Animal bites

S01.0-9/S11.0-2/S11.7-9/S21.0-2/S21.7-9/S31.0-5/S31.7-8/S41.0-1/S41.7-8/S51.0/S51.7-9/S61.0-1/S61.7-9/S71.0-1/S71.7-8/S81.0/S81.7-9/S91.0-3/S91.7/T01.0-3/T01.6/T01.8-9/T09.1/T11.1/T13.1/T14.0-1/A82.0-1/A82.9/Z24.2/Z20.3 + External Cause Code (W,X,Y,Z)

Note: Rabies and tetanus are notifiable medical conditions.

DESCRIPTION

Animal bites may be caused by:

  • domestic animals e.g. horses, cows, dogs, cats
  • wild animals e.g. jackals, mongooses (meerkats), bats

Animal bites may result in:

  • Wound infection, often due to mixed aerobic and anaerobic infection
  • Puncture wounds
  • Tissue necrosis
  • Transmission of diseases, e.g. tetanus, rabies.

NICD hotline for rabies advice: 0828839920

Suspected rabid bite

Any mammal bite can transmit rabies. Rabies incubation period is at least 9–90 days, but could be much longer. In suspected rabies exposure of a person by a domestic animal, attempt to trace source animal to determine likelihood of rabies. Observe the suspected rabid animal for abnormal behaviour for 10 days. If the animal remains healthy for 10 days, rabies is unlikely.

Note: If the animal has to be put down, care should be taken to preserve the brain, as the brain is required by the state veterinarian for confirmation of diagnosis. The animal must not be killed by shooting it in the head, as this will damage the brain.

Category Type of exposure Management
1
  • Touching/feeding of animal.

  • Licking of intact skin.
    		•
  • No treatment if history is reliable.

  • If history not reliable, treat as category 2.
    		•
    2
  • Nibbling of uncovered skin.

  • Superficial scratch without bleeding.
    		•
  • Wound management.

  • Administer full course vaccine. Only stop if animal tested negative for rabies or is still healthy after 10 days’ observation.

  • Don’t give immunoglobulin, except in immunocompromised patients.
    		•
    3
  • Bites/scratches that penetrate the skin and with any visible blood.

  • Licking of broken skin or mucous membranes e.g. eyes and mouth.

  • Bat bites:

    • –  Any close contact with a bat: single or multiple bites or scratches and bruising (even with minor bites or unapparent skin penetration).
    –  Direct physical contact with bat saliva or neural tissue; contact of mucous membranes with bat saliva, droppings or urine.
  • Wound management.

  • Administer full course vaccine.

  • Only stop if animal tested negative for rabies or is still healthy after 10 days’ observation.

  • Administer rabies immunoglobulin.

  • Administer tetanus vaccine.

  • Prescribe antibiotics.
    		•

    MEDICINE TREATMENT

    Emergency management

    Wound management:

    Wash wound thoroughly with soap under running water for 5–10 minutes.

    • Chlorhexidine 0.05%, solution.

    Apply disinfectant if available:

    • Povidone-iodine 10%, solution.

    CAUTION
    Do not suture bite wounds unless on the head/face.
    Clean thoroughly, dress (avoid compressive dressings) and review after 48 hours for secondary closure at that time.

    The following treatment may be commenced in facilities designated by Provincial/Regional Pharmaceutical Therapeutics Committees. If access to rabies vaccine and immunoglobulin is not immediately available refer urgently.

    Note : Rabies PEP (post exposure prophylaxis) schedule varies for immunocompromised patients. The degree to which a patient is immunocompromised should preferably be verified by a physician and includes congenital immunodeficiency, HIV infection, leukaemia, lymphoma, generalised malignancy, radiation, immunosuppressant medicines e.g. long-term therapy of corticosteroids, etc.

    Rabies immunoglobulin:

    • Only indicated for:
      • Category 3, immunocompetent patients.
      • Category 2 and 3 immunocompromised patients.
      • All bat exposures.
    • Available from the nearest district hospital.
    • If not immediately available, source and give as soon as possible.
    • Rabies immunoglobulin 20 IU/kg.
      • Infiltrate as much as possible in and around the wound and inject the rest IM (not buttock, unless the wound is on the buttock).
      • Follow with a complete course of vaccine.

    Rabies vaccination:

    • Only indicated for category 2 and 3 exposure.
    • Available from the nearest district hospital.

    Children

    • Rabies vaccine, 1 amp, IM anterolateral thigh.
      • Day 0 – single dose
      • Day 3 – single dose
      • Day 7 – single dose
      • Day 14 – single dose
      • Day 28 – single dose (only if immunocompromised).

    Adults

    • Rabies vaccine, 1 amp, IM deltoid.
      • Day 0 – single dose
      • Day 3 – single dose
      • Day 7 – single dose
      • Day 14 – single dose
      • Day 28 – single dose (only if immunocompromised).

    CAUTION
    Do not administer rabies vaccine into buttocks (gluteus maximus).

    Tetanus prophylaxis if not previously immunised within the last 5 years: Z23.5

    • Tetanus toxoid vaccine (TT), IM, 0.5 mL.

    Note: In a fully immunised person, tetanus toxoid vaccine or tetanus immunoglobulin may produce an unpleasant reaction, e.g. redness, itching, swelling or fever, but in the case of a severe injury the administration is justified.

    Antibiotic treatment (only for category 3 exposure, hand wounds):

    Children

    • Amoxicillin/clavulanic acid oral, 15–25 mg/kg/dose of amoxicillin component, 8 hourly for 5 days.
    Weight
    kg     		Dose
    mg
    (amoxicillin
    component)     		Use one
    of the
    following:     		Age
    months/years
    Susp
    125/31.5
    mg/5 mL     		Susp
    250/62.5
    mg/5 mL     		Tablet
    500/125
    mg/tab
    > 3.5 - 5kg 75 mg 3 mL 1.5 mL - > 1 - 3 mths
    > 5 - 7 kg 100 mg 4 mL 2 mL - > 3 - 6 mths
    > 7 - 9 kg 150 mg 6 mL 3 mL - > 6 - 12 mths
    > 9 - 11 kg 200 mg 8 mL 4 mL - > 12 - 18 mths
    > 11 - 14 kg 250 mg 10 mL 5 mL - > 18 mths - 3 yrs
    > 14 - 17.5 kg 300 mg 12 mL 6 mL - > 3 - 5 yrs
    > 17.5 - 25 kg 375 mg 15 mL 7.5 mL - > 5 - 7 yrs
    > 25 - 35 kg 500 mg 20 mL 10 mL 1 tablets > 7 - 11 yrs

    Children > 35 kg and adults

    • Amoxicillin/clavulanic acid, oral, 875/125 mg 12 hourly for 5 days.

    Severe Penicillin allergy (Z88.0)

    Children

    Children > 35 kg and adults

    • Macrolide, e.g.:
    • Azithromycin, oral, 500 mg daily for 3 days.

    AND

    Children

    Adults

    • Metronidazole, oral, 400 mg, 8 hourly for 5 days.

    PREVENTION

    • Regular vaccination of domestic cats and dogs.
    • Pre-exposure vaccine may be given to those at risk, e.g. occupation, endemic areas, laboratories.

    REFERRAL

    • Deep and large wounds requiring suturing.
    • Shock and bleeding.
    • Possible rabies exposure (for immunoglobulin and vaccination).
    • Severe infected wounds or infected wounds not responding to oral antibiotics.
    • Hand bites.