Critical Care Medicine-Infections and Immunologic Disease>>>>>Soft-Tissue, Bone, Joint Infections
Question 1#

A 32-year-old previously healthy man presents with fevers and hypotension. He was bitten by a dog 4 days ago with deep puncture wounds that required operative closure. He has a history of anaphylaxis to penicillin and cephalosporins and has been receiving trimethoprim-sulfamethoxazole since surgery. Tetanus toxoid was administered and his other immunizations are up to date. On examination, his wound shows evidence of cellulitis.

Which of the following changes to his antibiotic regimen is most appropriate?

A. Change trimethoprim-sulfamethoxazole to levofloxacin
B. Add vancomycin
C. Add clindamycin
D. No change necessary

Correct Answer is C

Comment:

Correct Answer: C

Prophylactic antibiotics are not typically required after animal bites. However, they reduce the rate of infection of high-risk bites: 

• Deep puncture wounds
• Wounds with underlying venous or lymphatic compromise
• Injury to the hands, genitals, face, or wounds near joints
• Wounds needing operative closure
• Wounds in patients who have impaired healing (ie, immunocompromised, diabetes mellitus)

Amoxicillin-clavulanate for 3 to 5 days is the preferred prophylactic agent. Alternatives in patients with cephalosporin allergies should have activity against both Pasteurella multocida (ie, trimethoprim-sulfamethoxazole, doxycycline, levofloxacin) and anaerobes (clindamycin, metronidazole). Thus, this patient has untreated anaerobic infection and would benefit from the addition of clindamycin. Changing to levofloxacin or adding vancomycin would not give the appropriate coverage. Tetanus toxoid should also be administered to all patients who have completed primary immunization but who’s booster has been 5 years of greater. 

Reference:

1. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;5(9):147.