Patient Scenarios: NICE Guideline on Insect and Animal Bites

The scenarios are fictitious but similar to those experienced by real patients, and are designed to help you reflect on what you have learnt after reading the article. They could be also be used for group discussion in an education or practice meeting. There are no right or wrong answers but some pitfalls to avoid. 

The following case studies, written by Dr Caroline Ward, relate to her expert article, Bites and stings: when to prescribe an antibiotic. The article discusses recommendations from the NICE guideline on antimicrobial prescribing for insect and animal bites.

Case 1: Erin, 21 Years Old

‘I was sitting outside in the park with some friends 2 days ago and I got bitten on the shoulder by an insect. It’s red and itchy and is getting worse. I think it’s infected and I might need some antibiotics.’

Context

Erin has no medical problems. Her only regular medication is the contraceptive pill. She is allergic to penicillin.

Examination

There is a central puncture wound with approximately 4 cm of surrounding swelling and erythema and some excoriation. There is no tracking and Erin is systemically well.

Questions for Reflection

1. What symptoms are more likely to indicate infection?
2. How should you manage her insect bite?
3. What advice should she be given?

How to Manage This Patient

Erythema and swelling are common after an insect bite or sting. Infection is uncommon but may be more likely if there is pain rather than itching, or if the patient has fever, malaise, nausea, shivering, or rigors. Occasionally, there may palpable regional lymph nodes or tracking (lymphangitis). Erin’s bite has no symptoms or signs of infection so she should be advised on self-care and directed to a community pharmacy. She should be told the likely duration of symptoms (up to 10 days), advised against scratching, and instructed to seek medical help if her symptoms worsen rapidly or significantly, or she becomes unwell.

Case 2: Thomas, 6 Years Old

Thomas’ father has brought him to see you. ‘Thomas was bitten on the foot by our dog this morning. He was kicking a tennis ball in the house with bare feet and the dog tried to grab it back, I don’t think she meant to bite Thomas. She’s never bitten anyone before. It bled a little but we washed his foot straight away and put some antiseptic cream on it.’

Context

Thomas has no medical problems. He is the youngest of three children and lives with both parents. He presents to the surgery infrequently; the last time was 2 years ago with an upper respiratory tract infection.

Examination

Thomas is systemically well with a normal temperature. He has two short superficial scratches on the lateral border of his right foot. The wound looks clean and there is no swelling or surrounding erythema.

Questions for Reflection

1. What other aspects of the child’s past medical history are important?
2. How should this bite be managed?
3. Are there any other important considerations?

How to Manage This Patient

As this is an animal bite, it is important to ascertain vaccination status and to consider whether he needs a tetanus vaccination. This dog bite is in a high-risk area (the foot) and has drawn blood, therefore a 3-day course of prophylactic antibiotics should be considered but are not obligatory. You may wish to discuss the advantages and disadvantages of treatment with the child’s parent and come to a shared decision. As this is a child with a bite, you should consider safeguarding issues, and take a thorough history to gain an understanding of the circumstances surrounding the bite. 

Case 3: Sarah, 41 Years Old

‘I got a new kitten a few weeks ago, I was playing with him yesterday afternoon when he bit my finger, it felt quite deep but didn’t bleed at the time. Today it is painful and looks red. I’m worried it’s infected.’

Context

Sarah works as a teacher and has had type 1 diabetes since she was 14 years old. Her blood glucose is well controlled, and she has no diabetic complications. Her only medication is her insulin. She is allergic to penicillin. She has had a complete immunisation course for tetanus.

Examination

Sarah is systemically well with a normal temperature. She has two puncture wounds on the lateral aspect of her left hand. There is surrounding erythema but no tracking. There is a small amount of purulent discharge.

Questions for Reflection

1. How should this bite be managed?
2. What investigations should you perform?
3. What safety-netting advice should you give to this patient?

How to Manage This Patient

This cat bite is in a high-risk area (the hand), it did not draw blood but now appears infected. Sarah needs treatment with antibiotics. She is allergic to penicillin so needs a 5-day course of doxycycline and metronidazole. You should ensure she is not pregnant before prescribing doxycycline. You may wish to organise a review at 5 days to ensure that the wound is healing as expected and if it is not, you could consider extending the course to 7 days total. As there is discharge from the wound, you should take a swab and send for culture. Sarah should be advised to seek medical attention if the wound is no better in 24–48 hours, worsens significantly at any time or she feels unwell, and/or feverish.

Case 4: Oliver, 24 Years Old

‘I got in a fight after a few drinks last weekend and hit someone. I thought I had broken my hand so went to A&E. It wasn’t broken but they said I had a bite mark from his tooth and gave me antibiotics to stop it getting infected, but it’s been getting worse for a few days.’

Context

Oliver has no medical problems, takes no regular medications, and has no allergies. You check Oliver’s A&E discharge letter and see that he was given 3 days of co-amoxiclav for prophylaxis of a human bite wound.

Examination

Oliver feels well and does not have a fever. He has a wound on the lateral aspect of his hand with surrounding erythema and some swelling.

Questions for Reflection

1. What else do you want to know from the history?
2. How should you manage this wound?

How to Manage This Patient

Antibiotic prophylaxis has not worked and he has developed an infection. You should check his compliance with the medication prescribed in A&E to ensure he has been taking the antibiotics as directed. As he has developed an infection while on co-amoxiclav prophylaxis, this may indicate infection with a resistant organism. Specialist advice on management should be sought.