Bite wounds and antibiotic prescription among patients presenting to an Australian emergency department

doi:10.1016/j.ienj.2015.10.007

International Emergency Nursing

Volume 27, July 2016, Pages 42-45

https://doi.org/10.1016/j.ienj.2015.10.007 Get rights and content

Highlights

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Epidemiology of mammalian bites presenting to a metropolitan emergency department.
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One hundred sixty mammalian bites were identified over the one-year study period.
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One hundred forty-three (89.40%) patients had high-risk bites, requiring antibiotics.
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Ninety (61.90%) patients received the guideline-recommended antibiotics.

Abstract

Introduction

Emergency department presentations after mammalian bites may be associated with injection of bacteria into broken skin and may require prophylactic antibiotics to prevent subsequent infection. We aim to describe the epidemiology of patients presenting with a mammalian bite injury and antibiotic choice to an Australian adult tertiary centre.

Methods

A retrospective cohort study was performed capturing all presentations after mammalian bite wounds between 01 Jan 2014 and 31 Dec 2014. An explicit chart review was conducted to determine management of each case. Cases were subgrouped into high- and low-risk groups as defined by the Australian Therapeutic Guidelines for animal bites.

Results

There were 160 cases of mammalian bite wounds included, with 143 (89.4%) patients grouped as high-risk and 17 (10.6%) patients identified as low-risk. High-risk features were delayed presentation > 8 hours (57 patients, 35.6%), bites to the head, hand or face (113 patients, 70.6%), and puncture wounds unable to be adequately debrided (74 patients, 46.3%). There was a significant association with delayed presentation of more than eight hours and clinically established infection [OR 36.2; 95% CI: 12.6–103.6; P < 0.001]. Prescriptions for antibiotics that adhered to current guidelines occurred in 99 (61.9%) cases.

Conclusions

This study highlights variability in antibiotic prescription practice among clinicians and the need for ongoing education on antibiotic stewardship. Intervention strategies, including ongoing education, are indicated to improve adherence to antibiotic guidelines.

Introduction

Mammalian bite wounds account for approximately 1–2% of all emergency department (ED) presentations in Australia and the United Kingdom (Evengiou et al, 2013, MacBean et al, 2007). In Australian EDs, 80% of bites are from dogs, 9% from humans, and 7% from cats (MacBean et al., 2007), with the remaining from other mammals, marine animals and reptiles (Dendle and Looke, 2008). Human and animal bite wounds can cause substantial tissue damage (including tendon damage, fractures and neurovascular damage), psychological distress or infection (Dendle and Looke, 2009). An estimated 3–18% of dog bites and 28–80% of cat bites become infected, which complicates the initial skin and tissue damage (MacBean et al., 2007). Causative organisms vary depending on the source of the bite. Human bites are associated with Staphylococcus aureus, Eikenella corrodens, Streptococcus species and beta-lactamase-producing anaerobic bacteria. Animal bites are associated with Pasteurella species, Staphylococcus aureus, Capnocytophaga canimorsus, Streptococcus species and anaerobic bacteria (Dendle and Looke, 2008)_.

Local skin and soft tissue infections are the most common causes of morbidity associated with bite wounds. Sepsis, fractures, osteomyelitis, meningitis and endocarditis are reported features in high-risk patients (Smith et al., 2000). Mortality in animal bites is usually associated with small children receiving bites to the head and neck (Dendle and Looke, 2009). However, there have been case reports of overwhelming sepsis from untreated bites (Iyidobi et al., 2012). This highlights the importance of early and appropriate treatment directed at preventing infective complications of bite wounds.

Management of bite wounds in the ED generally comprises wound washout, debridement, tetanus immunisation, and if appropriate rabies vaccination (Broom and Woods, 2006). In more severe bites, surgical evaluation may be required (Smith et al., 2000). It is recommended that prophylactic empiric antibiotics should be considered in cases where there is a high risk of subsequent infection (Box 1) (Campbell et al., 2009). Therapeutic Guidelines Australia provides peer-reviewed guidelines to assist clinicians in prescribing (eTG Complete, 2015). Oral amoxicillin with clavulanic acid 875/125 mg 12-hourly is considered to be the most appropriate first-line therapy in high-risk wounds as a defence against beta-lactamase-producing anaerobic bacteria (Raval et al., 2014). In patients with a penicillin allergy, oral ciprofloxacin 500 mg 12-hourly plus oral clindamycin 450 mg 8-hourly is indicated. In bite wounds with an established moderate to severe infection, admission to hospital is recommended, including an antibiotic regime of intravenous (IV) piperacillin with tazobactam 4/0.5g 8-hourly (eTG Complete, 2015).

The primary aim of this study was to describe the epidemiology of presentations after a mammalian bite injury to the ED of an adult tertiary referral centre. Secondary aims investigated the prescription of antibiotics and adherence to current clinical guidelines outlining the treatment for bites from human and animals.

Section snippets

Setting

The Alfred Hospital in Melbourne, Australia, is a major adult referral centre. The Alfred Hospital is the state of Victoria's adult primary referral centre for burns, haemophilia, acute haematological emergencies, hyperbaric therapy, HIV, bone marrow transplantation, heart–lung transplantation, cystic fibrosis and one of two centres for adult major trauma. The ED receives over 60,000 presentations per year, with an admission rate of around 50%. The ED is serviced by a fast-track service,

Results

Over the study period, there were 62,316 presentations to the ED and 472 cases who satisfied the search criteria, with 160 (33.9%) cases resulting from a mammalian source and included in the analysis (Fig. 1). Sex distribution among the included patients was equal (M:F = 79:81) with a mean age (SD) of 41.9 (1.4) years. Of the study population, 143 (89.4%) had features of high risk of infection, 113 (70.6%) had a bite to the head, hand or face, 57 (35.6%) had a delayed presentation, and 74

Discussion

Among all ED presentations in our study population, animal and human bites comprised 0.25%, with equal distribution between men and women. Delayed presentation of more than eight hours was associated with significantly higher rates of clinically identifiable infection, and patients requiring hospitalisation as a result of their bites were significantly older. Our study demonstrates a moderate rate of adherence (61.9%) to local antibiotic guidelines, suggesting an area for improvement.

The most

Conclusions

Animal bites to our tertiary referral ED were common, with the majority from dogs and affecting hands and fingers. Most cases were able to be discharged home from the ED, with delayed presentation associated with established infection. Prophylactic antibiotics and prescription for established cases followed local guidelines in 61% of cases, indicating an area of improvement. Intervention strategies, including education, need to be implemented to improve adherence to antibiotic guidelines.

Conflicts of interest

Dr. Mitra is supported by a fellowship from the National Health and Medical Research Council, Commonwealth of Australia.

References (16)

N. Babovic et al.
Cat bite infections of the hand: assessment of morbidity and predictors of severe infection
The Journal of Hand Surgery
(2014)
TongE.Y. et al.
Partnered medication review and charting between the pharmacist and medical officer in the emergency short stay and general medicine unit
Australasian Emergency Nursing Journal
(2015)
Australasian College of Emergency Medicine
Guidelines on the Implementation of the Australasian Triage Scale in Emergency Department
(2013)
J. Broom et al.
Management of bite injuries
Australian Prescriber
(2006)
S.G. Campbell et al.
A cellulitis guideline at a community hospital – we can reduce costs by standardizing care
JEPHC
(2009)
A. Crocker et al.
Factors affecting adherence to evidence-based guidelines in the treatment of URI, sinusitis, and pharyngitis
Journal of Community Hospital Internal Medicine Perspectives
(2013)
C. Dendle et al.
Review article: animal bites: an update for management with a focus on infections
Emergency Medicine Australasia
(2008)
C. Dendle et al.
Management of mammalian bites
Australian Family Physician
(2009)

There are more references available in the full text version of this article.

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Nursing workforce models, education and training needs to reflect the skill set required to respond to wound, skin and ulcer conditions to ensure that high quality skin and wound care continues outside of the emergency department.
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View full text

Bite wounds and antibiotic prescription among patients presenting to an Australian emergency department

Highlights

Abstract

Introduction

Methods

Results

Conclusions

Introduction

Section snippets

Setting

Results

Discussion

Conclusions

Conflicts of interest

The Journal of Hand Surgery

Australasian Emergency Nursing Journal

Guidelines on the Implementation of the Australasian Triage Scale in Emergency Department

Management of bite injuries

Australian Prescriber

A cellulitis guideline at a community hospital – we can reduce costs by standardizing care

JEPHC

Factors affecting adherence to evidence-based guidelines in the treatment of URI, sinusitis, and pharyngitis

Journal of Community Hospital Internal Medicine Perspectives

Review article: animal bites: an update for management with a focus on infections

Emergency Medicine Australasia

Management of mammalian bites

Australian Family Physician