Editoriales

Buenos Aires 04 de Enero del 2021

DOGS and CATS BITES - Pasteurella Multocida Infection  

 

 

Dog and Cat Bites - Pasteurella Multocida Infection

 

                                                                               Sara L Cross, MD; Michael S.Bronze, MD
                                       
                                                                                             Updated to Nov - 2019
 

 
Causes of P. multocida infection incluide the folowing:

  • Dog bite or lick
  • Cat bite, lick, or scratch
  • Idiopathic (no history of pet exposure)
  • Immunosuppression

Background
Pasteurella multocida is a small, gram-negative, nonmotile, non–spore-forming coccobacillus with bipolar staining features. The bacteria typically appear as single bacilli on Gram stain; however, pairs and short chains can also be seen. P multocida often exists as a commensal in the upper respiratory tracts of many livestock, poultry, and domestic pet species, especially cats and dogs. In fact, Pasteurella species are some of the most prevalent commensal bacteria present in domestic and wild animals worldwide. [1P multocida infection in humans is often associated with an animal bite, scratch, or lick, but infection without epidemiologic evidence of animal contact may occur.
Pasteurella multocida infection.
Wound infections associated with animal bites usually have a polymicrobial etiology, mandating the empiric use of broad-spectrum antimicrobials targeted at both aerobic and anaerobic gram-negative bacteria. Nevertheless, Pasteurella species are commonly isolated pathogens in most animal bites, especially in dog- and cat-related injuries.
These injuries can be aggressive, with skin manifestations typically appearing within 24 hours following a bite. These wounds can exhibit a rapidly progressive soft-tissue inflammation that may resemble group A β-hemolytic Streptococcus pyogenes infections.
Deeper soft tissue can also be affected, manifesting as tenosynovitis, septic arthritis and osteomyelitis. More-severe disseminating infections may also develop, including endocarditis or meningitis, the latter mimicking Haemophilus Influenzae or Neisseria Meningitides infections in young children. Fortunately, Pasteurella species are fairly sensitive organisms and can be treated with a penicillin-based regimen. Patients with P multocida infection who present without evidence of an animal bite are more likely to have invasive infection such as respiratory or bloodstream infection. [2]

Pathophysiology
Local: P multocida infection usually presents as an infection that complicates an animal bite or injury. Complications include rapidly progressive cellulitis, abscesses, tenosynovitis, osteomyelitis, and septic arthritis. [3The latter two are particularly common following cat bites because of their small, sharp, penetrative teeth. [4Non-native septic arthritis can also occur. [5]
Respiratory: P multocida may cause upper respiratory tract infections, including sinusitis, otitis media, mastoiditis, epiglottitis, pharyngitis, and Ludwig angina. [7In rare cases, P multocida may also cause lower respiratory tract infections, including pneumonia, tracheobronchitis, lung abscess[8and empyema, [9usually in individuals with underlying pulmonary disease.
Cardiovascular: P multocida has been reported to cause native- [10and prosthetic-valve endocarditis, [11pericarditis, mycotic aneurysms, [12vascular graft infections, [13central venous catheter infections, bacteremia, sepsis, septic shock and disseminated intravascular coagulation. [15]
Central nervous system: P multocida is an uncommon cause of meningitis, subdural empyema and brain abscess [17P multocida meningitis has been associated with cat licks and bites occurring on the face in persons at the extremes of age. [18]
Gastrointestinal: P multocida rarely causes gastrointestinal problems but has been associated with appendicitis, hepatosplenic abscesses, and spontaneous bacterial peritonitis. P multocida has been isolated in patients with polymicrobial peritoneal dialysis catheter–associated peritonitis. [19]
Ocular: P multocida periocular abscess, [20conjunctivitis, corneal ulcers and endophalmitis have been reported.
Genitourinary tract: P multocida pyelonephritis, renal abscess, epididymitis and cervicitis have been reported in rare cases.
Degenerative joint disease, rheumatoid arthritis, and prosthetic joints have been associated with the development of P multocida septic arthritis. [21]
P multocida infections during pregnancy and in utero transmission have also been reported. [252627]
Localized P multocida infections carry an excellent prognosis. Significant morbidity has been associated with musculoskeletal P multocida infections, especially those involving the hand. Disseminated P multocida infections carry a 25-30% overall mortality risk

Epidemiology
According to the American Pet Products Association, approximately 180 million dogs and cats live in the United States, cats currently outnumbering dogs by 12 million. Animal bites account for 1% (300,000) of annual emergency department visits. The estimated cost in health care expenditures has been reported to be $30 million per year. Approximately 10% of animal bites require medical attention; 1-2% eventually require hospitalization.
Approximately 5 million animal bites are reported annually. The vast majority of animal bites involve dogs (85-90%), followed by cats (5-10%).
Infectious complications occur in approximately 15-20% of dog-related bites and more than 50% of cat-related ones. Dog bites are associated with younger animals engaging in playful activities, mostly with children. German shepherd, pit bull, Staffordshire terrier, and mixed breeds are most commonly involved with human bites, while the golden retriever and Labrador retriever are least. Cat bites are usually provoked, typically by female felines, and occurring on the upper extremities or face. Sharp and long teeth of cats can easily penetrate human skin and create a deep puncture wound and even inoculate the periosteum component of bones. Indeed, cat-related wounds more commonly progress to more serious and deeper-tissue infections, including osteomyelitis and meningitis.

Epidemiology International
P multocida infections occur worldwide. Cats are involved in 60-80% of human P multocida infections. Moreover, P multocida is isolated in 50% of dog bites.

Mortality/Morbidity
It is estimated that 10-20 human deaths per year occur following an animal bite.
Infectious complications occur in approximately 15-20% of dog-related bites and more than 50% of cat-related ones. Following a bite, a rapidly progressive cellulitis may develop; deeper structures, including tendons, joints, and bones, can become affected, especially in cat-related injuries. Dissemination can occur.
Chronic obstructive pulmonary disease is a risk factor for P multocida respiratory tract infection, [22which carries a mortality rate of approximately 30%. Diabetes mellitus [23and liver dysfunction [24are predisposing conditions associated with pasteurellosis and associated bacteremia.

Age
All age groups can be affected by P multocida infections. Young children seem to be frequently involved in nonfatal dog bites. P multocida meningitis typically occurs in persons at the extremes of age.

History
A history of animal exposure, whether occupational or recreational, should alert the physician to the possibility of a zoonosis. [28]
A detailed pet history, including exposure to pets owned by friends or strangers, should reveal the possibility of Pasteurella infection. However, cases of Pasteurella infection occur in the total absence of an epidemiological link.

Physical
Findings of P multocida infection relate to the site of infection, as follows:

  • Local - Erythema, warmth, pain and tenderness, purulent discharge, lymphangitis, joint swelling, decreased range of motion
  • Respiratory - Sinus tenderness, hoarseness, pharyngeal erythema, rales and rhonchi upon chest auscultation, dullness to percussion, changes in vocal fremitus
  • CNS - Focal neurologic deficits, signs of meningeal irritation (eg, nuchal rigidity, Brudzinski sign, Kernig sign)
  • Abdominal - Abdominal tenderness, guarding and rebound, hepatosplenomegaly, costovertebral angle tenderness
  • Ocular - Corneal ulcer, conjunctival injection, decreased visual acuity
  • Cardiovascular - Hypotension, tachycardia, new cardiac murmur, embolic phenomenon
  • Lymph nodes - Regional adenopathy

 Differential Diagnoses

Prognosis
Soft-tissue P multocida infections carry an excellent prognosis. Deeper wounds, especially hand infections, may be associated with prolonged morbidity.
P multocida pulmonary infections, CNS involvement, bacteremia, and endocarditis carry a mortality rate of approximately 30%. Recent data show that patients presenting without evidence of an animal bite more frequently had respiratory and bloodstream infections and were relatively immunocompromised at baseline. These patients had a worse prognosis than patients with evidence of animal bite on presentation. [2]

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