今日の臨床サポート

動物咬創、ヒト咬創

著者: 久保健児 日本赤十字社和歌山医療センター 感染症内科部

監修: 山本舜悟 京都市立病院 感染症科/京都大学 医療疫学(非常勤講師) 

著者校正/監修レビュー済:2021/07/14
参考ガイドライン:
  1. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America https://pubmed.ncbi.nlm.nih.gov/24973422/
  1. 海外渡航者のためのワクチンガイドライン2019
患者向け説明資料

概要・推奨   

  1. 創部は、生理食塩水を使ってシリンジで圧をかけて十分に洗浄するよう推奨される。水道水は生理食塩水の代替として使用してもよい(推奨度1)
  1. 創部の洗浄時に、ヨードなどを含有した洗浄水をルーチンに用いることは推奨されない。正常組織への有害性とを天秤にかけて、汚染が強い場合には使用してもよい(推奨度2)
  1. 咬傷は、例外を除いて一次縫合は避け、待機的一次縫合にするよう推奨される(推奨度2)
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  1. Pasteurella spp.は、咬傷部位の感染以外に、肺炎など全身のさまざまな臓器に病像を呈することがあり、イヌ・ネコとの接触歴があれば疑う(推奨度1)。
  1. 全身の紫斑や急速に悪化する病像では、イヌ・ネコとの接触歴があれば、まれな原因菌としてのCapnocytophaga canimorsusを疑う(推奨度1)。
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  1. 閲覧にはご契約が必要となります。閲覧にはご
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧に
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
久保健児 : 特に申告事項無し[2021年]
監修:山本舜悟 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 参考ガイドライン、予防抗菌薬・創閉鎖に関するエビデンス、狂犬病の疫学などの記載について、見直しを行った。

病態・疫学・診察

疾患情報(疫学・病態)  
日本では:[1]
  1. 約1,000万匹のイヌが飼育され、年間約5,000~6,000件のイヌ咬傷が保健所を通じて環境省に報告され、死亡例は年間1~4人である。ただし全数把握ではないので、氷山の一角と考えられる。
 
米国では:[2]
  1. 疾患の頻度は高く、一生涯で2人に1人が受傷し、90%はイヌ・ネコによる。
  1. 約6,200~6,800万匹のイヌがペットとして飼われていて、年間約470万件のイヌ咬傷があり、約80万人が受診し、約6,000人が入院し、死亡例は年間12人という報告がある
  1. ER部門を受診した約37万人の集計では、5~9歳が15.2%と最多で、14歳以下の小児が42.0%を占めていた。受傷部位は、0~4歳の最多は頭頚部(64.9%)、15歳以上は上肢(55.4%)であった。職業関連(郵便配達、動物病院、電気・ガスのメーターを読む、家屋修繕など)は16歳以上のうち8.0%であった。
 
  1. 咬傷による感染症は、患者の皮膚および咬んだ動物・ヒトの口腔内に由来する、好気性菌と嫌気性菌の混合感染であり、これらをカバーするように推奨される(注意:嫌気性菌は検出されにくいため培養で同定されなくてもカバーするほうがよい)(推奨度1)
  1. 咬傷は混合感染が多いことを示したprospective研究がある。
  1. 1999年のTalanらの研究にて、米国18カ所の救急外来でイヌ・ネコ咬傷による感染症の原因細菌を集計した結果、50例のイヌ咬傷と57例のネコ咬傷において、中央値で5菌種(0から16菌種)が検出された(抗菌薬投与歴あり・骨髄炎例・切断例を除く)。
  1. これは微生物研究施設での培養結果を含めた集計だが、病院内細菌検査室のみに限ると中央値で1菌種(0から5菌種)の検出となり有意に検出率が低かった(P<0.001)。
  1. 好気性菌と嫌気性菌ともに検出されたのは56%、好気性菌のみは36%、嫌気性菌のみは1%、検出なしは7%であった。
  1. 最多の原因菌は、Pasteurella spp.で、イヌの50%P. canisが多い)、ネコの75%P. multocidaが多い)を占めた。
  1. ほかに多かったのは、好気性菌:Streptococci, Staphylococci, Moraxella, Neisseria、嫌気性菌:Fusobacterium, Bacteroides, Porphyromonas, Prevotellaなどであった[3]
  1. また、2003年のTalanらの研究にて、50例のヒト咬傷感染症において、中央値で4菌種(好気性菌3菌種、嫌気性菌1菌種)が検出された。好気性菌と嫌気性菌ともに検出されたのは54%で、好気性菌のみは44%、嫌気性菌のみは2%であった。
  1. 内訳は、Streptococcus anginosus (※Viridans streptococcusの1グループ、以前のS. milleri)(52%), Staphylococcus aureus (30%), Eikenella corrodens (30%), Fusobacterium nucleatum (32%), Prevotella melaninogenica (22%), Candida spp.(8%)であった。
  1. clenched-fist injuryでは、Fusobacterium, Peptostreptococcus, Candida spp.が多かった[4]
  1. 原因微生物の想定および同定の際には、これらのことを念頭に置くよう推奨される。
 
イヌ・ネコ咬傷の原因微生物

1994年4月~1995年、米国カリフォルニアのUCLAなど18カ所の救急外来で、イヌ・ネコ咬傷により皮膚軟部組織感染を発症した症例の培養結果を集計したもの。
 
参考文献:
Talan DA, Citron DM, Abrahamian FM, Moran GJ, Goldstein EJ: Bacteriologic analysis of infected dog and cat bites. Emergency Medicine Animal Bite Infection Study Group. N Engl J Med. 1999 Jan 14;340(2):85-92.

出典

img1:  著者提供
 
 
問診・診察のポイント  
  1. いつ、何に(ヒトまたは動物)、どこを咬まれたかを確認する。

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文献 

著者: Centers for Disease Control and Prevention (CDC)
雑誌名: MMWR Morb Mortal Wkly Rep. 2003 Jul 4;52(26):605-10.
Abstract/Text In 1994, the most recent year for which published data are available, an estimated 4.7 million dog bites occurred in the United States, and approximately 799,700 persons required medical care. Of an estimated 333,700 patients treated for dog bites in emergency departments (EDs) in 1994, approximately 6,000 (1.8%) were hospitalized. To estimate the number of nonfatal dog bite-related injuries treated in U.S. hospital EDs, CDC analyzed data from the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP). This report summarizes the results of the analysis, which indicate that in 2001, an estimated 368,245 persons were treated in U.S. hospital EDs for nonfatal dog bite-related injuries. Injury rates were highest among children aged 5-9 years. To reduce the number of dog bite-related injuries, adults and children should be educated about bite prevention, and persons with canine pets should practice responsible pet ownership.

PMID 12844076  MMWR Morb Mortal Wkly Rep. 2003 Jul 4;52(26):605-10.
著者: D A Talan, D M Citron, F M Abrahamian, G J Moran, E J Goldstein
雑誌名: N Engl J Med. 1999 Jan 14;340(2):85-92. doi: 10.1056/NEJM199901143400202.
Abstract/Text BACKGROUND AND METHODS: To define better the bacteria responsible for infections of dog and cat bites, we conducted a prospective study at 18 emergency departments. To be eligible for enrollment, patients had to meet one of three major criteria for infection of a bite wound (fever, abscess, and lymphangitis) or four of five minor criteria (wound-associated erythema, tenderness at the wound site, swelling at the site, purulent drainage, and leukocytosis). Wound specimens were cultured for aerobic and anaerobic bacteria at a research microbiology laboratory and, in some cases, at local hospital laboratories.
RESULTS: The infected wounds of 50 patients with dog bites and 57 patients with cat bites yielded a median of 5 bacterial isolates per culture (range, 0 to 16) at the reference laboratory. Significantly more isolates grew at the reference laboratory than at the local laboratories (median, 1; range, 0 to 5; P<0.001). Aerobes and anaerobes were isolated from 56 percent of the wounds, aerobes alone from 36 percent, and anaerobes alone from 1 percent; 7 percent of cultures had no growth. Pasteurella species were the most frequent isolates from both dog bites (50 percent) and cat bites (75 percent). Pasteurella canis was the most common isolate of dog bites, and Past. multocida subspecies multocida and septica were the most common isolates of cat bites. Other common aerobes included streptococci, staphylococci, moraxella, and neisseria. Common anaerobes included fusobacterium, bacteroides, porphyromonas, and prevotella. Isolates not previously identified as human pathogens included Reimerella anatipestifer from two cat bites and Bacteroides tectum, Prevotella heparinolytica, and several porphyromonas species from dog and cat bites. Erysipelothrix rhusiopathiae was isolated from two cat bites. Patients were most often treated with a combination of a beta-lactam antibiotic and a beta-lactamase inhibitor, which, on the basis of the microbiologic findings, was appropriate therapy.
CONCLUSIONS: Infected dog and cat bites have a complex microbiologic mix that usually includes pasteurella species but may also include many other organisms not routinely identified by clinical microbiology laboratories and not previously recognized as bite-wound pathogens.

PMID 9887159  N Engl J Med. 1999 Jan 14;340(2):85-92. doi: 10.1056/NE・・・
著者: David A Talan, Fredrick M Abrahamian, Gregory J Moran, Diane M Citron, Jonah O Tan, Ellie J C Goldstein, Emergency Medicine Human Bite Infection Study Group
雑誌名: Clin Infect Dis. 2003 Dec 1;37(11):1481-9. doi: 10.1086/379331. Epub 2003 Nov 7.
Abstract/Text Previous studies of infected human bites have been limited by small numbers of patients and suboptimal microbiologic methodology. We conducted a multicenter prospective study of 50 patients with infected human bites. Seventy percent of the patients and assailants were young adult men. Fifty-six percent of injuries were clenched-fist injuries and 44% were occlusional bites. Most injuries were to the hands. Fifty-four percent of patients were hospitalized. The median number of isolates per wound culture was 4 (3 aerobes and 1 anaerobe); aerobes and anaerobes were isolated from 54% of wounds, aerobes alone were isolated from 44%, and anaerobes alone were isolated from 2%. Isolates included Streptococcus anginosus (52%), Staphylococcus aureus (30%), Eikenella corrodens (30%), Fusobacterium nucleatum (32%), and Prevotella melaninogenica (22%). Candida species were found in 8%. Fusobacterium, Peptostreptococcus, and Candida species were isolated more frequently from occlusional bites than from clenched-fist injuries. Many strains of Prevotella and S. aureus were beta-lactamase producers. Amoxicillin-clavulanic acid and moxifloxacin demonstrated excellent in vitro activity against common isolates.

PMID 14614671  Clin Infect Dis. 2003 Dec 1;37(11):1481-9. doi: 10.1086・・・
著者: P H Brakenbury, C Muwanga
雑誌名: Arch Emerg Med. 1989 Dec;6(4):251-6.
Abstract/Text The value of prophylactic antibiotics in the treatment of animal bites is uncertain. A prospective double blind stratified trial was performed comparing a broad spectrum antibiotic amoxycillin/clavulanate with placebo in full thickness animal bite wounds in a series of 185 consecutive patients. In wounds less than 9 h old, no significant benefit was found with the antibiotic. In older wounds, presenting 9-24 h after injury, the infection rate was reduced significantly (P = 0.023), although the numbers were small. We recommend the use of such an antibiotic on wounds 9-24 h old and query its use in more recent injuries, unless tendons or joints are likely to be involved.

PMID 2692580  Arch Emerg Med. 1989 Dec;6(4):251-6.
著者: P Cummings
雑誌名: Ann Emerg Med. 1994 Mar;23(3):535-40. doi: 10.1016/s0196-0644(94)70073-7.
Abstract/Text STUDY OBJECTIVES: To determine whether prophylactic antibiotics prevent infection in patients with dog bite wounds.
DESIGN: Meta-analysis of published studies.
METHODS: A literature search was performed to identify published, randomized trials of prophylactic antibiotics for dog bite wounds. The relative risk for infection in treated patients compared with controls was used as the measure of effect, and a summary relative risk was calculated.
RESULTS: Eight randomized trials were identified. The estimated cumulative incidence of infection in controls was 16%. The relative risk for infection in patients given antibiotics compared with controls was 0.56 (95% confidence interval, 0.38 to 0.82). About 14 patients must be treated to prevent one infection.
CONCLUSION: Prophylactic antibiotics reduce the incidence of infection in patients with dog bite wounds. The full costs and benefits of antibiotics in this situation are not known. It may be reasonable to limit prophylactic antibiotics to patients with wounds that are at high risk for infection.

PMID 8135429  Ann Emerg Med. 1994 Mar;23(3):535-40. doi: 10.1016/s019・・・
著者: I Medeiros, H Saconato
雑誌名: Cochrane Database Syst Rev. 2001;(2):CD001738. doi: 10.1002/14651858.CD001738.
Abstract/Text BACKGROUND: Bites by mammals are a common problem and they account for up to 1% of all visits to hospital emergency rooms. Dog and cat bites are the most common and people are usually bitten by their own pets or by an animal known to them. School-age children make up almost a half of those bitten. Prevention of tetanus, rabies and wound infection are the priorities for staff in emergency rooms. The use of antibiotics may be useful to reduce the risk of developing a wound infection.
OBJECTIVES: To determine if the use of prophylactic antibiotics in mammalian bites is effective in preventing bite wound infection.
SEARCH STRATEGY: Relevant RCTs were identified by electronic searches of MEDLINE, EMBASE, LILACS and the Cochrane Controlled Trials Register databases in November 2000.
SELECTION CRITERIA: We included randomised controlled trials which studied patients with bites from all mammals. Comparisons were made between antibiotics and placebo or no intervention. The outcome of interest was the number of infections at the site of bite.
DATA COLLECTION AND ANALYSIS: Two reviewers extracted the data independently. All analyses were performed according to the intention-to-treat method.
MAIN RESULTS: Eight studies were included. The use of prophylactic antibiotics was associated with a statistically significant reduction in the rate of infection after bites by humans. Prophylactic antibiotics did not appear to reduce the rate of infection after bites by cats or dogs. Wound type, e.g. laceration or puncture, did not appear to influence the effectiveness of the prophylactic antibiotic. Prophylactic antibiotics were associated with a statistically significant reduction in the rate of infection in hand bites (OR 0.10, 95% CI 0.01 to 0.86; NNT = 4, 95% CI 2 to 50).
REVIEWER'S CONCLUSIONS: There is evidence from one trial that prophylactic antibiotics reduces the risk of infection after human bites but confirmatory research is required. There is no evidence that the use of prophylactic antibiotics is effective for cat or dog bites. There is evidence that the use of antibiotic prophylactic after bites of the hand reduces infection but confirmatory research is required.

PMID 11406003  Cochrane Database Syst Rev. 2001;(2):CD001738. doi: 10.・・・
著者: Nicole Thomas, Itzhak Brook
雑誌名: Expert Rev Anti Infect Ther. 2011 Feb;9(2):215-26. doi: 10.1586/eri.10.162.
Abstract/Text Human and animal bites may lead to serious infection. The organisms involved tend to originate from the oral cavity of the offending biter, as well as the environment where the injury occurred. A variety of aerobic as well as anaerobic organisms have been isolated from bite wounds, with infection ranging from localized cellulitis to systemic dissemination, leading to severe disease ranging from abscess to bone and joint infection, to endocarditis and brain abscess. Immediate wound management, including recognition of the most commonly associated infectious pathogens, and judicious use of empiric antibiotics are crucial in providing the best care after a bite. Here, we discuss the common animal bite associated infections, and provide the most up to date information regarding their management.

PMID 21342069  Expert Rev Anti Infect Ther. 2011 Feb;9(2):215-26. doi:・・・
著者: Richard L Oehler, Ana P Velez, Michelle Mizrachi, Jorge Lamarche, Sandra Gompf
雑誌名: Lancet Infect Dis. 2009 Jul;9(7):439-47. doi: 10.1016/S1473-3099(09)70110-0.
Abstract/Text Bite infections can contain a mix of anaerobes and aerobes from the patient's skin and the animal's oral cavity, including species of Pasteurella, Streptococcus, Fusobacterium, and Capnocytophaga. Domestic cat and dog bite wounds can produce substantial morbidity and often require specialised care techniques and specific antibiotic therapy. Bite wounds can be complicated by sepsis. Disseminated infections, particularly those caused by Capnocytophaga canimorsus and Pasteurella multocida, can lead to septic shock, meningitis, endocarditis, and other severe sequelae. An emerging syndrome in veterinary and human medicine is meticillin-resistant Staphylococcus aureus (MRSA) infections shared between pets and human handlers, particularly community-acquired MRSA disease involving the USA300 clone. Skin, soft-tissue, and surgical infections are the most common. MRSA-associated infections in pets are typically acquired from their owners and can potentially cycle between pets and their human acquaintances.

PMID 19555903  Lancet Infect Dis. 2009 Jul;9(7):439-47. doi: 10.1016/S・・・
著者: M K Sudarshan, S N Madhusudana, B J Mahendra, N S N Rao, D H Ashwath Narayana, S Abdul Rahman, F -X Meslin, D Lobo, K Ravikumar, Gangaboraiah
雑誌名: Int J Infect Dis. 2007 Jan;11(1):29-35. doi: 10.1016/j.ijid.2005.10.007. Epub 2006 May 4.
Abstract/Text OBJECTIVE: Human rabies has been endemic in India since time immemorial, and the true incidence of the disease and nationwide epidemiological factors have never been studied. The main objectives of the present study were to estimate the annual incidence of human rabies in India based on a community survey and to describe its salient epidemiological features.
METHODS: The Association for Prevention and Control of Rabies in India (APCRI) conducted a national multi-center survey with the help of 21 medical schools during the period February-August 2003. This community-based survey covered a representative population of 10.8 million in mainland India. Hospital-based data were also obtained from the 22 infectious diseases hospitals. A separate survey of the islands of Andaman, Nicobar, and Lakshadweep, reported to be free from rabies, was also undertaken.
RESULTS: The annual incidence of human rabies was estimated to be 17,137 (95% CI 14,109-20,165). Based on expert group advice, an additional 20% was added to this to include paralytic/atypical forms of rabies, providing an estimate of 20,565 or about 2 per 100000 population. The majority of the victims were male, adult, from rural areas, and unvaccinated. The main animals responsible for bites were dogs (96.2%), most of which were stray. The most common bite sites were the extremities. The disease incubation period ranged from two weeks to six months. Hydrophobia was the predominant clinical feature. Many of the victims had resorted to indigenous forms of treatment following animal bite, and only about half of them had sought hospital attention. Approximately 10% of these patients had taken a partial course of either Semple or a cell culture vaccine. The islands of Andaman, Nicobar, and Lakshadweep were found to be free of rabies.
CONCLUSION: Human rabies continues to be endemic in India except for the islands of Andaman, Nicobar, and Lakshadweep. Dogs continue to be the principal reservoir. The disease is taking its toll on adult men and children, the majority from rural areas, due to lack of awareness about proper post-exposure immunization. The keys to success in the further reduction of rabies in India lies in improved coverage with modern rabies vaccines, canine rabies control, and intensifying public education about the disease.

PMID 16678463  Int J Infect Dis. 2007 Jan;11(1):29-35. doi: 10.1016/j.・・・
著者: Dennis L Stevens, Alan L Bisno, Henry F Chambers, E Dale Everett, Patchen Dellinger, Ellie J C Goldstein, Sherwood L Gorbach, Jan V Hirschmann, Edward L Kaplan, Jose G Montoya, James C Wade, Infectious Diseases Society of America
雑誌名: Clin Infect Dis. 2005 Nov 15;41(10):1373-406. doi: 10.1086/497143. Epub 2005 Oct 14.
Abstract/Text
PMID 16231249  Clin Infect Dis. 2005 Nov 15;41(10):1373-406. doi: 10.1・・・
著者: Ritin Fernandez, Rhonda Griffiths
雑誌名: Cochrane Database Syst Rev. 2012 Feb 15;2:CD003861. doi: 10.1002/14651858.CD003861.pub3. Epub 2012 Feb 15.
Abstract/Text BACKGROUND: Although various solutions have been recommended for cleansing wounds, normal saline is favoured as it is an isotonic solution and does not interfere with the normal healing process. Tap water is commonly used in the community for cleansing wounds because it is easily accessible, efficient and cost effective; however, there is an unresolved debate about its use.
OBJECTIVES: The objective of this review was to assess the effects of water compared with other solutions for wound cleansing.
SEARCH METHODS: For this fourth update we searched the Cochrane Wounds Group Specialised Register (searched 9 November 2011); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4); Ovid MEDLINE (2010 to October Week 4 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, November 8, 2011); Ovid EMBASE (2010 to 2011 Week 44); and EBSCO CINAHL (2010 to 4 November 2011).
SELECTION CRITERIA: Randomised and quasi randomised controlled trials that compared the use of water with other solutions for wound cleansing were eligible for inclusion. Additional criteria were outcomes that included objective or subjective measures of wound infection or healing.
DATA COLLECTION AND ANALYSIS: Two review authors independently carried out trial selection, data extraction and quality assessment. We settled differences in opinion by discussion. We pooled some data using a random-effects model.
MAIN RESULTS: We included 11 trials in this review. We identified seven trials that compared rates of infection and healing in wounds cleansed with water and normal saline; three trials compared cleansing with no cleansing and one trial compared procaine spirit with water. There were no standard criteria for assessing wound infection across the trials, which limited the ability to pool the data. The major comparisons were water with normal saline, and tap water with no cleansing. For chronic wounds, the relative risk of developing an infection when cleansed with tap water compared with normal saline was 0.16, (95% CI 0.01 to 2.96). Tap water was more effective than saline in reducing the infection rate in adults with acute wounds (RR 0.63, 95% CI 0.40 to 0.99). The use of tap water to cleanse acute wounds in children was not associated with a statistically significant difference in infection when compared to saline (RR 1.07, 95% CI 0.43 to 2.64). We identified no statistically significant differences in infection rates when wounds were cleansed with tap water or not cleansed at all (RR 1.06, 95% CI 0.07 to 16.50). Likewise, there was no difference in the infection rate in episiotomy wounds cleansed with water or procaine spirit. The use of isotonic saline, distilled water and boiled water for cleansing open fractures also did not demonstrate a statistically significant difference in the number of fractures that were infected.
AUTHORS' CONCLUSIONS: There is no evidence that using tap water to cleanse acute wounds in adults increases infection and some evidence that it reduces it. However there is not strong evidence that cleansing wounds per se increases healing or reduces infection. In the absence of potable tap water, boiled and cooled water as well as distilled water can be used as wound cleansing agents.

PMID 22336796  Cochrane Database Syst Rev. 2012 Feb 15;2:CD003861. doi・・・
著者: S Gouin, H Patel
雑誌名: Can Fam Physician. 2001 Apr;47:769-74.
Abstract/Text OBJECTIVE: To review office interventions for minor wounds not requiring sutures, such as abrasions, bites, and lacerations.
QUALITY OF EVIDENCE: Most information on minor wound management comes from descriptive studies. Few comparative studies examine the effectiveness of topical antisepsis for minor wounds. Several clinical trials have demonstrated that tissue adhesives produce short- and long-term cosmetic results equivalent to those achieved with suture materials.
MAIN MESSAGE: Sterile saline is the least toxic solution for wound irrigation. Chlorhexidine (2%) and povidone iodine (10%) have been the most investigated antiseptic solutions. Systemic antibiotics are unnecessary for wounds unlikely to be infected. All bite wounds require special attention. Primary closure of bite wounds is indicated in certain circumstances: less than 12-hour-old nonpuncture wounds, uninfected wounds, and low-risk lesions (such as on the face). In spite of their many advantages, skin tapes should be used for low-tension wounds only. The popularity of tissue adhesives has greatly increased. Since the advent of newer products (with increased bonding strength and flexibility), adhesives are used to manage most lacerations except those in areas of high tension (e.g., joints) and on mucosal surfaces.
CONCLUSION: Minor wounds not requiring sutures can be managed easily in the office.

PMID 11340758  Can Fam Physician. 2001 Apr;47:769-74.
著者: G R Fleisher
雑誌名: N Engl J Med. 1999 Jan 14;340(2):138-40. doi: 10.1056/NEJM199901143400210.
Abstract/Text
PMID 9887167  N Engl J Med. 1999 Jan 14;340(2):138-40. doi: 10.1056/N・・・
著者: C Maimaris, D N Quinton
雑誌名: Arch Emerg Med. 1988 Sep;5(3):156-61.
Abstract/Text Dog-bite wounds are often left open because of their reputation for infection if primarily closed. A prospective randomized trial comparing primary closure with leaving the wound open was performed to assess infection and cosmesis. Ninety-six patients with 169 lacerations had thorough surgical debridement and irrigation of their wounds. Ninety-two wounds were sutured and 77 left open. No prophylactic antibiotics were given. A total of 13 wounds developed infection: seven sutured and six unsutured wounds (not statistically significant), giving an overall infection rate of 7.7%. Significantly (P less than 0.01), more wound infections occurred in the hand in both groups compared to the rest of the body, indicating that particular attention should be paid to management of such wounds. It was concluded that dog-bite wounds should receive thorough surgical treatment and can be safely sutured at presentation. Special care should be given to hand wounds.

PMID 3178974  Arch Emerg Med. 1988 Sep;5(3):156-61.
著者: Soumyadeep Bhaumik, Richard Kirubakaran, Sirshendu Chaudhuri
雑誌名: Cochrane Database Syst Rev. 2019 Dec 6;12:CD011822. doi: 10.1002/14651858.CD011822.pub2. Epub 2019 Dec 6.
Abstract/Text BACKGROUND: Mammalian bites are a common presentation in emergency and primary healthcare facilities across the world. The World Health Organization recommends postponing the suturing of a bite wound but this has not been evaluated through a systematic review.
OBJECTIVES: To assess the effects of primary closure compared with delayed closure or no closure for mammalian bite wounds.
SEARCH METHODS: In July 2019 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.
SELECTION CRITERIA: We included randomised controlled trials which compared primary closure with delayed or no closure for traumatic wounds due to mammalian bite.
DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles, abstracts and full-text publications, applied the inclusion criteria, and extracted data. We pooled data using a random-effects model, as appropriate. We used the Cochrane 'Risk of bias' tool and assessed the certainty of the evidence using the GRADE approach.
MAIN RESULTS: We found three trials (878 participants) that compared primary closure with no closure for dog bites and one trial (120 participants) that compared primary closure with delayed closure. No other mammalian bite studies were identified. The trials were from the UK (one trial), Greece (one trial) and China (two trials). Overall, participants from both sexes and all age groups were represented. We are uncertain whether primary closure improves the proportion of wounds which are infection-free compared with no closure, as the certainty of evidence for this outcome was judged to be very low (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.97 to 1.05; 2 studies, 782 participants; I2 = 0%). We downgraded the evidence by one level for high risk of bias and two levels for imprecision. There is no clinically important difference in cosmesis (acceptable physical/cosmetic appearance) of dog bite wounds when primary closure is compared with no closure (mean difference (MD) -1.31, 95% CI -2.03 to -0.59; 1 study, 182 participants). The certainty of evidence for this outcome was judged to be moderate (we downgraded our assessment by one level for imprecision). We are uncertain whether primary closure improves the proportion of dog bite wounds that are infection-free compared with delayed closure, as the evidence for this outcome was judged to be very low (RR 0.98, 95% CI 0.90 to 1.07; 1 study, 120 participants; I2 = 0%). We downgraded the evidence by one level for high risk of bias and two levels for imprecision. None of the four trials reported any adverse outcomes such as death or rabies but they were, in any case, unlikely to have been large enough to have satisfactory power to provide precise estimates for these. Important outcomes like time to complete wound healing, proportion of wounds healed, and length of hospital stay were not evaluated.
AUTHORS' CONCLUSIONS: All the studies we identified concerned dog bites. There is no high-certainty evidence to support or refute existing recommendations concerning primary closure for dog bites. The potential benefits and harms of primary closure compared with delayed or no closure for mammalian bites remain uncertain and more robust trials are needed.

Copyright © 2019 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
PMID 31805611  Cochrane Database Syst Rev. 2019 Dec 6;12:CD011822. doi・・・
著者: K Agrawal, T Ramachandrudu, A Hamide, T K Dutta
雑誌名: Ann Plast Surg. 1995 Feb;34(2):201-2.
Abstract/Text A case of generalized tetanus after human bite of the finger is reported. The patient recovered with institutional care. We propose that secondary invasion by Clostridium tetani is the cause for infection. It could be prevented by immediate tetanus prophylaxis, thorough debridement, and primary repair of the wound.

PMID 7741442  Ann Plast Surg. 1995 Feb;34(2):201-2.

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