A 24-year-old woman comes to the emergency department with a cat bite. There was blood at the puncture site, which she rapidly cleaned with water. The cat demonstrated no abnormal behavior. The patient has no significant past medical history and received a tetanus booster 4 years ago. She developed hives after receiving penicillin 5 years ago but has since tolerated cephalosporins without allergic reaction. She takes no medications.
She is afebrile, her vital signs are normal, and she has no rash. There is a clean-appearing puncture wound on the medial left hand with mild swelling and surrounding erythema. There is no tenderness over the surrounding bone. The wound is cleaned.
Which of the following is the best next step in managing this patient?

Question

A 24-year-old woman comes to the emergency department with a cat bite.  There was blood at the puncture site, which she rapidly cleaned with water.  The cat demonstrated no abnormal behavior.  The patient has no significant past medical history and received a tetanus booster 4 years ago.  She developed hives after receiving penicillin 5 years ago but has since tolerated cephalosporins without allergic reaction.  She takes no medications.
She is afebrile, her vital signs are normal, and she has no rash.  There is a clean-appearing puncture wound on the medial left hand with mild swelling and surrounding erythema.  There is no tenderness over the surrounding bone.  The wound is cleaned.
Which of the following is the best next step in managing this patient?

Quizplus · Accepted Answer

11ec193a_963a_b4c9_853d_b79efe4954e8_MD0002_00 This patient presents with a cat bite resulting in a deep puncture wound to the hand. Cat bites can be quite deep. Although cat saliva contains multiple different bacteria (eg, Streptococcus and anaerobic bacteria), Pasturella multocida is found in nearly 50% of cat bites. These infections, particularly when located on extremities, can progress to bone and/or joint infections. Antibiotic prophylaxis can reduce infection rates and is recommended for animal bite wounds near lymphatics and blood vessels, on the hand, close to joints and/or bones, requiring surgical intervention, and in immunocompromised hosts. Amoxicillin/clavulanate is preferred for prophylaxis and doxycycline/metronidazole is recommended in patients with penicillin allergy. Doxycycline or TMP-SMX-based regimens also are used to treat MRSA infections in high-risk patients. Antibiotics ineffective against P multocida include first-generation cephalosporins (cephalexin), penicillinase-resistant penicillins (dicloxacillin), and macrolides (erythromycin) (Choice A). Wounds should be irrigated with debris removal and should be left open to heal by secondary intention rather than primary closure (Choice C). Careful follow-up is warranted to assess for deeper infection that may require extended antibiotic therapy. Primary closure may be done at that time if there are no signs of infection. Nonhealing wounds will likely require surgical debridement. Patients should also receive tetanus booster if indicated and be considered for rabies vaccine. (Choice D) Tetanus immunoglobulin is recommended for patients with high-risk bites who have not been recently immunized against tetanus (< 5 years). < (Choice E) Wound culture following animal bites has not been demonstrated to be clinically useful. Some organisms, including P multocida, are fastidious and difficult to grow in culture. Educational objective: Prophylactic antibiotics are warranted following a cat bite with deep injury. Antibiotic coverage should include an agent that treats Pasturella multocida. Amoxicillin/clavulanate is preferred as first-line therapy, and doxycycline/metronidazole is used in patients with penicillin allergy. Many physicians give the first dose intravenously followed by oral medications for 3-5 days. __________ References: Bite wounds and infection. (http://www.ncbi.nlm.nih.gov/pubmed/1562653) Dog, cat and human bites: a review. (http://www.ncbi.nlm.nih.gov/pubmed/7490347) Management of cat and dog bites. (http://www.ncbi.nlm.nih.gov/pubmed/7625323)

A 24-Year-Old Woman Comes to the Emergency Department with a Cat