
Neisseria species
Eikenella corrodens
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C) Prophylactic Antibiotics Regimens
for animal bite wounds
Empirical Rx:
Oral amoxicillin-clavulanic acid
Duration 5-7 days

For patient with allergy history of life threatening reactions to

penicillin:
Oral clindamycin + fluoroquinolone
Oral clindamycin + tetracycline
Oral clindamycin + Septrin (paediatric)

For patient with allergy history of non-life threatening

reactions to penicillin:
Oral cefuroxime + metronidazole

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C) Treatment of established bite wound
infection
Treatment after wound swab for C/ST
depends on the progress; usually 7-14 days; extend if there are
joint/ bone involvement
Parenteral therapy preferred for admitted patient with
infected bites
IV/Oral amoxicillin-clavulanic acid
Other alternatives: second /third generation cephalosporin
+ antianaerobic agents OR carbapenems
For patient with allergy history of life threatening
reactions to penicillin:
Oral clindamycin + fluoroquinolone
Oral clindamycin + tetracycline
Oral clindamycin + Septrin ( paediatric)
For patient with allergy history of non-life threatening
reactions to penicillin:
Oral cefuroxime + metronidazole

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Patients with Penicillin
allergy
Pregnant women : tetracycline, Septrin
,Metronidazole contraindicated
Children: tetracycline and fluoroquinolones
contraindicated
May consider Macrolide e.g. azithromycin
250mg 500mg per day under such situation
Patient observed closely for treatment failure

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D) Tetanus

Tetanus only occurs when spores of C. tetani gain access

into tissues.

usual mode of entry is through puncture wound or

laceration. Injury itself is often trivial and in 20% of cases
there is no evidence of wound.

spores germinate from wound and toxin tetanospasmin is

released into blood stream. It is then taken up into motor
nerve endings and transported into CNS.

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Tetanus prone wound:
wound complicated by delay in treatment for over
6 hr
deep puncture wounds
avulsion
heavily contaminated wounds
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D) Tetanus management:
Active Immunisation with tetanus toxoid
(TT)
Long lasting protection greater than or equal to 10 years for
most recipients. Boosters are recommended at 10-year
intervals.

3 doses of 0.5 ml (TT) by IMI

1st : on the day of attendance
2nd: 1 to 2 months after 1st dose
3rd: 6 to 12 months after 2nd dose

Complications:
Fever /painful local erythematous or nodular reaction at
injection site

Contraindications
Previous anaphylactic reaction
Acute respiratory infection or other active infection

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D)Tetanus management:
Passive immunisation

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 D) Tetanus management:
Wound care and antibiotics

Prompt and thorough surgical wound toilet is of key

importance.
In HK, drug addicts and elderly people are presented with
neglected wounds.
Antibiotic prophylaxis cannot replace proper wound cleaning,
debridement and proper immunisation.
Eradication of organism from infection source:
through cleaning of wound and extensive debridement of
necrotic tissue after antitoxin has been given.
antibiotics to destroy spores:

metronidazole 500mg IV 8 hrly for 10 days. More

effective than penicillin.
erythromycin has been used but should not be
routinely used.

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E) Rabies
Rabies infects mammals only.
Last local and imported human rabies cases occurred in 1981
and 2001 respectively.
Animal rabies has not been reported in HK since 1987. ( 1980-
1987: 32 dogs, 2 cats)
Animal highly suspicious of being rabid:
Animal is from rabies infected area
The biting incident was unprovoked and the animal has
bitten more than one person or other animal
The animal shows clinical signs and symptoms of
rabies, e.g. increase salivation, shivering, change in
behaviour, paralysis or restlessness
Wild mammals: raccoons, skunks, foxes, coyotes

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 E) Management of Rabies

Rabies should be considered in patients suspected acute

progressive viral encephalitis, regardless of a history of
animal bite.
Once a patient develops symptomatic rabies, available
diagnostic tests include:
Assays for viral antibodies in the serum or cerebrospinal
fluid (CSF);
Viral isolation from CSF or saliva;

Viral antigen detection in biopsies of skin, corneal

impressions or brain tissue;
Reverse transcription PCR of saliva, CSF or related
tissues (such as salivary glands or brain tissue).

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 E) Management of Rabies
Active immunization of Human diplod cell vaccine (HDCV) on day 0,3,7,14,28
Adults :Deltoid muscle
Infants and small children: Mid anterior thigh muscles
Victims who have previously immunised either with a five-dose
course or as prophylaxis against rabies within the past 5 years
should receive 2 doses of HDCV on day 0,3. HRIG is not
recommended
5 dose full course is recommended if vaccination is incomplete or
received more than 5 yrs ago. Consider passive immunisation.
Adverse reactions:
Local reactions(30-74%): pain, erythema, swelling, itchiness at
injection site
Systemic reactions(5-40%): headache, nausea, abdominal
pain, myalgia, dizziness
Guillain-Barr syndrome

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 E) Management of Rabies

Passive immunisation with Human Rabies Immune Globin

( HRIG)
Single administration of 20 IU/kg
Infiltrated around the wounds as much as possible and
any remaining volume should be administrated IM at an
anatomical site distant from vaccine administration.
Adverse reaction: local pain or low grade fever.

Immunosuppressive agents, anti-malarials,

immunocompromised state can interfere the development
of active immunity after vaccination.
Pregnancy is not a contraindication to post-exposure
prophylaxsis. No foetal abnormalities have been
assocaited with rabies vaccination.

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 F) Pasteurella multocida
Commonly associated with cat bite infection ( 75%),
occasionally dog bite (50%) as well
A cause of rapidly progressive infections similar to
Group A Streptococcus or Vibrio (i.e. patient may
present within a few hours of a cat bite with
established severe infection)
Often clinical evidence of wound infection within a few
hours of a bite injury, a scratch or lick.
Cellulitis or abscesses +/- bacteremia

Occasional cause of pneumonia and endocarditis

Other: metastatic seeding of internal organs from

bacteremia.
CNS: meningitis (rare), most often in young children
or the elderly.
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 F) Pasteurella multocida

Diagnosis
Based on culture (swab, blood, body fluid). May be confused

with Haemophilus or Neisseria spp. on Gram stain.

TREATMENT
Sensitive to Amoxicillin/clavulanate , Ampicillin/-sulbactam,

Penicillin, Ciprofloxacin, levofloxacin, doxycycline

First generation cephalosporins, cloxacillin, erythromycin

and clindamycin ineffective

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 F) Capnocytophaga canimorsus

Clinical presentation
Facultatively anaerobic gram-negative rod, part of normal oral

flora of dogs and cats.

Many patients have history of dog bite or scratch, less

commonly in cats
Cellulitis

Bacteremia/sepsis

Meningitis and endocarditis (rare)

Severe: shock, DIC, acral gangrene, disseminated

purpura, renal failure, meningitis and pulmonary infiltrates
Fulminant sepsis following dog > cat bites, particularly in
asplenic patients, alcoholics or immunosuppressed

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F) Capnocytophaga canimorsus

Treatment
Mild Cellulitis /Dog or Cat Bites
Preferred : Amoxicillin/clavulanate
Alternative: Clindamycin, doxycycline

Severe Cellulitis /Sepsis

Penicillin G 2-4 mU q 4h IV or Clindamycin 600mg IV q 8h.
Alternative : Ceftriaxone 1-2q IV qd, ciprofloxacin 400mg IV
q12h or meropenem 1g IV q8h.
Prevention
In all asplenic patients with amoxicillin/clavulanate for 7-
10d
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F) Bartonella henselae
Cat Scratch Disease(CSD)

Affect both normal and immunocompromised hosts.

80 % of cases occur in children.
Linked to exposure to cats, especially kitten and cats with fleas.
CSD can result from a cat scratch or bite, as well as from a
fleabite.
Characterized by self-limited regional lymphadenopathy near the
site of organism inoculation.
Occasionally life threatening manifestations (5-14%) include
visceral organ, neurologic, and ocular involvement because of the
dissemination of organism. In AIDS patients: Bacillary
angiomatosis
Diagnosis : a positive B. henselae antibody titer or a positive
Warthin Starry stain or PCR analysis of tissue. Very difficult to
isolate from tissue specimens.
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 F) Bartonella henselae
Cat Scratch Disease(CSD)
Treatment
Antibiotics are not indicated in most cases but they may be
considered for severe or systemic disease.
Reduction of lymph node size (no REDUCTION in the duration of
symptoms) has been demonstrated with a 5-day course of
azithromycin and may be considered in patients with severe,
painful lymphadenopathy.
Immunocompromised patients should be treated with antibiotics:
Trimethoprim-sulfamethoxazole,Gentamicin,
Ciprofloxacin,Rifampin
B. henselae is generally resistant to penicillin & amoxicillin

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 F) Francisella Tularensis

Gram negative coccobacillus.

Clinically similar to plague, incubation period 3-5 days
Abrupt onset of fever, severe generalised headache, malaise,
myalgias, abdominal pain, chest discomfort, diarrhoea, vomiting.
Ulceroglandular form (most common): painful ulcer with
raised borders, regional lymphadenopathy.
20% present with typhoidal fever-like illness without
lymphadenopathy and may become hypotensive with severe
watery diarrhoea.
The organism should be handled in a BSL-3 containment facility because
of the risk to laboratory personnel.
May be identified in lymph nodes by silver stain.
Diagnosis is usually presumptive, antibody titre rise (>1:160) after 2
weeks.

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Take Home Message

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Tetanus
Description

Clostridium tetani is
the bacterium that
causes tetanus, and it
is mainly found in the
soil.
In developed
countries, most cases
occur in older adults.
In developing
countries, about half
of the cases of tetanus
are found in neonates.
Description
There are four main types of tetanus
Generalized
Local
Neonatal
Cephalic
Symptoms of tetanus are cause by
disinhibition of the nervous system.
The source of a tetanus infection is a wound,
where Clostridium tetani enters the body.
 The Discovery of Tetanus

Hippocrates (right)
was said to describe
tetanus as far back as
the 5th century B.C.
Nicolaier first
produced tetanus in
animal specimens.
Kitasato isolated the
organism from a
human victim and
neutralized the toxin.
How Tetanus Was Discovered

The bacterium
Clostridium tetani is
abundant in soil and
Tetanus was
produced by
injecting soil
specimens in
animals.
Symptoms

Begin about 8 days after infection.

Lockjaw or trismus occurs, which is muscle
stiffness in the jaw.
Autonomic dysfunction.
Respiration difficulty.
Symptoms

Severe muscle spasms occur, bringing many

complications:
Fracture of spine or long bones
Abnormal heartbeats
Flexion of arms and legs
Laryngospam
 Diagnosis
History of injury or
presence of wound
is used.
History of parental
drug use or personal
IV drug use
strengthens
diagnosis.
Diagnosis

Differential diagnosis includes:

Painful conditions of the lower jaw is included
Abnormalities in the peripheral nervous system
Meningitis
Bells palsy
Stiffmans syndrome
Appropriate history and physical examination
can differentiate most of these.
Pathology
Clostridium tetani
usually enters the
body through a
wound.
The spores
germinate, and two
toxins are produced:
Tetanospasmin
Tetanolysin
 Pathology
The toxin starts out as a polypeptide, and changes into two
chains.
The heavy chain travels to the central nervous system,
which activates the light chain.
The light chain releases an inhibitor which causes muscle
spasms to occur.
Treatment

The treatment involves:

Neutralizing the toxin
Removing the source of the toxin
Supportive care for muscle spasms, respiration,
and autonomic instability
Recovered patients must receive a tetanus
immunization series, due to the fact that
survivors of tetanus have a greater risk of
getting it again.
 Treatment

Passive
immunization with
human immune
globulin shortens the
course of tetanus
and may lesson
severity.
Penicillin and
metronidazole are
the antibiotics
commonly used.
Treatment

The spasms cause by tetanus can be

extremely harmful and cause many
complications.
Sedatives can be used to control spasms.
Neuromuscular blocking agents are used to
relax muscles.
Metronidazole, diazepam, and
benzodiazepine and most commonly used to
control spasms.
Prognosis

The death rate is high in children and the

elderly.
The worldwide mortality rate is 50%, and it is
30% in the United States.
Drug users have a high rate of death
because of complications due to the drug.
Untreated tetanus is usually fatal within a few
weeks.
Prognosis

The four types of tetanus all have different

mortality rates.
Generalized tetanus has a 50% mortality rate.
Local tetanus has a 1% mortality rate.
Neonatal tetanus has a 70% mortality rate.
Cepahic tetanus has a 15-30% mortality rate.
 Prognosis

The amount of tetanus bound to the nerves

affects prognosis, and the more toxin, the
poorer the prognosis.
Surgical removal of damaged tissue and
medical treatment improve prognosis.
 Recent Dicoveries
Magnesium sulphate
has be proven to
control spasms
without sedation and
artificial ventilation.
Faulty vaccination
histories have be
studied and may not
always be accurate
for tetanus
vaccinations.
Recent Discoveries

Intrathecal tetanus immunoglobulin has been

recently tested and it was concluded that TIG
results in less deaths and shorter hospital
stay.
Tetanus toxiod in a mother provides extended
protection against neonatal tetanus.
Gangreene Gas
CLINICAL
MANIFESTATIONS
Onset is heralded by acute pain at the site of
the wound, followed by edema, tenderness,
exudate, and progression of pain.
Systemic findings initially include tachycardia
disproportionate to the degree of fever, pallor,
diaphoresis, hypotension, renal failure, and
later, alterations in mental status.
Crepitus is suggestive but not pathognomonic of
Clostridium infection and is not always present.
CLINICAL
MANIFESTATIONS
Diagnosis is based on clinical manifestations,
including the characteristic appearance of
necrotic muscle at surgery.
Untreated gas gangrene can lead to
disseminated myonecrosis, suppurative
visceral infection, septicemia, and death
within hours.
Etyology
Clostridial myonecrosis is caused by
Clostridium species, most often Clostridium
perfringens, which are large, gram-positive,
spore-forming anaerobic bacilli with blunt ends.
Other Clostridium species (eg, C. sordellii, C.
septicum, C. novyi) also can be associated
with myonecrosis.
Mixed infection with other gram-positive and
gram-negative bacteria is common.
C. Perfringens dari kultur

Pewarnaan langsung dari exudat

EPIDEMIOLOGY
Clostridial myonecrosis usually results from
contamination of open wounds involving muscle.
The sources of Clostridium species are soil,
contaminated objects, and human and animal feces.
Dirty surgical or traumatic wounds with significant
devitalized tissue and foreign bodies predispose to
disease.
Nontraumatic gas gangrene occurs occasionally
from Clostridium organisms in the gastrointestinal
tract and in immunocompromised people.
DIAGNOSTIC TESTS
Anaerobic cultures of wound exudate, involved soft tissue and muscle,
and blood should be performed.
Because Clostridium species are ubiquitous, their recovery from a
wound is not diagnostic unless typical clinical manifestations are
present.
A Gram-stained smear of wound discharge demonstrating characteristic
gram-positive bacilli and absent or sparse polymorphonuclear
leukocytes suggests clostridial infection.
Tissue specimens and aspirates (not swab specimens) are appropriate
for anaerobic culture. Because some pathogenic Clostridium species
are exquisitely oxygen sensitive, care should be taken to optimize
anaerobic growth conditions.
A radiograph of the affected site can demonstrate gas in the tissue.
Occasionally, blood cultures are diagnostic.
TREATMENT
Early and complete surgical excision of necrotic tissue and removal of foreign material is
essential.
Management of shock, fluid and electrolyte imbalance, hemolytic anemia, and other
complications is crucial.
High-dose penicillin G (250 000400 000 U/kg per day) should be administered
intravenously. Clindamycin, metronidazole, imipenem or meropenem, and chloramphenicol
can be considered as alternative drugs for penicillin-allergic patients or for treatment of
polymicrobial infections. The combination of penicillin G and clindamycin may have better
efficacy than penicillin alone.
Hyperbaric oxygen may be beneficial, but adequately controlled data on its efficacy are not
available.
Treatment with antitoxin is of no value.
ISOLATION OF THE
HOSPITALIZED PATIENT :

Standard precautions are

recommended.