Injury 53 (2022) 227–236

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Educational article

Biting the hand that feeds you: Management of human and animal
bites
Katherine L. Elcock a,∗, Jenny Reid b, Olga L. Moncayo-Nieto c, Philippa A. Rust d
a
Medical student, University of Edinburgh
b
GP Trainee, NHS Borders and Global Health Academy, University of Edinburgh
c
Consultant Microbiologist / Honorary Senior Clinical Lecturer in Microbiology, Royal Infirmary of Edinburgh/University of Edinburgh
d
Consultant Hand & Wrist Surgeon, Hooper Hand Unit, St John’s Hospital, Livingston, West Lothian EH54 6PP, United Kingdom

a r t i c l e i n f o a b s t r a c t

Keywords: Bites from animal and humans represent a very small proportion of all the patients presenting to emer-
Bite gency departments, However, they require prompt medical and surgical intervention in order to minimise
Animal
the risk of infection, that may lead to limb and life-threatening complications. In this review article we
Human
synthesise the existing literature for treatment of human and animal bites and offer practical considera-
Infection
Limb complications tions when managing bite injuries.
© 2021 Elsevier Ltd. All rights reserved.

Introduction
Animal bites, including those from humans, account for 1% of
overall presentations to emergency departments in high income
healthcare settings [1,2]. Although bites from dogs, cats and hu-
mans are the most common, bites from farm and more exotic an-
imals also occur [3–7]. The type of animal can be used to predict
the pattern of injury, including anatomical site, severity, type of
injury and subsequent infection [2,7–9]. A number of studies indi-
cate that animal bites have a high rate of wound infection [10,11].
Early medical and surgical intervention can minimise the risk of
infection, that may lead to limb and life-threatening complications.
As such, it is important for clinicians to be aware of the common
presentations of bite injuries and the current guidelines for man-
agement.
This review synthesises the existing literature for treatment of
human and animal bites and offers practical considerations when
managing bite injuries.
Anatomy and mechanisms of injury
Dog bites
The upper extremities, head and neck are the most commonly
reported anatomical location of dog bites [3,4,12–15]. A 2014 study
found the most common age group admitted to hospital with dog
∗
Corresponding author: University of Edinburgh Medical School, Royal Infirmary
of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4TJ
E-mail address: s1705450@ed.ac.uk (K.L. Elcock).
bites were children under 9 years old and that, overall, females are
more commonly admitted to hospital than males [4].
Anatomical site of injury varies with age: adults are more com-
monly bitten on the hand and wrist, and children on the face
or neck [4]. With an average jaw strength of 256N and a spec-
trum of teeth ranging from rounded molars to long sharp canines,
adult dog teeth are capable of inflicting crush-type wounds caus-
ing devascularisation and bony avulsion, as well as inoculation of
infection (Fig. 1A) [16,17].
It is helpful to record a description of the bite, for example
a ‘snap and release’ mechanism is more likely to cause a punc-
ture wound, whereas a gripping or tearing mechanism can cause
broader tissue damage [13]. Soft tissue injury of the upper limb is
most commonly described in the literature, followed by soft tissue
injury of the head [4]. Soft tissue injury of the lower limbs and
open fractures are much rarer occurrences [4].
Cat bites
Cat bites represent approximately 20% of animal bites present-
ing to A&E [18]. Similarly to dog bites, cat bites commonly occur
on the hand and wrist, with a reported frequency of 45-63% of cat
bites presenting to hospital [19,20]. However, compared to dogs,
the teeth of cats are smaller, sharper and narrower, and thus ca-
pable of causing deeper puncture injuries which can pierce joint
capsules and inoculate oral flora deeper into periosteum and bone
(Fig. 1B) [2,16]. For this reason, cat bite wounds are associated
with higher rates of infection compared to bites from other ani-
mals [15,21].

https://doi.org/10.1016/j.injury.2021.11.045
0020-1383/© 2021 Elsevier Ltd. All rights reserved.
K.L. Elcock, J. Reid, O.L. Moncayo-Nieto et al.
Fig. 1. Photographs depicting the dental anatomy of some common animals: (A) dog, (B), cat, (C) horse, and (D) sheep.
Other common animal bites
Reports describing bites from other animals, including horses,
sheep, rats and monkeys, indicate that the hand is a common
anatomical location [22–25]. Pig bites are most commonly seen on
the forearm and lateral thigh and snake bites in the lower extrem-
ities [7,26–30]. Fig. 1 shows the varying dentition between dogs,
cats, horses and sheep. Horses have six upper and lower incisors
which have been reported to inflict bite injuries to the digits, par-
ticularly in children when feeding (Fig. 1C) [22,31–34]. Notably, ru-
minants, such as sheep, have a dental pad on the upper jaw in-
stead of upper incisors (Fig. 1D), which may account for fewer re-
ports in the literature of bites from sheep [34]. This review focuses
on bite injuries most common in a European setting.
Human bites
Human bites account for 2-3% of bites presenting to hospitals
[16]. Common sites of injury are the hands, including digits (25-
50%) and the face, including ears (35%) [16,35–37]. Some human
bite injuries may be associated with violence or assault, therefore
gaining an adequate history is essential. History taking in these
cases may be difficult and there may be medicolegal implications.
Human bites can be further classified into clenched fist bites
and occlusive bites. Kennedy et. al described clenched fist bites as
the most common type of human bite; however, a study of 388 pa-
tients presenting with human bites over a seven year period found
that only 7.7% of human bite presentations were clenched fist bites
[35].
Clenched fist bites, commonly referred to as ‘fight bites’, are
caused by the collision of a clenched fist and the teeth of an-
other human [16]. They are most commonly reported in males and
typically there is a delay in presentation to hospital [38,39]. Due
to minimal soft tissue protection and prominent positioning, the
third, fourth or fifth metacarpophalangeal joints (MCPJ) are most
often damaged [16,38–40]. A study of 194 skin lacerations due to
clenched fist injuries showed that 75% suffered damage to tendon,
joint, cartilage and/or bone [39]. Finger extension on relaxation of
the hand following a ‘fight bite’ can create a closed environment,
as the damaged extensor tendon retracts to seal the inoculated tis-
sues and joint capsule (Fig. 2)[41]. This ‘trap door phenomenon’
can result in bacterial colonisation of the wound, leading to sep-
tic arthritis and osteomyelitis [16,40]. An occasionally associated
bony injury is the ‘boxer’s fracture’, a fracture of the 4th or 5th
metacarpal neck with volar flexed angulation [41]. These fractures
lead to loss of the knuckle contour, de-functioning of the extension
tendon with an extensor lag and, when significantly flexed, promi-
nence of the metacarpal head in the palm on grip.
Occlusive bites are caused by a classic bite mechanism of teeth
closing over tissue. These types of bites may be associated with
228
Injury 53 (2022) 227–236
sexual activity, assault, abuse or self-defence [16]. The anatomical
location of occlusive bites varies depending on type of crime, age
and sex of victim, with men typically suffering more bites to the
arm and women to the breast [42]. Injury from occlusive bites can
range from a semi-circular imprint to traumatic amputation, and
hand bites are associated with higher rates of infection [16,43]. The
most common facial bite injuries reported are those to the ear car-
tilage [37].
Microbiology
Risk factors for developing infection
Infection is the most common complication following an animal
or human bite [44,45]. It is therefore important for the clinician
to be aware of the risk factors that predispose bacterial coloni-
sation and increase the likelihood of infection from a bite injury,
including the risk of viral transmission. Research has shown the
major risk factors for developing infection to include: site of in-
jury on hand or arm, assailant animal (cat>dog), puncture-type
wounds, full-thickness wounds, delay-to-treatment, female sex, age
(neonates, infants and >50 years), immunocompromised or comor-
bid host [1,14,19,46–49].
Injuries on the hand or avascular structure
The most common anatomical location for bites are the hands,
arms and face [2,50]. However, rates of infection are higher in bites
of the hand and wrist, due to the small compartments within the
hand enclosing nerves, vasculature, tendons and joints, compared
to the maxillofacial region, which has better venous drainage and
arterial supply [2,51,52]. Inoculation of closed deep palmar spaces
in the hand (including the flexor sheaths, radial or ulnar bursae,
and thenar and midpalmar spaces) require special consideration as
infection can spread easily and rapidly between spaces. Similarly,
avascular structures including ear cartilage, have been shown to
have increased rates of infection [37].
Assailant animal (cat > dog)
The type of animal also affects the likelihood of a bite becom-
ing infected; for example, cat bites are twice as likely to become
infected as dog bites [15,21]. A range of infection rates are reported
in the literature, with cat bite infection rates ranging from 30-50%
and dog bite from 2-20% [10,49,53,54]. The increased rate of in-
fection following cat bites, is thought to be due to a deeper pierc-
ing mechanism of inoculation afforded by the smaller teeth of cats
(Fig. 3) [15,21,54]. Not only are the teeth of cats more likely to
penetrate into bone and joint capsules, but the small nature of the
puncture wounds makes them more likely to be missed by clini-
cians [15].
K.L. Elcock, J. Reid, O.L. Moncayo-Nieto et al.
Fig. 2. A human hand exhibiting ‘trap-door phenomenon’.
[A] The red arrow indicates the path of penetration of human teeth through skin (blue), extensor tendon (green) and joint capsule (pink) over metacarpophalangeal joint in
right hand.
[B] On finger extension, the locations of rupture no longer align. This not only seals any inoculated bacteria inside the wound, but also conceals the true extent of injury
from the patient and clinician. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
Fig. 3. A human hand showing a common anatomical location of a clenched fist
injury on the 3rd and 4th MCP joints.
Wound type
Historically, puncture wounds were thought to have higher
rates of infection [14,50]. However, more recently, Dire et. al found
no increase in infection rates for puncture wounds, but noted that
they were more likely to be treated with extensive antimicro-
bial therapy [48]. Extensive tissue damage caused by full thickness
wounds, for example due to a tearing injury, has been shown to
predispose colonisation of bacteria and increase likelihood of in-
fection compared to partial-thickness wounds [14,48].
Delay to treatment
Early management on presentation decreases the likelihood of
developing an infection [14,47]. Callaham et al. found that 44% of
patients presenting between 24 and 48 hours after the injury went
on to develop infection, compared to only 8.8% of patients pre-
senting within 24 hours [14]. However, other studies have found
no significant difference in infection rates relating to delay [48].
Human bites commonly present late due to factors such as embar-
rassment and fear of legal consequences, and this delay increases
the risk of infection [37,55].
Demographics
The higher incidence of bite infection in females is likely linked
to the higher rate of cat bites in females compared to males
229
Injury 53 (2022) 227–236
[21,44]. The reason for this further disparity could be owing to the
higher incidence of cat owners amongst females [56].
Studies of animal bite patients have found that those over the
50 years of age are six times more likely to develop infection than
those under 50 years [6,14,48]. An increased susceptibility to infec-
tion is seen in elderly populations and is commonly attributed to
a declining immune response, senile physiologic changes and en-
vironmental influences [57]. Neonates and infants are also more
likely to develop infection following bite injuries [6,58].
Patients who take immunosuppressive medication or have im-
munocompromising conditions such as diabetes, cancer, asplenism,
Acquired Immunodeficiency Syndrome (AIDS) and alcoholism, are
more likely to develop infection [6,58–60]. An increased awareness
of patient groups at increased risk of infection can help facilitate
prompt, appropriate and thorough treatment.
Common pathogens cultured from bite wounds
Research demonstrates that cultures taken from infected ani-
mal bites are most commonly polymicrobial and can be aerobic or
anaerobic bacteria [7,9,20]. Cultured species typically reflect those
found in the oral cavities of the assailant animal; either oral com-
mensal flora or residual bacteria from food ingestion [7–9,61]. In
some cases, particularly those of aquatic animal bites, the infect-
ing bacteria can originate from the surrounding environment, or
the victim’s skin [7,62]. Whilst a wide array of pathogens have
been implicated in bite infections, studies indicate that Streptococ-
cus, Staphylococcus and Eikenella species to be the most frequently
cultured from human bites, Pasteurella from domestic animals and
Actinobacillus from livestock [7–9,16,20,34,38,61,62]. A summary of
the most common bacteria isolated from human and animal bites
can be found in Table 1.
Dog and cat bite pathogens
Pasteurella is an aerobic Gram negative bacillus that colonises
the oral mucosa of cats and dogs [63–68] The main species and its
sub-species P. multocida and P. canis were the most commonly cul-
tured pathogens found in the bites of dogs and cats [2,20,62,63].
Studies on cultures of patients with infected wounds have found
them to contain an average of five isolates [20]. As well as Pas-
teurella, other commonly cultured aerobes include Staphylococcus,
K.L. Elcock, J. Reid, O.L. Moncayo-Nieto et al. Injury 53 (2022) 227–236

Table 1
Summary of common anatomical locations and bacteria cultured from infected human and animal bites

Assailant Common anatomical location Common bacteria cultured from infected bite
Human Hand (middle, ring and little MCPJs) Streptococcus anginosus
Face (including ear) Staphylococcus aureus
Genitalia Fusobacterium nucleatum
Eikenella corrodens
Dog [7,65,76] Hand Pasteurella sp.
Wrist
Face - P. canis
- P. multocida

Staphylococcus sp.

- S. aureus
- S. epidermidis

Streptococcus sp.

- S. mitis
- S. mutans

Neisseria sp.

- N. weaveri

Moraxella sp.Bacteroides sp.Fusobacterium sp.

cat [7,59,65] Hand Pasteurella sp.
Wrist
Face - P. multocida

Staphylococcus sp.

- S. epidermidis
- S. warneri

Streptococcus sp.

- S. mitis
- S. sanguis
- S. mutans

Neisseria sp.

- N. weaveri

Moraxella sp.

- M. catarrhalis

Bacteroides sp.Fusobacterium sp.Corynebacterium sp.

- C. aquaticum

Pig [7,26–29] Lateral thigh [26] Streptococcus sp.

Forearm [27] Pasteurella sp.
Bacteroides sp.
Proteus sp.
Escherichia coli
Horse [7,77,78] Hand [79] Actinobacilus lignieresii
Actinobacillus equuli–like bacterium
Staphylococcus aureus
Neisseria sp.
Streptococcus sp.
Rat [7,80–85] Hand Streptobacillus moniliformis
Spirillum minus
Monkey [7,86] Hand Eikenella sp.
Streptococci sp.
Enterococci sp.
Staphylococcus epidermidis
Neisseria sp.
Haemophilus sp.
Snake [87–89] Lower extremities Morganella morganii,
Group D streptococcus
Providencia rettgeri
Bacteroides sp.
Enterobacter sp.
Escherichia coli

230
K.L. Elcock, J. Reid, O.L. Moncayo-Nieto et al.
Streptococcus, Moraxella and Neisseria species. Microbiological iden-
tification has advanced significantly through use of novel tech-
niques. These advances have highlighted an increase in the iden-
tification of Neisseria species such as N. weaveri and N. zoodegmatis
as genuine pathogens able to cause significant disease [64–66].
Less commonly found are anaerobes including Bacteroides, Fu-
sobacterium and Capnocytophaga canimorsus [20,67]. Anaerobes
tend to be found in polymicrobial cultures rather than in isolation
[20].
Pasteurella wound infection has an early onset, typically pre-
senting within 12-24 hours on injury [63]. Early features of the
infection include inflammation, ranging from local cellulitis to pu-
rulent or bloody discharge to abscesses, septic arthritis and os-
teomyelitis [2,61,62]. If left untreated, local infection can progress
to sepsis and other complications including peritonitis, endocardi-
tis and meningitis, particularly in the immunocompromised and
comorbid [2,61,62]. The recognition of this characteristic onset
of Pasteurella infection can aid in distinguishing it from other
pathogens, such as Staphylococcus or Streptococcus [20], and there-
fore guide the doctor to the correct treatment (discussed below).
Other animal bite pathogens
Bites from other animals are most commonly polymicrobial and
are outlined in Table 1.
Human bite pathogens
The reported rate of infection of human bites is around 10-20%
[37,55]. Infection can be attributed in part to the high number and
concentration of microbes found in the oral cavity of humans [52].
Similar to animal bites, infected human bites are usually
polymicrobial, containing isolates of both aerobes and anaerobes.
A study of 50 patients with infected human bites found the most
common organisms isolated in culture were Streptococcus angi-
nosus (54%), Staphylococcus aureus (52%), Fusobacterium nucleatum
(32%) and Eikenella corrodens (30%) [38]. These findings are sup-
ported by more recent studies [16,68,69].
It is also important to consider the mechanism of the bite and
whether there was contact with blood from the biter, as human
bites have been reported as a source of transmission of blood-
borne viruses (BBVs) such as Hepatitis B, Hepatitis C and Human
Immunodeficiency Virus (HIV) [70–74].
Lohiya et al. reviewed a total of 273 (resident to staff) bite in-
cidents in long-term care facility in California between 20 0 0 and
2011 [75]. They reported an incidence of 36 bites per 10 0 0 resident
years. The prevalence amongst their residents for BBVs was of 5%
HBsAg carriers, 0.8% of Hepatitis C antibody carriers and 0% of HIV
antibody. They could not demonstrate evidence of bite-related BBV
transmission events. Cresswell et al. undertook a systematic review
of the literature on the risk of HIV transmission through biting or
spitting [72]. They could not identify evidence of HIV transmission
related to spitting but found nine cases of HIV infection following
a bite. Of these, only four were classified as confirmed or highly
plausible. None were in the UK or related to emergency workers.
They advocate that necessary conditions for the transmission of
HIV appear to be the presence of untreated HIV infection, severe
trauma (involving puncture of the skin) and the presence of blood
in the mouth of the biter. In the absence of these conditions, post-
exposure prophylaxis is not indicated.
Initial management
Irrigation and debridement
Large volume irrigation of bite wounds with 0.9% sodium
chloride is an important initial step in preventing infection
231
Injury 53 (2022) 227–236
[2,45,46,54,90–93]. Recommendations specify use of a 20mL sy-
ringe and 19-gauge needle in the Emergency Department or in an
operating theatre, depending on the severity of the injury [2,90,91].
Administration of local anaesthesia is recommended to allow suffi-
cient irrigation and debridement [2,46]. Copious use of plain water
to irrigate laceration wounds has been shown to be non-inferior
to saline; however, bite wounds are often excluded in these trials
and as such, no evidence specific to bite wounds has been found
for inclusion in this review [94–96].
Tetanus and rabies immunisation
A tetanus booster is recommended if over ten years have
elapsed since tetanus vaccination [97]. Individual risk assessment
should be carried out and where there is uncertainty, local guide-
lines should be consulted in. Tetanus transmission is more com-
mon in dog and cat bites, as these animals can be coprophagic
[97].
Rabies in animals has been eradicated from the UK since the
1920s, however, bites acquired overseas may pose a risk; particu-
larly dog and bat bites from endemic countries such as India and
Thailand [98]. Where post-exposure prophylaxis is indicated, local
guidelines or a virologist should be consulted [97,98].
Further initial management steps
Further initial management steps to be completed in an Emer-
gency Department include:
 Elevation of the affected limb to reduce swelling.
Elevation of the bitten limb can reduce inflammation and pro-
mote drainage of oedema [2,44,46,97].
 Appropriate radiological imaging.
Usually plain radiographs, to exclude foreign bodies (e.g. teeth)
and any bony injuries [99].
 Pus or wound swab for microbiology prior to wound irriga-
tion and antibiotic therapy.
It is good practice to obtain wound culture, via aspiration or
swab, prior to commencing antimicrobial therapy or irriga-
tion [100]. However, this is found to have little predictive
value [76,90].
 Prompt antibiotic therapy, either oral or intravenous accord-
ing to severity and local antimicrobial guidelines. See below.
Medical management
Dog and cat bites
Empirical antibiotic therapy
Due to the polymicrobial nature of infected animal bites, empir-
ical broad-spectrum antibiotic therapy targeted at Pasteurella, Neis-
seria, Streptococci, Staphylococci, and anaerobes is recommended
[20,61]. Co-amoxiclav is widely recommended for animal and hu-
man bites [20,49].
Recommendation: Empirical Co-amoxiclav (if penicillin allergy
– doxycycline or ceftriaxone and metronidazole).
Prophylactic antibiotics
The benefit of prophylactic antibiotics in non-infected animal
bites is disputed throughout the literature, with several studies
showing no statistically significant difference in rates of infection
K.L. Elcock, J. Reid, O.L. Moncayo-Nieto et al.
Fig. 4. Characteristics of high-risk animal bites that may necessitate prophylactic antibiotics.
of low-risk wounds between patients treated with antibiotic pro-
phylaxis and those who are not [43,46,49,53,90–92,101,102]. How-
ever, some studies have identified factors that classify a bite injury
as high-risk and have shown the benefit of prophylactic antibiotics
in these cases (Fig. 4) [90,91,102].
Based on evidence from international literature, prophylactic
antibiotics are recommended for use only in high-risk bite wounds.
Despite this, a survey in 2013 identified that 98% of plastic surgery
units in the UK routinely use prophylactic antibiotics to manage all
animal bite wounds [2]. However, severe and/or deep bite injuries
are more likely to be referred for specialist review.
Recommendation: Prophylactic antibiotic use in high-risk ani-
mal bite wounds only.
Human bites
Empirical antibiotic therapy
For each clinical situation we provide a recommendation based
on the literature; however, clinicians should follow local antimicro-
bial guidelines and may seek advice from the microbiology team.
The polymicrobial nature of human bites necessitates empirical
management using broad spectrum antibiotics with aerobic, anaer-
obic and anti- β -lactamase cover [38,103]. There is increasing re-
sistance of E. corrodens to clindamycin, and Co-amoxiclav is con-
sidered superior; a combined therapy of amoxicillin and clavulanic
acid [38,104].
Recommendation: Empirical Co-amoxiclav (if penicillin allergy
– doxycycline or ceftriaxone and metronidazole).
Prophylactic antibiotics
A review in 2005 concluded that prophylactic antibiotic man-
agement was not indicated in low-risk human bites, defined as
bites penetrating no deeper than the epidermis and not involving
structures of the hand, feet or skin overlying cartilaginous struc-
tures or joints [105]. These injuries would often be treated in
Emergency Departments or General Practice as they do not require
surgical management.
Recommendation: Prophylactic antibiotics recommended for
deep bites (excludes epidermal) and/or involving the hand, feet or
overlying cartilaginous structures or joints.
Risk assessment for blood-borne viruses
Undertake a clinical risk assessment of the possibility of BBV
from the biter and consider discussion with a virologist. Post-
exposure prophylaxis following a bite from an HIV-positive person
232
Injury 53 (2022) 227–236
is not routinely recommended unless in extreme circumstances as
described above.
Surgical management
Surgical management may be indicated in bite injuries to treat
infection and prevent secondary morbidity and mortality. A further
common indication for surgery is to explore the wound and repair
any damaged structures, such as nerves, muscle fascia and tendons,
to restore function and, in larger skin wounds, for cosmesis.
Closure versus Non-closure
Signs of clinical infection are a contraindication for wound clo-
sure in the Emergency Department or acute setting. Many bite
wounds are left to heal by secondary intention or are closed only
after thorough washout and debridement (multiple operations may
be required) and a period of antibiotic therapy [2].
There remains uncertainty whether primary closure versus de-
layed closure or no closure affects infection rates in dog bites, and
further research is needed [106]. However, use of validated cos-
metic outcome scores found ‘no clinically important difference in
cosmesis’ between wounds treated with primary closure versus no
closure [106,107].
Recommendation:
- Primary closure of animal bite wounds is acceptable only if
there is adequate irrigation and debridement.
- Wounds at high risk of infection should be left to heal by sec-
ondary intention unless the wound size is such that it would
take too long to heal, and cosmetic closure is indicated (delayed
closure once infection has resolved).
Surgical management of complicated human and animal bite wounds
Bite wounds complicated by underlying fractures, tendon
and/or nerve injuries should only undergo definitive treatment (i.e.
internal fixation) following thorough irrigation and debridement,
to minimise the risk of infection [2]. Active infection is an absolute
contraindication to osteosynthesis or tendon or nerve repair.
K.L. Elcock, J. Reid, O.L. Moncayo-Nieto et al.
Fig. 5. Diagram showing treatment plan for animal/human bite injuries presenting to the Emergency Department.
Recommendation:
- Primary management: irrigation and debridement of wound.
- Secondary management: soft tissue repair and fracture fixation.
If the contamination is severe, the repair many need to be de-
layed until a later stage.
Swab and culture of wound tissue
The Infectious Diseases Society of America (IDSA) recommends
obtaining blood cultures, tissue aspirates and skin biopsies for mi-
crobiological culture from patients that have suffered bites [97].
Whilst limited evidence shows non-inferiority and, in some
cases, increased sensitivity of a swab polymerase chain reaction
(PCR) compared to curetted wound tissue for bacterial isolation,
this is not currently recommended for diagnosis as it is labour in-
tensive and expensive [108–110].
Tissue specimens for microbiological culture may also be taken
from animal bites requiring surgical management. Studies on
233
Injury 53 (2022) 227–236
periprosthetic joint infection provide evidence to indicate that five
intraoperative culture samples held for at least eight days is suf-
ficient to diagnose a joint infection [111,112]. However, evidence
pertaining to infected animal bite wounds was not found.
Conclusion
Bite injuries, both due to human or animal bites, are a common
presentation to Emergency Departments and are often reviewed by
surgical trainees. Prompt and appropriate initial management may
prevent infection, injury site morbidity, sepsis and other morbidity.
Acute irrigation and empirical therapy may avoid hospital admis-
sion. An awareness of the common anatomical sites, polymicrobial
nature and need for timely irrigation and empirical antibiotic ther-
apy of bite injuries is paramount. This review draws from litera-
ture to provide key considerations and recommendations for the
medical and surgical management of patients presenting with bite
injuries.
K.L. Elcock, J. Reid, O.L. Moncayo-Nieto et al.
CME learning points
• Bite infection rates reported for cats and dogs are 30-50% and
2-20%, respectively [10,49,53,54]. The increased infection rate
following cat bites may be due to a deeper piercing mechanism
of inoculation afforded by their smaller teeth.
• Streptococcus, Staphylococcus and Eikenella species are the most
commonly cultured organisms from human bites.
• Pasteurella and its sub-species P. canis and P. multocida are the
most commonly cultured pathogens found in the bites of dogs
and cats, respectively.
• Pasteurella wound infection has an early onset, typically pre-
senting within 12-24 hours on injury.
• Due to the polymicrobial nature of infected animal bites, em-
pirical broad-spectrum antibiotic therapy targeted at Pasteurella,
Neisseria, Streptococcus, Staphylococcus, and anaerobic species is
recommended
• Following a ‘fight bite’ over the MCPJ, finger extension on re-
laxation of the hand can create a closed environment, as the
damaged extensor tendon retracts to seal the inoculated tissues
and joint capsule. Flexor sheath and deep space infections in
the hand are a surgical emergency.
• Wounds at high risk of infection should be left to heal by sec-
ondary intention unless the wound size is such that it would
take too long to heal, and cosmetic closure is indicated.
Conflict of interest
The authors declare no conflict of interest in relation to the
content of this manuscript.
Appendix 1
Search Terms:
1 [[“human”[MeSH Terms] OR “animals”[TEXT WORD] OR mam-
malian[TEXT WORD] OR cat [TEXT WORD] OR dog∗ [TEXT
WORD] OR horse∗ [TEXT WORD] OR sheep∗ [TEXT WORD]
OR pig∗ [TEXT WORD] OR rat∗ [TEXT WORD] OR snake∗ [TEXT
WORD]] AND bite∗ AND management [TEXT WORD]]
2 [[“human”[MeSH Terms] OR “animals”[TEXT WORD] OR mam-
malian[TEXT WORD] OR cat [TEXT WORD] OR dog∗ [TEXT
WORD] OR horse∗ [TEXT WORD] OR sheep∗ [TEXT WORD]
OR pig∗ [TEXT WORD] OR rat∗ [TEXT WORD] OR snake∗ [TEXT
WORD]] AND bite∗ AND treatment [TEXT WORD]]
3 [[“human”[MeSH Terms] OR “animals”[TEXT WORD] OR mam-
malian[TEXT WORD] OR cat [TEXT WORD] OR dog∗ [TEXT
WORD] OR horse∗ [TEXT WORD] OR sheep∗ [TEXT WORD]
OR pig∗ [TEXT WORD] OR rat∗ [TEXT WORD] OR snake∗ [TEXT
WORD]] AND bite∗ AND antibiotics [TEXT WORD]]
4 [[“human”[MeSH Terms] OR “animals”[TEXT WORD] OR mam-
malian[TEXT WORD] OR cat [TEXT WORD] OR dog∗ [TEXT
WORD] OR horse∗ [TEXT WORD] OR sheep∗ [TEXT WORD]
OR pig∗ [TEXT WORD] OR rat∗ [TEXT WORD] OR snake∗ [TEXT
WORD]] AND bite∗ AND microbiology [TEXT WORD]]
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