Soft tissue infections due to human bites

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The Journal of Immunology and Clinical Microbiology © 2016
Case Report
J Immunol Clin Microbiol. 2016; 1(1): x-x
DOI: 10.5455/jicm.2016.1.224190
Soft tissue infections due to human bites
Fatma Meral Ince1*, Emel Aslan1, Özcan Deveci1, Recep Tekin1
1 Dicle University Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Diyarbakir Turkey
Introduction
Human bites are relatively rare; they are the injuries with the
greatest risk (%10-50) for the development of infections (1).
Infections secondary to human bite are reported to be more
dangerous compared to animal bites (1-3). While the infection
may be caused by the pathogens in the mouth flora of the
biter, it may also be caused by the pathogens on the skin of the
bitten person (4). The most common bacteria associated
with infections secondary to human bites are α and β
hemolytic streptococci, Staphylococcus aureus,
Staphylococcus epidermidis, Corynebacterium spp. and
Eikenella corrodens. These two patients with soft tissue
infections secondary to human bites are presented in this
article since they are interesting cases which are rarely
presented in literature.
*Corresponding Author: Fatma Meral Ince; Dept. of
Infectious Diseases and Clinical Microbiology, Dicle
University Medical Faculty, Diyarbakir, Turkey.
E-mail: drmeralince@gmail.com Received: March 07, 2016
Accepted:March 17, 2016 Published Online: March 23, 2016
Case 1
The 62-year old female patient, whose 4th digit in her left hand
was bitten by her disabled child 6 days ago, had initially
presented to a healthcare centre where her wound was dressed
and oral antibiotherapy was prescribed. When her complaints
escalated, the patient presented to our clinic. She was admitted
to our clinic with the diagnosis of necrotic and infectious
wound and soft tissue infection in the 4th digit in her left hand
(Figure 1). Since she had a swelling and subcutaneous edema
between the necrotic 4th finger towards the dorsal aspect of her
hand as well as increased echogenicity in her soft tissues, she
was started on a regimen with 4x1.5 grams of intravenous (IV)
ampicillin-sulbactam. During the operation conducted by the
department of orthopedics, the patient underwent a
debridement and a bacterial culture samples were collected.
The patient’s left hand was placed in a short splint and
elevated. No growth was observed in the wound culture.
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J Immunol Clin Microbiol
Abstract
Background: Human bites are potentially dangerous wounds constituting an important cause of morbidity. Infections
caused by human bites are reported to be more severe than infections caused by animal bites. The aim of this article is
to present two patients with soft tissue infections secondary to human bites, which are rare in the literature.
Case presentation: The first patient is a 62-year old female whose 4th digit of her left hand was bitten by her disabled
child and became necrotic. The second patient is a 35-year old female patient whose 2nd digit in her left hand was
bitten by her husband five days ago. Both patients had undergone debridement for the necrotic infections in the area
of the lesion and prescribed the appropriate antibiotherapy. Rest, elevation and immobilization were maintained. The
reconstruction and physiotherapy gave satisfactory results.
Conclusion: Human bite wounds have long had a bad reputation for severe infection and frequent complication. For
this reason, prophylactic antibiotic treatment should be given after human bite to prevent infection. If the infection
signs and symptoms develop, rapid diagnosis, appropriate antibiotic and surgical therapy should be applied instantly.
Key words: Human bite, soft tissue infection, debridement

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When the patient had a temperature on the third day of the
antibiotherapy, blood cultures were obtained from both her
arms and her medication as changed to 3x1 grams of IV
meropenem. The patient’s dressings were changed every day.
The necrotic tissue on the 4th digit of the patient’s left hand
was debrided by the Plastic and Reconstructive Surgery
department and the wound was dressed. When significant
improvement was observed at the wound site (Figure 2) and
the infection improved, the patient was discharged on the 12th
day of the meropenem therapy with a prescription for oral
levofloxacin treatment and a follow up visit by the Plastic and
Reconstructive Surgery outpatient clinic scheduled a week
later. She was also recommended physiotherapy for hand
movements and a home exercise program by the
Rehabilitation Department. No sign of local or deep infection
was observed during the follow up visits on an outpatient
basis.
Figure 1. Lesion formed after the bite
Figure 2. Appearance after the treatment
Case 2
A 35-year old female patient whose 2nd digit in her left hand
was bitten by her husband five days ago presented to a
healthcare center when she observed redness, increased
temperature and swelling in the wound area. When her
complaints became more severe in spite of the oral
ciprofloxacin prescribed at this center, she presented to the
emergency room of our hospital. After the debridement
performed by the Plastic and Reconstructive Surgery
department on the 2nd finger of her left hand, the patient was
admitted to our clinic. A cell culture was performed and she
was started on 3×4.5 g of IV empirical piperacillin-
tazobactam. Her left upper limb was elevated. No growth was
observed in the wound culture. The dressings were changed on
a daily basis. The superficial tissue USG performed on the
dorsal aspect of her left hand indicated an abscess, which was
drained by the Orthopedics department through a one cm
incision made on the focus of the abscess. When the patient’s
discharge diminished and her infection symptoms regressed on
the 10th day of the treatment, the spectrum of the
antibiotherapy was narrowed and the treatment was switched
to 4x1.5 g of IV ampicillin-sulbactam. The necrotic tissue in
the 3rd digit of the left hand was debrided by the Plastic and
Reconstructive Surgery department. On the 7th day of the
ampicillin-sulbactam treatment, the patient was discharged
with a prescription for 3x1 g of cefazol and recommended
daily dressing changes. A follow up visit was scheduled by the
Plastic and Reconstructive Surgery department for the
following week in order to close the tissue defect in the 3rd
digit of her left hand. Three weeks after her discharge, the
patient was operated by the Plastic and Reconstructive
Surgery department and the defect between the 3rd dorsal
proximal phalanx and the distal phalanx of the left hand was
repaired with the flap elevated from her left femoral region.
Discussion
Human bites are potentially dangerous wounds constituting an
important cause of morbidity (5). Although injuries due to
human bites are rarely observed, they carry the greatest risk
(10-50%) for the development of infections (1). It is reported
that infections that occur due to human bites are more
dangerous than animal bites (1-3). Human saliva is known to
contain 108 microbes/ml and up to 50 different species of
bacteria (6). This is the reason why the infection rates
secondary to human bites are higher than other injuries (5).
The most common bacteria blamed for the infections
secondary to human bites are α and β haemolytic Streptococci,
Staphylococcus aureus, Staphylococcus epidermidis,
Corynebacterium spp. and Eikenella corrodens (1). No
bacterial growth was observed in the cultures obtained from

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3 J Immunol Clin Microbiol 2016; 1(1): x-x
our patients and this may be explained with the antibiotherapy
the patients received before presenting to us.
Human bites are most commonly observed in the hands and
wrists. In a study conducted on 388 patients, more than 50.3%
of the patients were bitten on their hands or fingers, 23.5%
were bitten on an extremity, and 17.8% were bitten on their
head or neck (7). Besides infection, human bites may also
result in tendon ruptures and even amputations. The ratio of
amputations is reported between 7% and 20% in the literature
(8). Both our patients were bitten on their toes and treated with
the appropriate antibiotics after rinsing and debridement. Our
second patient had to be operated due to the tissue defect
located between the 3rd dorsal proximal phalanx and the distal
phalanx of her left hand and the defect was closed using the
flap lifted from the left femoral region.
In patients at the early phase (the first 24 hours), those without
concurrent diseases and without damage to the joint capsule or
tendon injury, local wound care and treatment with oral broad-
band antibiotics are reported to be adequate (3). In case of
large or deep tissue injuries, systemic infection symptom or
lack of response to the ambulant therapy, patients should be
admitted to the hospital (9). Delays in hospitalizing the
patient, performing the debridement or starting the IV
antibiotherapy may worsen the treatment response (10,11). In
these kinds of infections, rest, elevation and immobilization
should primarily be maintained, the infected tissues should be
debrided and closed sections should be drained. In addition,
the appropriate antibiotic treatment should be started
according to the clinical manifestation and the culture results.
Physiotherapy should be scheduled at the earliest convenience
depending on the infection and the patient should be followed
up in terms of hand functions (9,10). In both the patients
followed up at our clinic, IV antibiotic treatment was started at
an early phase and debridements were performed before
immobilization. The following reconstruction and
physiotherapy led to satisfactory results.
Conclusion
Human bite wounds have long had a bad reputation for severe
infection and frequent complication. For this reason,
prophylactic antibiotic treatment should be given after human
bite to prevent infection. If the infection signs and symptoms
develop, rapid diagnosis, appropriate antibiotic and surgical
therapy should be applied instantly.
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Cite This Article as
Ince FM, Aslan E, Deveci O, Tekin R. Soft tissue infections
due to human bites. J Immunol Clin Microbiol. 2016; 1(1): x-x.
doi:10.5455/jicm.2016.1.224190
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