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Three Part Question

In [adults with a human bite] does [surgical debridement] prevent [infection]?

Clinical Scenario

A 31 year prison warden presented to the emergency department with a human bite wound to his leg after a quarrel with an inmate. There was deep puncture of tissue and a lot of blood. Pain releif and tetanus immunisation was given. After the wound was cleaned you want to know whether surgical debridement reduces the risk of infection.

Search Strategy

MEDLINE - 1966 -06/05 and EMBASE -1988 06/05 using the OVID interface.
human bite$.mp. or exp Bites, Human/ AND [debridement.mp. or exp DEBRIDEMENT/exp Debridement/ or debride.mp.OR exp Irrigation/ or irrigate.mp.] AND [exp INFECTION/ or exp WOUND INFECTION/ or infection.mp.] LIMIT to human AND English language.

Search Outcome

39 papers were found on MEDLINE and 44 papers on EMBASE. Altogether 3 papers provided the best evidence for the clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Zubowicz V N, Gravier M 1990 Atlanta	48 adult patients with human bites to the hand. Inclusion criteria were: Bite less than 24 hours old, bites not infected and absence of systemic infection, and bites not penetrating a joint capsule or injuring a tendon.	Prospective Randomised study (A PRS)	Infection: Antibiotics plus debridement vs no antibiotics plus debridement	0/33 vs 7/15	Open mouth wounds predominated clench fist injuries
Chidzonga M M 1998 Zimbabwe	22 consecutive patients with human bites of the face. Antibiotics given and primary closure of the wound in all patients.	Prospective study	Wound infection following surgical debridement	1 infection (5%) in the whole group, vs 21 (95%) patients with no infection	The study mainly looked at black females, and majority (90.9%) were lower lip bites. Antibiotics were given to all patients and no comparison of no antibiotic vs antibiotics.
Tonta K and Kimble F W 2001 Australia	35 males with human bites mainly with clench fist injuries.	A 5 year retrospective study	Return to full motion after injury	41% full range of motion after debridement	This study used a small number of subjects. The study concentrates on time of presentation and many patients were lost to follow up.

Comment(s)

Zubowicz et al showed that early presentation, and surgical debridement, in combination with antibiotics reduced the risk of wound infection. It is not known whether debridement without antibiotics is effective in reducing wound infection in this study. Chidzonga et al focused on wounds to the face. This study found that debridement and daily wound care are insufficient without prophylactic antibiotics. Tonta et al showed that debridement increased the return to full range of motion of the hand. It is more likely that no infection is present in order to regain full range motion.

Clinical Bottom Line

Surgical debridement of bite wounds is insufficient without antibiotics. Antibiotics are effective in preventing infection.

References

1. Zubowicz V N, Gravier M, a prospective randomised study Management of early human bites of the hand: Plastic and Reconstructive surgery: 1991 July, 88 (1) 111-114
2. Chidzonga M.M, A review of 22 cases. Human bites of the face: South African Medical Journal: Feb 1998, 88 (2)150-52.
3. Tonta K and Kimble F W, Human Bites of the Hand: the Tasmanian experience, ANZ J Surgery: Aug 2001, 71 (8) 467-471.