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Rapid Responses: Rapid Responses published:
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Dog Bites: Don't forget PTSD
- John S Watts (26 February 2007)
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What not to do with dog bites
- Margaret K Cook (27 February 2007)
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Cephalexin is also a poor choice for animal bites
- Len D Moaven (28 February 2007)
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Prophylactic antibiotics
- Fiona M Murphy, Dr. Aisling Diamond (5 March 2007)
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Good article spoiled by barbed comments
- Graeme Mackenzie (6 March 2007)
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On Anthropomorphism and Bite Biases
- Charlotte J. Wallewein (16 April 2007)
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Primary closure of dog bite injuries
- Nadeem Akhtar, Matthew Smith, Sarah Chadwich (23 April 2007)
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Do not underestimate the risk of C. canimorsus
- Dirk J. Houwers (9 May 2007)
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John S Watts, Specialist Registrar in Child Psychiatry Orchard House Family Mental Health Centre, 17 Church Street, St. Peters, Broadstairs, Kent. CT10 2TT
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Editor - I enjoyed the Clinical Review article by Morgan and Palmer which offered a timely summary of the assessment and management of people bitten by dogs in the UK.(1) However, I was disappointed that no mention was made of the need for a psychiatric assessment, or even the consideration of psychiatric issues during the history and examination. There is evidence to show that children are at risk of developing Post-Traumatic Stress Disorder (PTSD) following such injuries.(2) Indeed, in a survey of 22 Belgian children who were bitten by dogs, 12 had symptoms of PTSD two to nine months following the bite.(3) Interestingly, the authors of this paper go on to say "...this survey leads to the conclusion that child victims of dog bites should be considered at risk for development of PTSD and need early psychological support".(3) Although I would not expect a full psychiatric history and examination to be completed by all clinicians who deal with dog bites, I would suggest that thought is given to the impact of such trauma on the psychological health of the victim, and where present, appropriate consultation from psychiatric professionals sought. 1. Morgan M, Palmer J. Clinical Review Dog Bites. BMJ 2007;334:413-7 (24 February.) 2. Rossman BBR, Bingham RD, Emde RN. Symptomatology and Adaptive Functioning for Children Exposed to Normative Stressors, Dog Attack, and Parental Violence. Journal of the American Academy of Child & Adolescent Psychiatry 1997;36(8):1089-97 (August.) 3. Peters V, Sottiaux M, Appelboom J, Kahn A. Posttraumatic Stress Disorder after Dog Bites in Children. The Journal of Pediatrics 2004;144:121-2 (January.) Competing interests: None declared |
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Margaret K Cook, Retired Consultant Haematologist St John's Hospital Livingston EH54 6PP
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Dear Editor, I read the article on Dog Bites in the British Medical Journal issue of 24 February with considerable interest. When I worked as a Consultant Haematologist, I had occasion to see in a relatively short space of time, three otherwise healthy patients who had received dog bites, and in whom the wounds rapidly extended to narcotising fasciitis. These patients were admitted to the Plastic Surgery Unit, and required extensive disfiguring surgery. I was called upon to assess whether they had any evidence of immune compromise. In each of these patients, the only factor identified was that in response to the initial injury, they had taken a non-steroidal anti inflammatory drug (NSAID). Some literature in connection with severe acute respiratory syndrome (SARS) and avian influenza suggests that NSAIDS and aspirin may promote Reyes syndrome and a fatal outcome in these infections to which the patients have little if any natural immunity. It is well recognised now that children with viral infections may get Reyes syndrome if given aspirin, for which it is not recommended for children under 16 in the UK. The otherwise excellent article did not specify that NSAIDs and aspirin should be avoided in dog bites, though it mentioned that patients on steroid therapy were at increased risk of infection. The relatively weak anti-inflammatory effect of NSAIDs and aspirin can cause significant morbidity when patients are challenged with novel organisms. Finally, I am fascinated by the increased risk to patients with post- mastectomy lymph oedema who are bitten, and can not find a reference to this particular aspect. Is the risk only when the bite is on the affected limb, or is it a more general risk? I would be delighted if the authors could give me more information. Yours sincerely, Margaret K Cook Retired Consultant Haematologist (St John's Hospital, Livingston) 24 Orchard Road South, Edinburgh EH4 3HZ No competing interests Competing interests: None declared |
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Len D Moaven, Director 24 Hope Street Seven Hills Australia
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I enjoyed the article. Much is rightly made of the poor choice of erythromycin and flucloxacillin for dog bites. But I would also add cephalexin (or first generation cephalosporins) to the list. They are commonly used (in Australia) and they often have in vitro activity against Pasteurella (and hence may be reported as sensitive) but often fail in vivo. Competing interests: Clinical microbiologist in private practice |
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Fiona M Murphy, SHO A&E Causeway Hospital BT53 6BP, Dr. Aisling Diamond
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The Causeway Hospital, Coleraine N.I. has yearly attendances of approximately 41,000. Between 05/03/06 and 05/03/07 51 people attended this department following dog bites. This unit does not use prophylactic antibiotics for dog bites. Consequently, there is no evidence that this group of patients re-attended with infected wounds. We agree that wound management is important but we do not advocate prophylactic antibiotics. Competing interests: None declared |
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Graeme Mackenzie, Out of Hours GP CUMBRIA
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This was an excellent article. Why spoil it by barbed generalisations about primary care? The picture shown and the text makes comments about poor primary care management of dog bites. Why does poor managment by individuals become an implied generalisation about primary care? The article would have been just as effective with a comment along the lines of, "a wound inappropriately sutured...". General practitioners tend to keep the failings of "secondary care" to themselves. We live in an imperfect world: made more imperfect by these sort of comments. Editor, please note. Competing interests: None declared |
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Charlotte J. Wallewein, Vet Med hopeful, Medical Secretary, and professional trainer of both dogs and doctors. Calgary Health Region Calgary, Alberta T3B 4H7
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Both Morgan & Palmer’s1 review of the treatment of dog bites and Besser’s2 addendum to the article fail to address the ultimate issue of why dogs bite. It is unfortunate that, despite the inroads that have been made toward our understanding of animal behaviour, anthropomorphism remains rampant in contemporary discussions of this topic. Although the mention was brief, and it was certainly not the purpose of the paper to discuss dog behaviour, analyses such as “dogs resent being disturbed while eating” and “they can be jealous of attention given to other family members”1 are neither verifiable, nor useful, when attempting to understand risk factors for dog bites. Attributing human emotions to dogs (jealousy and resent) affects the way that people interact with animals and may result in them putting themselves at risk (i.e. by attempting to “dominate” a dog that is being “resentful” rather than safely desensitizing an animal who is displaying, by human standards, inappropriate behaviour). While it is true that a dog may display agonistic behaviours when disturbed while eating, or behaviours that resemble jealousy amongst both people and other animals, it cannot be proven that these emotions are actually being felt by the animal and therefore such descriptions are best omitted.
I also find interesting the fact that no mention is made of the danger of cat bites. Although cat bites are said to be less prevalent than dog bites3, they are certainly capable of producing profound infection, and cat bite wounds may require hospitalization more frequently than those inflicted by their canid counterparts4. Additionally, cats are the primary host of Bartonella henselae, the aetiological agent of Cat Scratch Disease (whose name nicely captures the mode of transmission) which sends an estimated 2000 people to hospital annually in the United States alone5. Cats bite, dogs bite, hamsters bite – even humans bite each other, arguably more frequently than cats3 – and it is unlikely that any of these species can be prohibited from interacting with people (perhaps barring hamsters). Education programs to prevent animal bites in both children and adults are essential, as many people still believe that animals bite “without warning” (rarely the case, in reality). A greater understanding and appreciation of both the potential benefits and dangers of companion animals will be necessary if we are to continue to cohabit in an environment of liability and litigation.
1. Morgan M., Palmer J. Dog bites. BMJ 2007;334:413-17. (24 February.)
2. Besser R. Dog attacks: it’s time for doctors to bite back. BMJ 2007;334:425. (24 February.)
3. MacBean CE., Taylor DE., Ashby K. Animal and human bite injuries in Victoria, 1998-2004. MJA;186(1):38-40.
4. Stump JL. Animal bites. http://www.emedicine.com/emerg/topic60.htm (accessed Apr 2007).
5. Chomel BB., Boulouis H-J., Maruyama S., Breitschwerdt EB. Bartonella spp. in Pets and Effect on Human Health. Emerg Infect Dis 2006;12(3):389-394.
Competing interests: None declared |
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Nadeem Akhtar, SpR Plastic Surgery Northern General Hospital, Sheffield. S5 &HA, Matthew Smith, Sarah Chadwich
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Dear Sir, We read with interest the clinical review of the management of dog bites published recently in the BMJ.1 Whilst we agree with the overall message of this excellent article we find the advice on surgical management confusing. We feel the authors over-emphasize the occasions when such wounds require a second look and delayed primary closure. They also imply that primary closure of extremity wounds is bad practice and could lead to litigation. In a 5 year review of our experience of the surgical treatment of 114 children with dog bite injuries, 96% had their wounds closed primarily and only 3 developed infection.2 However, in keeping with other reports of childhood dog bites,3-5 the most frequent site of injury was the face (59%). This study helped us establish guidelines to optimize our clinical care including; early cleaning and dressing of all wounds, antibiotic prophylaxis starting preoperatively and primary closure where possible after irrigation and debridement. We recently re-audited our practice and analysis of both sets of data showed a total of 49 children with dog bite wounds of the extremities. In 90% the wounds were closed primarily including 3 skin grafts and 1 local flap. There were only 2 cases of infection, both successfully treated with antibiotics. Of course, guidelines are not designed to be comprehensive and each wound needs to be evaluated to determine the best method of treatment. In our original study 68% of the patients had more than one injury and 20% of these were puncture wounds which may not need suturing. Furthermore, in severe injuries with extensive tissue contusion, a second look might be necessary to ensure adequate debridement of devitalized tissue especially if complex reconstruction is required. Although we have only reviewed our paediatric practice, we use the same principles for the management of adult patients with dog bite injuries. We are currently reviewing the findings in this patient group but don’t expect there to be any significant differences. We believe that the surgical management of these injuries should be evidence based and not determined by fear of litigation. We advocate the primary closure not delayed closure of dog bite wounds in all areas to give the best functional and cosmetic result. Yours sincerely, Nadeem Akhtar Matt Smith Sarah Chadwick 1.Morgan M, Palmer J. Dog bites. BMJ 2007;334:413-7. (24 February) 2.Akhtar N, Smith MJ, McKirdy S, Page RE. Surgical delay in the management of dog bite injuries in children, does it increase the risk of infection? J Plast Reconstr Aesthet Surg. 2006;59(1):80-5 3.Palmer J, Rees M. Dog bites of the face: a fifteen year review. Br J Plast Surg 1983;36:315-8. 4.Tuggle DW, Taylor DV, Stevens RJ. Dog bites in children. J Pediatr Surg 1993;28:912-4. 5.Wiseman NE, Chochinov H, Fraser V. Major dog attack injuries in children. J Pediatr Surg 1983;18:533-6. Competing interests: None declared |
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Dirk J. Houwers, Vet Microbiologist/Senior Teacher Vet Faculty, University of Utrecht, Yalelaan 1, 3584 CL Utrecht, the Netherlands
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Many case reports on Capnocytophaga canimorsus infection after dogbite describe its disastrous consequences, locally or systemically. Its clinical course may be more rapid than the microbiological diagnostic procedures, even if they are appropriate -these bacteria require a specific approach. Nevertheless, these events appear to be comparatively rare. C.canimorsus is most probably part of the normal oral flora of dogs, hence every bite incident bears the risk of transmission. Basically, every (bite)wound is contaminated and this is only a problem if the bacteria present get the time to reach their replication phase. Usually, this is prevented by the victims defences which are strongly aided by adequate wound treatment. I wonder if the risk of selecting/inducing antimicrobial resistance induced by taking a single oral dose of co-amclav immediately after the incident outweighs the consequences of a wound infection, including those of long term antimicrobial treatment. In view of the uncertainties associated with more than superficial wounds and the -small- chance of a C.canimorsus-infection, I advise my veterinary students to consider this option after rigorous treatment of the wound in the event that they are bitten by one their patients. Dirk J. Houwers, DVM, PhD, specialist veterinary microbiology Competing interests: None declared |
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