A 4-year-old girl is brought to the office due to a cat bite. Her parents say that the girl and her friend were attempting to dress up the family's cat when it bit the patient on the right thumb. The bite occurred approximately an hour ago. The parents washed the girl's thumb with soap and water before bringing her to the office. The cat has been with the family since it was a kitten and is fully vaccinated. The girl has a history of anaphylaxis following peanut and soy exposure, and her parents carry injectable epinephrine. Vital signs are within normal limits. The patient has minimal pain. Examination reveals a single puncture wound on the pad of the right thumb. There is no erythema, drainage, or tenderness to palpation. Range of motion is normal. The remainder of the examination is unremarkable. Which of the following is the best next step in management of this patient?

Question

A 4-year-old girl is brought to the office due to a cat bite.  Her parents say that the girl and her friend were attempting to dress up the family's cat when it bit the patient on the right thumb.  The bite occurred approximately an hour ago.  The parents washed the girl's thumb with soap and water before bringing her to the office.  The cat has been with the family since it was a kitten and is fully vaccinated.  The girl has a history of anaphylaxis following peanut and soy exposure, and her parents carry injectable epinephrine.  Vital signs are within normal limits.  The patient has minimal pain.  Examination reveals a single puncture wound on the pad of the right thumb.  There is no erythema, drainage, or tenderness to palpation.  Range of motion is normal.  The remainder of the examination is unremarkable.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bfce_6e30_8f63_a93f06cb2b85_MD0005_00 Mammalian bites can lead to infection from either oral flora of the animal (eg, Pasteurella, oral anaerobes) or skin flora of the patient (eg, Streptococcus pyogenes, Staphylococcus aureus). Cat bites are considered particularly high-risk as feline teeth are thin and sharp, resulting in puncture wounds that inoculate bacteria deep into tissue. Bites also carry a higher risk of infection if they are on the hands/feet, >12 hours old, and in immunocompromised patients. For patients with any of these historical features, wounds should be left open to heal by secondary intention and antibiotic prophylaxis should be provided. Amoxicillin-clavulanate is the first-line agent for prophylaxis following mammalian bites as it provides coverage against both gram-negative (eg, Pasteurella) and gram-positive (eg, S pyogenes) organisms as well as oral anaerobes. (Choice A) Despite this patient's benign physical examination, cat bites are highly likely to result in infection without antibiotic prophylaxis. Observation alone would not be appropriate management. (Choice C) Azithromycin can be used for the treatment of cat-scratch disease due to Bartonella henselae. However, azithromycin prophylaxis neither prevents the development of cat-scratch disease nor provides coverage against more common organisms such as Pasteurella. (Choices D and E) Clindamycin has activity against oral anaerobes and gram-positive organisms (eg, Streptococcus, Staphylococcus) but is not active against gram-negative organisms (eg, Pasteurella). Similarly, trimethoprim-sulfamethoxazole has activity against Pasteurella but lacks activity against oral anaerobes or Streptococcus. These agents can be used in combination for bites in penicillin-allergic patients, but neither is sufficient as monotherapy. Educational objective: Mammalian bites can cause infection from gram-negative, gram-positive, and anaerobic organisms from the animal's oral flora or the patient's skin flora. For high-risk bites (eg, cat bites, bites on hand/foot), first-line management is prophylaxis with amoxicillin-clavulanate. References: Dog and cat bites. (http://www.ncbi.nlm.nih.gov/pubmed/25250997)

A 4-Year-Old Girl Is Brought to the Office Due to a Cat