AN ABSESS DUE TO PASTEURELLA MULTOCIDA AFTER A CAT SCRATCH: A CASE REPORT AND EVALUATION OF ANTIBIOTIC PROPHYLAXIS
EVALUATION OF ANTIBIOTIC PROPHYLAXIS AFTER A CAT SCRATCH Abstract:
Pasteurella multocida has been isolated from %50 to 70 of healty cats and most commonly associated with acute skin and soft tissue infections following an animal bite or scratch. As the zone and depth of injury can lead to more serious infections such as deep tissue infections, septic arthritis, osteomyelitis. However, no predictive factor showing which wound would be infected. In our case, patient whom applied with abscess after a cat scratch and P.multocida was found as a causative agent. This situation has caused to review us, once more, that which cases should be taken antibiotic prophylaxis in addition to immunoprophylaxis in the first admission. Antibiotic prophylaxis should be used for 3-5 days in selected case if they include; moderate to severe crushing injuries especially edematous form, less than 8 hours old, bone or joint penetration, hand wounds, especially emphasizes the importance of hand injuries and deep penetrations.
Key words: Pasteurella multocida, antibiotic prophylaxis, cat scratch.
KEDİ TIRMALAMASI SONRASI PASTEURELLA MULTOCİDA’YA BAĞLI ABSE: OLGU SUNUMU VE ANTİBİYOTİK PROFİLAKSİSİNİN DEĞERLENDİRİLMESİ
KEDİ TIRMALAMASI SONRASI ANTİBİYOTİK PROFİLAKSİSİNİN DEĞERLENDİRİLMESİ
Özet:
Sağlıklı kedilerin %50 ile 70’ inde Pasteurella multocida izole edilmekte ve hayvanın tırmalaması yada ısırması ile oluşan yaralanma sonucunda gelişen deri ve yumuşak doku infeksiyonlarına sıklıkla neden olabilmektedir. Yaralanmanın olduğu bölge ve derinliği itibariyle derin doku infeksiyonları, septik artrit, osteomyelit gibi çok daha ciddi infeksiyonlara yol açabilmektedir. Buna rağmen hangi yaranın infekte olacağını gösteren prediktif faktör yoktur. Bizim olgumuz kedi tırmalaması sonrası oluşan abse ile başvuruda bulunmuş ve etken olarak Pasteurella multocida saptanmıştır. Bu durum, ‘‘ilk başvuruda immünoprofilaksiye ilaveten antibiyoprofilaksi hangi vakalara uygulanmalı?’’ sorusunu bir kez daha gözden geçirmemize neden olmuştur. Antibiyotik profilaksisi seçilmiş vakalarda kullanılmalıdır. Orta şiddetli, özellikle ezilme şeklindeki ödematöz yaralanmalarda 8 saat geçmeden, kemik veya eklem penetrasyonu ihtimali varsa, el yaralanmalarında, 3-5 gün süre ile önerilmekte ve özellikle el yaralanmaları ve derin penetrasyonlarda önemi vurgulanmaktadır.
Anahtar Kelimeler: Pasteurella multocida, antibiyoprofilaksi, kedi tırmalaması.
AN ABSESS DUE TO PASTEURELLA MULTOCIDA AFTER A CAT SCRATCH: A CASE REPORT AND EVALUATION OF ANTIBIOTIC PROPHYLAXIS INTRODUCTION
Pasteurella multocida infections are occasionally find on the extremities of the body due to cat scratch [1]. Pasteurella multocida has been isolated from %50 to 70 of healty cats and most commonly associated with acute skin and soft tissue infections following an animal bite or scratch [1,2]. There is no predictive factor indicating which wounds may be infected. Antibiotic prophylaxis; early and for a period of 3-5 days is recommended in selected cases [1].
CASE PRESENTATION
60-year-old male patient was admitted to the Infection Diseases Clinic because of the wound on the left arm and hand caused by cat scratch four days ago. On examination there were numerous deep line and crusted over scrathes of the patient forearm and hand. There was an abscess that 2x3 cm in size on the line of the scratching and the it was draining spontaneously from a few holes. The patient was admitted to Emergency Department within 24 hours, immunoprophylaxis was performed by physician, but he had not received antibiotic treatment. Abscess formation developed on the third day of cat scratch. Around the holes pain, terderness and pruritus were seen as a symptom. The patient had no fewer. On laboratory white blood cell count was 6300 10^3/uL, sedimentation rate was 6 mm/h, C-Reactive Protein was 6.5 mg/L and routine biochemical tests were within normal limits. Pasteurella multocida was isolated from the wound culture.
Amoxicillin-clavulanic acid 1 g was administered q12 h, and debridement of the wound performed by the physician. Finally, the patient completely recovered after ten days of therapy.
DİSCUSSİON
Cellulitis is one of common infection after cat bites. Local infections are characterized by the rapid appearance of erythema, warmth, tenderness, and frequently purulent drainage. 21% to 39% of cases present wound drainage [3]. Pasteurella multocida is the most common microoganism in soft tissue infection due to cat bites and abscess is most common complication [4]. Zong. Z at al [3] reported that abscess developed at the injury site in 3 days after exposure, similar to our case.
In a review that includes 34 cases of Pasteurella multocida infections; they have been reported the most common infections caused by Pasteurella multocida are local wound infections, serious local complications include septic arthritis and osteomyelitis most commonly involving a finger or hand after a cat bite. Bacteremia, meningitis, brain abscess, spontaneous bacterial peritonitis, intra-abdominal abscess are the other systemic infections by Pasteurella multocida infection [3]. Microorganisms are frequently isolated from wound infection occured by bite injuries and injuries ranged from relatively minor wounds to major injuries that included open fractures, persistent deep infection including osteomyelitis, nerve laceration, tendon laceration, or tissue loss [1]. Therefore we consider that the antibiotic prophylaxis should be performed to the patients after cat bite or scratch, in addition to immunoprophylaxis.
With 85% of such injuries harboring potential pathogens we cannot reliably predict which wounds will be infected. However we consider antibiotic prophylaxis for moderate to severe injury less than 8 hours old, especially if edema or crush injury is present. If bone or joint penetration is possible, for hand wounds, for immunocompromised patients, if the wound is adjacent to prosthetic joint and if the wound is in the genital area antibiotic prophylaxis should be performed. We consider performing antibiotic prophylaxis for especially hand injuries due to cat scratch because of the importance of complications.
In Dire DJ's study, 216 cases were prospective analized after cat bites / scratching during the 2-year. Type of injury and depth of the wound were indicated the most important factor for determinating the development of infection [5].
Recommendations about case selection for antibiotic prophylaxis vary. The use of prophylactic antibiotics in wounds that are seen early but as yet are uninfected .Selected cases should be treated with oral therapy for 3 to 5 days. Antibiotherapy should coverage include P. multocida, S. aureus ve anaerobes. Amoxicillin-clavulanic acid is as a first choice antibiotic in therapy. Clindamycine, doxycycline, moxifloxacine and macrolides are recommended for local wound infections caused by P. multocida [1].
To our knowledge, this was the rare report about P. Multocida infection after a cat scratch in Turkey. Our patient succesfully treated by amoxicillin-clavulanic acid with surgical procedures.
As a result, site of injury especially on hands and forearm, deep location of injury, multiple injuries which neighbouring to the bone or joint are important factors for the risk of infection after a cat scratch. Therefore we thought necessity of antibiotic prophylaxis in addition to immunoprophylaxis initially.
REFERENCES
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2. Weber DJ, Wolfson JS, Swartz MN, Hooper DC. Pasteurella multocida infections. Report of 34 cases and review of the literature. Medicine (Baltimore).1984 May;63(3):133-54.
3. Zong Zhi-yong, Gao Yan-yu, Wang Xiao-hui. Subcutaneous abscess caused by Pasteurella multocida in a patient due to a cat bite. CMJ2005;118(12):1045-1046
4. Benson LS, Edwards SL, Schiff AP, Williams CS, Visotsky JL. Dog and cat bites to the hand: treatment and cost assessment. J Hand Surg Am. 2006 Mar;31(3):468-73.
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Figüre 1: An abcess on the left arm caused by cat scratch.