Human and animal bites may cause a wide spectrum of tissue damage, ranging from superficial breaks in the integument to cellulitis, septic arthritis, and osteomyelitis. In an emergency-room setting, the bite victim is often treated empirically with an oral antibiotic. The drug selected should possess activity against the polymicrobial flora most likely to cause such an infection. The culpable bacterial species include streptococci, staphylococci
(usually S. aureus), Pasteurella multocida (especially important in cat bites), oral anaerobes (Prevotella and Porphyromonas spp, are common, whereas Fusobacterium nucleatum is not), and Eikenella corrodens. Amoxi-cillin/clavulanate is generally considered the best choice to cover infection with these organisms. However, penicillin-allergic patients need alternative treatment.
Goldstein and Citron (Santa Monica, CA) evaluated the in vitro efficacy of the newer macrolides azithromycin, clarithromycin, and roxithromycin against isolates commonly cultured from bite wounds. Azithromycin was found to be the most active against many of the aerobes, including P. multocida [minimal inhibitory concentration for 90% of isolates (MICW) < 2fig/mlj and E. corrodens, and was 2 to 4 dilutions more active than erythromycin versus anaerobes. Overall, clarithromycin was less active than azithromycin, and roxithromycin was even less active than erythromycin.
Neither Goldstein nor others in the workshop had substantive clinical experience with the newer macrolides in bite wound management. Yet, in light of the above in vitro data, there was consensus that at least azithromycin merited clinical evaluation in the penicillin-allergic patient. However, two caveats were stressed. First, in the emergent care of bite wounds, particularly clenched-fist injuries, copious irrigation followed by elevation of the affected extremity is essential for cure; no antimicrobial is likely to be of benefit without such intervention. Second, if the bite wound extends to bone and osteomyelitis ensues, the consequences may be devastating. In this scenario (which is not uncommon when the infection is due to P. multocida), it is probably best to avoid therapy with any of the macrolides.
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