Prophylactic oral antibiotics for low-risk dog bite wounds.

The use of prophylactic antibiotics in the initial treatment of noninfected dog bite wounds is controversial. All patients with noninfected dog bite wounds who presented to our emergency department (ED) over a two-year period were considered for entry into a randomized prospective study. Patients were excluded from the study if they had any high-risk criteria for infection: puncture wounds, hand or foot wounds, wounds greater than 12 hours old, a history of immunocompromising disorders, or the use of immunosuppressive drugs. Patients in the antibiotic group (n = 89) were treated with local wound care and given either dicloxacillin, cephalexin, or erythromycin orally for seven days. Patients in the control group (n = 96) received local wound care only. All patients had their wounds irrigated with a 1% povidone-iodine solution and debrided and sutured if clinically indicated. All patients were subsequently reevaluated for clinical signs of wound infection. The groups were similar in age, sex, time of delay in seeking treatment, anatomic sites of wounds, depths and types of wounds, and number of wounds requiring suturing. The wound infection rates for the antibiotic and control groups were 1.1 and 5.1%, respectively. This difference was not significant (P = 0.212). There were 36 wounds in the antibiotic group and 37 wounds in the control group that were full thickness. The infection rates for these wounds were 2.8 and 13.5%, respectively. This was not statistically significant (P = 0.132). This study suggests that prophylactic oral antibiotics in low-risk dog bite wounds are not indicated.     

Human bites in children.

Human bites are common during childhood and usually result from fights or aggressive play with another child. Bites may present as indentation marks, scratches, abrasions, contusions, or lacerations. Most human bite wounds are sustained on the upper extremities, followed by the face and neck, the trunk, and the lower extremities. Infection is the most common complication. Cultures of an infected bite wound yield an average of five microorganisms. This article reviews the current recommendations on the management of human bite wounds in children.     

Human bites in children. A six-year experience

Three hundred twenty-two human bites in children, occurring during a six-year period, were reviewed. The majority occurred during warm-weather months between 2 PM and 11 PM. The upper extremities (42%), face and neck (33%), and trunk (22%) were most commonly bitten. At the time of injury, children were most often engaged in fights (61%) or play (26%). Seventy-five percent of wounds were superficial abrasions, 13% were punctures, and 11% were lacerations. None of the 242 abrasions became infected as opposed to 38% of the punctures and 37% of the lacerations. Other factors associated with increased risk of infection were delay in initial physician assessment beyond 18 hours after injury, location of the bite on the upper extremities, and occurrence of injury during sports activities. Prophylactic use of penicillin was probably not effective in reducing infection rates in these children; however, prospective data are needed to properly address this issue.     

Microbiology of human and animal bite wounds in children

Aspirates from bite wounds in 39 children (21 with animal bites and 18 with human bites) were cultured for aerobic and anaerobic bacteria. Aerobic bacteria only were recovered in 7 (18%) wounds, anaerobic bacteria only in 3 (8%) and mixed aerobic and anaerobic bacteria in 29 (74%). A total of 59 isolates was recovered from animal bites (2.8/specimen): 37 aerobes (1.8/specimen); and 22 anaerobes (1.0/specimen). A total of 97 isolates were recovered from human bites (5.4/specimen): 44 aerobes (2.4/specimen); and 53 anaerobes (3.0/specimen). The most frequent isolates in both types of wounds were Staphylococcus aureus, anaerobic cocci and Bacteroides spp. Present only in animal bites were Pasteurella multocida, Pseudomonas fluorescens and M-5. Present only in human bites were Group A streptococci. Eighteen beta-lactamase-producing organisms were isolated in 16 wounds. This study demonstrates the polymicrobial aerobic-anaerobic nature of human and animal bite wounds.     

Red-back spider bites to Perth children, 1979-1988

The aim of this study was to describe the pattern of illness caused by red-back spider bites to children in Perth, Western Australia, over a 10 year period, and to compare it with that in adults. The case-notes of 241 (89%) of the 271 children admitted to Princess Margaret Hospital and Fremantle Hospital with suspected red-back spider bite from 1979 to 1988 were available for analysis. A definite bite was defined as a definite bite by a positively identified red-back spider, positive identification of a red-back spider with no definite bite but the later development of typical symptoms or no definite history of red-back spider bite but strong clinical evidence and complete recovery after administration of antivenom. Systemic envenomation was accepted if there were symptoms of vomiting, generalized pain or sweating, or abdominal pain.
Sixty-five per cent of children were definitely bitten. As found in previous adult and mixed studies, there was a peak incidence in the warmer months with a male preponderance (68%); 81% of bites were to the extremities and 83% of bites occurred in the daytime. The syndrome produced in children was usually similar to that seen in adults.
Twenty-one per cent of children received antivenom, a rate comparable to previous studies in older age groups; however, no child received more than one ampoule. Compared with data extracted from a previously published study at Fremantle Hospital, in which 37% of adults treated with antivenom received more than one ampoule, these findings suggest that contrary to current opinion children may not be at an increased risk of morbidity from latrodectism.     

Pasteurella multocida meningitis in infancy. An avoidable infection

Pasteurella multocida is a common commensal in the upper respiratory tracts of cats and dogs. Infection with P multocida in humans usually follows infected bite wounds; however, infection in humans unrelated to animal bites is rare. We describe two infants with P multocida meningitis in whom infection was probably related to nontraumatic facial licking by household pet dogs. Both patients recovered fully. Although the risk is low, parents should be informed that mucous membrane exposure to household pets may expose an infant to the risk of systemic P multocida infection.     

Subdural empyema complicating cerebrospinal fluid shunt infection.

Subdural empyema has not been reported previously as a complication of cerebrospinal fluid (CSF) shunt surgery. An infant submitted to CSF shunt insertion for congenital hydrocephalus developed subdural empyema after a failed attempt to treat a superficial scalp wound infection with oral antibiotics. Enterobacter cloacae was isolated from the empyema. Temporizing management of the preceding superficial wound infection with oral antibiotics probably was the cause of this exotic pathogen. The treatment of infected scalp wounds contiguous with shunt hardware must be surgical.     

Follow-up urine cultures and fever in children with urinary tract infection

BACKGROUND: The American Academy of Pediatrics practice parameter for urinary tract infection suggests a repeat urine culture if the expected clinical response is not achieved within the first 48 hours of therapy. The utility of repeat urine cultures and clinical significance of fever at 48 hours is unclear. OBJECTIVES: To determine the frequency of positive repeat urine cultures in children admitted to the hospital with urinary tract infection, and to describe the fever curves of children admitted to the hospital with urinary tract infection. DESIGN AND METHODS: We reviewed all cases of urinary tract infection in children 18 years and younger who were admitted during a 5-year period to Children's Hospital of Wisconsin (Milwaukee). We recorded temperatures from hospital admission to discharge, age, sex, initial and follow-up culture results, antibiotics received, imaging performed, and medical history. RESULTS: Urinary tract infection was identified in 364 patients, and 291 (79.9%) had follow-up urine cultures. None were positive. Follow-up cultures produced 21,388.50 US dollars in patient charges. Fever lasted beyond 48 hours in 32% of patients. Older children were more likely to have fever beyond 48 hours. CONCLUSIONS: Follow-up urine cultures were of no utility in children hospitalized for urinary tract infection, including those with fever lasting beyond 48 hours or those with an underlying urologic disease. Fever beyond 48 hours is common and should not be used as a criterion for obtaining a repeat urine culture. These conclusions are valid for children with vesicoureteral reflux. Such an approach would result in significant cost savings.     

Review of 59 patients hospitalized with animal bites

We reviewed the charts of 59 pediatric and adult patients hospitalized because of animal bites (46 dog bites, 10 cat bites, 3 monkey bites). The bites of 40 of the 59 patients were infected at the time of admission. Gram-stained specimens correctly predicted the infecting bacteria in only 5 of 20 cases. Eighty-three percent of the bacterial isolates were penicillin-susceptible. Before admission 14 patients had received outpatient antibiotic prophylaxis and the infections in 11 of these 14 patients were caused by bacteria susceptible to the prophylactic antibiotic. Complications were more common if antimicrobial therapy had not been altered according to susceptibility testing results. Of the 59 patients 19 were admitted immediately after being bitten because of severe uninfected bites. Of these 19 patients 18 received prophylactic antibiotics and none developed a serious complication.     

Snake Bite in Children: A Five Year Population Study from South-East Queensland

A consecutive series of 71 childhood snake bite incidents is reported. The children were admitted for suspected or confirmed snake bite to four hosptials in south-east Queensland in the 5-year period 1971–1975. Toddlers (1–3 years) constituted the most common age group involved. Information on predisposing factors leading to the bite was available in 33 cases; in 75% of these the children were not provoking the snake, which contrasts with the findings from adult series. The snake was seen in 58% of cases, and felt but not seen in a further 16%. Lay identification was made in 18% only. Definite puncture marks were present in 73% of cases. In 73% of victims there were no observed constitutional signs or symptoms whatsoever suggesting, in practice, that bites are generally by snakes of low potential danger. Seventeen per cent showed signs of envenomation. Antivenene was used in two cases. One fatality occurred, but the rest recovered without sequelae. In two of the 71 cases an effective tourniquet was applied.     

Bacteraemia and antibiotic use in respiratory syncytial virus infections

Aims: To examine the frequency of and risk factors for bacteraemia in children hospitalised with respiratory syncytial virus (RSV) infection; and to determine current use of antibiotics in hospitalised children with RSV infection. Methods: Retrospective study of all children, aged 0–14 years, admitted to a tertiary children''s hospital with proven RSV infection over a four year period. Children with concurrent bacteraemia and RSV infection were identified, and risk factors examined for bacteraemia. The case notes of a randomly selected comparison sample of 100 of these RSV infected children were examined to assess antibiotic use and population incidence of risk factors for severe RSV infection. Results: A total of 1795 children had proven RSV infection, and blood cultures were sent on 861 (48%). Eleven (0.6%) of the 1795 RSV positive children had bacteraemia. RSV positive children had a significantly higher incidence of bacteraemia if they had nosocomial RSV infection (6.5%), cyanotic congenital heart disease (6.6%), or were admitted to the paediatric intensive care unit (2.9%). Forty five (45%) of the random comparison sample of RSV infected children received antibiotics. Conclusions: Bacteraemia is rare in RSV infection. Children with RSV infection are more likely to be bacteraemic, however, if they have nosocomial RSV infection, cyanotic congenital heart disease, or require intensive care unit admission.     

Bacteraemia and antibiotic use in respiratory syncytial virus infections.

AIMS: To examine the frequency of and risk factors for bacteraemia in children hospitalised with respiratory syncytial virus (RSV) infection; and to determine current use of antibiotics in hospitalised children with RSV infection. METHODS: Retrospective study of all children, aged 0-14 years, admitted to a tertiary children's hospital with proven RSV infection over a four year period. Children with concurrent bacteraemia and RSV infection were identified, and risk factors examined for bacteraemia. The case notes of a randomly selected comparison sample of 100 of these RSV infected children were examined to assess antibiotic use and population incidence of risk factors for severe RSV infection. RESULTS: A total of 1795 children had proven RSV infection, and blood cultures were sent on 861 (48%). Eleven (0.6%) of the 1795 RSV positive children had bacteraemia. RSV positive children had a significantly higher incidence of bacteraemia if they had nosocomial RSV infection (6.5%), cyanotic congenital heart disease (6.6%), or were admitted to the paediatric intensive care unit (2.9%). Forty five (45%) of the random comparison sample of RSV infected children received antibiotics. CONCLUSIONS: Bacteraemia is rare in RSV infection. Children with RSV infection are more likely to be bacteraemic, however, if they have nosocomial RSV infection, cyanotic congenital heart disease, or require intensive care unit admission.     

Human bite marks. Differential diagnosis

Human bite marks are common findings in cases of fights among children, child abuse, sexual abuse, among institutionalized persons, and in a number of homicide cases. Human bites can mimic annular or arciform dermatoses. These are reviewed from both a clinical and histologic viewpoint. An example is presented of a 2 year-old girl with several annular lesions that were clinically mistaken for a dermatophyte infection. Antifungal medications were ineffective. After several days, a dermatologist identified the lesions as human bites. Physicians and other health care workers must be able to differentiate the clinical appearance of bite marks from other dermatologic diseases at an early stage so as to initiate proper therapy and counseling and, if indicated, a search for the perpetrator.     

A bite in the playroom: Managing human bites in child care settings

Young children bite each other frequently in child care settings, but the bites rarely break the skin and the risk of infection is minimal. Nevertheless, parents and child care personnel may be concerned about infection, especially with blood-borne viruses. The present document reviews the literature concerning infections following bites in child care settings, and provides recommendations for prevention and management of such incidents.     

Management of Pseudomonas osteochondritis complicating puncture wounds of the foot

Pseudomonas osteochondritis following puncture wounds of the foot is described in 13 children. All children had received at least one oral antibiotic and local wound therapy before admission; none had improved on these modalities. Pseudomonas aeruginosa was isolated alone from seven patients and with one or more other organisms from six patients. Initial administration of parenteral antibiotics active against Pseudomonas for one to 14 days did not result in clinical improvement. Eradication of Pseudomonas osteochondritis occurred in each patient only after thorough surgical debridement and curettage of all infected tissue. Following thorough surgical debridement, anti-Pseudomonas antibiotic therapy was continued for five to 14 days (10.8 +/- 2.7 days). The successful treatment of Pseudomonas osteochondritis should include adequate surgical debridement of all infected tissue; following thorough debridement, only one to two weeks of anti-Pseudomonas antibiotic therapy appears to be necessary.     

Snake bites in children in The Gambia

This is a retrospective study of the demographic features, treatment and outcome of 28 cases of snake bite admitted to the department of paediatrics of the Royal Victoria Hospital, Banjul, The Gambia over a 3-year period. The age range was 2-14 years and the male:female ratio was 2.1:1. Most bites were on the legs and occurred near home. Most snake bites presented early at hospital and marked swelling of the affected limb was the most common clinical sign. Shock, restlessness and regional adenitis of the affected limb were common in children who died. The case fatality rate was 14.3%. Most children did not receive specific antivenom therapy.     

Live virus vaccines in human immunodeficiency virus-infected children: a retrospective survey

Live virus vaccines can cause serious adverse reactions when administered to immunocompromised patients. Because children infected with human immunodeficiency virus (HIV) may be immunosuppressed, immunization of these children with live virus vaccines is a potential problem. A retrospective survey was conducted by the New York City Department of Health, with consultation from the Centers for Disease Control, to evaluate the frequency of serious adverse events following receipt of live vaccines among children with HIV infection receiving pediatric care in New York City and New Jersey. Outpatient records of 319 children being cared for by 16 participating physicians were reviewed. Of the 319 charts, 221 (69%) contained vaccination histories. Perinatal transmission of HIV infection was suspected for 208 (94%) of the 221 cases and infection via transfusion for the remaining 13 (6%). Of the 221 for whom immunization histories were available, 180 (81%) had received at least one dose of live oral polio vaccine and 70 (32%) had received measles, mumps, and rubella vaccine. There were 120 children for whom a temporal relationship between immunization and onset of symptoms of immunodeficiency could be seen; 46/120 had received at least one dose of oral polio vaccine and 23/45 had received measles, mumps, and rubella vaccine after onset of symptoms. Although follow-up of this population has been limited, there were no reports of serious adverse events such as typical or atypical measles, paralytic poliomyelitis, or aseptic meningitis in the month following vaccination.(ABSTRACT TRUNCATED AT 250 WORDS)     

Stoma closure in infants and children

Fifty-two infants and children admitted consecutively for elective stoma closure were prospectively studied. The routine management consisted of pre-operative bowel preparation, singledose per-operative antibiotics, and intraperitoneal end-to-end anastomosis. A single layer of interrupted extramucosal sutures was used. No drains were inserted and all wounds were left exposed. There were no clinical signs of anastomotic leak or dysfunction. Two superficial wound infections occured, giving an overall complication rate of 4%. Offprint requests to: E. M. Kiely