AUTHOR AND EDITOR INFORMATION

Section 1 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Human bite wounds are notoriously deceptive and are perhaps the most potentially disastrous type of bite wound because of the abundant pathogenic oral flora found in humans. The extent of injury is often underestimated and the wound is undertreated. Although controversies exist regarding optimal management of human bites, the basic tenets of meticulous wound care are the same as those with other contaminated wounds. The goals of therapy are to minimize possible soft tissue deformity and to prevent or appropriately treat infection. Recognition of the high risk of infectious complications and early aggressive treatment are mandatory to prevent serious wound infection and its associated complications.

Pathophysiology

Human bite wounds of the head and neck occur as occlusive bites with avulsion, laceration, and crushing of the tissues. Occlusive bites occur when a body part is bitten with sufficient force to violate integrity of the skin.

Bacterial inoculum of wounds by any mechanism or at any anatomic location deserves special consideration because it is composed of a rich mixture of aerobic and anaerobic oral flora. Human saliva can have as many as 100 million organisms per milliliter, and cultures of human bite wounds are commonly polymicrobial. Aerobes and anaerobes are represented almost equally in cultures. 

Several bacterial species commonly found in human bite wounds produce the enzyme beta-lactamase, rendering them resistant to penicillin. Common aerobes isolated include Streptococcus species, Staphylococcus species, Eikenella corrodens, Haemophilus species, and Corynebacterium. Staphylococcus aureus is isolated in up to 30% of infected human bite wounds and is associated with some of the most severe infections, resulting in the highest complication rates. E corrodens, a slow-growing gram-negative bacillus frequently associated with chronic infection and abscess formation, is isolated in 30% of human bite wounds as well. Common anaerobes isolated include Prevotella, Fusobacterium, Bacteroides, and Peptostreptococcus species. Morbidity of human bites is primarily related to infection and its sequelae, leading to permanent functional and/or cosmetic impairment.

In addition to the acute risk of localized infection, human bites pose the potential for the transmission of systemic infections, which can be life threatening. Hepatitis B transmission via human bites is well documented. In approximately 75% of patients with hepatitis B, the antigen is detectable in their saliva, and it is approximately 100 times more infectious than HIV. 

Although the transmission rate of HIV from saliva is epidemiologically insignificant, HIV can be found in the saliva of affected patients. However, salivary inhibitors with antiretroviral properties are thought to decrease the infectivity of HIV in saliva in most cases. As a result, the risk of transmission of HIV via human bites is exceedingly low; the real threats from a human bite are wound infection and hepatitis B and/or hepatitis C transmission.¹

Frequency

United States

Human bites are ranked as the third leading cause of all bites seen in hospital emergency departments (after dog and cat bites), accounting for 3.6-23% of bite wounds. However, the true frequency is difficult to estimate because most human bites are probably unreported or patients fail to seek medical attention. Of those reported, approximately 60% occur in the upper extremity, while 15% occur in the head and neck region, most commonly the ears, nose, or lips. The remainder occurs on the breasts, genitals, thighs, and other areas.

Mortality/Morbidity

Approximately 10-18% of human bite wounds develop infection. This substantial infection rate is multifactorial. The bacterial inoculum of a human bite is rich in oral flora, as saliva contains as many as 100 million organisms per milliliter, with as many as 190 different species.

Often, the severity of injury is initially underestimated, especially by the inexperienced observer, and appropriately aggressive treatment is not initiated. Patients frequently present days to weeks after injury, when infection is well established and medical attention is unavoidable. Moreover, most human bite injuries occur on the hands, and hand wounds of any cause have infection rates higher than similar wounds in other anatomic locations.

Various viral and other infectious diseases may be transmitted through human bites; examples include hepatitis B, hepatitis C, herpes simplex virus, syphilis, tuberculosis, actinomycosis, and tetanus. Evidence suggests that the transmission of HIV via human bites is biologically possible but unlikely.

Human bite wounds are generally thought to result in complications. However, compliant patients who promptly seek medical attention after injury have an excellent prognosis.

Sex

The incidence of human bites is more common among males.

Age

The peak incidence of human bites, including occlusive bites and clenched-fist injuries, is 10-34 years of age. Occlusive bites most commonly occur among toddlers in daycare centers; these bites are usually superficial and rarely become infected. Clenched-fist injuries occur when a closed fist impacts another individual's teeth, leaving an injury over the dorsal aspect of the metacarpophalangeal joints.

CLINICAL

Section 3 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

A careful, detailed history is necessary to facilitate communication between various healthcare professionals and to document the justification for the plan of care. When questioned about the nature of the injury, patients often mislead clinicians because of embarrassment or a fear of legal repercussions. Human bite injuries are often associated with assault and involve the legal or judicial system; therefore, the clinical documentation should be clear, concise, and complete.

Particularly important components of the patient's history are the following:

• Circumstances surrounding the injury, such as the precipitating event or activity, exact mechanism of injury, time and location of occurrence, whether other involved parties are known to the patient and available if testing is indicated, and any treatment initiated before the patient's presentation
• Signs and symptoms related to the wound, such as pain, fever, swelling, discharge, and odor
• Medications and allergies to medications
• Use of tobacco, alcohol, and/or recreational drugs
• Tetanus immune status
• Ability of the patient to comprehend the magnitude of his or her injury and to cooperate with the treatment plan
• Comorbid conditions that may place patient at a higher risk for infection or its sequelae, such as diabetes mellitus, chronic edema of the region (eg, previous ipsilateral axillary node dissection for an upper-extremity wound), previous splenectomy, liver disease, immunosuppression, prosthetic valve or joint, or regional arterial or venous disease

Physical

• Thorough examination is necessary to evaluate the overall state of health, comorbidity, and nutritional status of the patient before the wound is specifically assessed.
• Wound assessment can be difficult and often inadequately performed. Appropriate wound examination may require the administration of intravenous pain medication or a regional nerve block to ensure the patient's comfort.
• All bite marks in a young child should raise suspicion of abuse. The normal intercanine distance of an adult is 2.5-4.0 cm. Therefore, any human bite marks with an intercanine distance over 3.0 cm were likely inflicted by an adult.²
• Important aspects of wound assessment include the following:  
• • Location
  • Shape
  • Size
  • Type (ie, puncture, laceration, avulsion, crush)
  • Penetration depth
  • Drainage (ie, quantity, character, odor)
  • Foreign body presence (eg, tooth fragments, particulate matter)
  • Tissue loss
  • Tenderness
  • Asymmetry
  • Surrounding erythema, edema, cellulitis, or crepitation
  • Regional neurovascular status
  • Regional lymphadenopathy
  • Violation of cartilage, joint space, or bone: This may be difficult to detect on initial examination and may require surgical exploration for adequate diagnosis.
• The American Board of Forensic Odontology has established guidelines for wound documentation in assault cases (although they are not the standard in all centers):  
• • Photographic documentation
  • Wound diagram, including notation of the arch pattern and intercanine width
  • Bite mark impressions
  • Wound swabbing for tissue typing

Causes

• Human bite wounds to the head and neck occur in a variety of situations and may involve the following:  
• • Aggressive behavior, often in combination with alcohol
  • Rough sexual play or sexual assault
  • Domestic violence
  • Child abuse
  • Seizure-related tongue and/or lip lacerations
  • Nose biting as punishment for adultery, which occurs in several cultures
  • Accidents during sporting events
  • Aggressive child play in daycare centers

WORKUP

Section 4 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Laboratory studies are required if bacteremia or sepsis is suspected.
• Obtain appropriate baseline viral titers from the patient and the assailant (if applicable and available).

Imaging Studies

• Radiographs may be useful in evaluating foreign bodies (eg, tooth fragments), air in a joint, or injuries occurring over bone to reveal fractures.
• Radiographs of chronic wounds may reveal underlying osteomyelitis.

Other Tests

• Routine culture of every human bite wound is unnecessary.
• • Cultures are costly, demonstrate no growth in more than 80% of cases, and rarely alter first-line therapy.
  • Furthermore, wounds that subsequently manifest signs of infection often have bacteriologic profiles that differ from those shown on initial cultures.
• Cultures are indicated in wounds with signs of infection (eg, cellulitis, swelling, purulence) and in wounds showing no clinical improvement despite appropriate antimicrobial therapy.
• • Obtain aerobic and anaerobic cultures, and grow them for 7-10 days to identify slow-growing pathogens. This will allow for the quantification and identification of bacterial species and their antibiotic susceptibilities.
  • Obtain cultures before the start of antimicrobial therapy whenever possible.

TREATMENT

Section 5 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

Meticulous wound care is the cornerstone of human bite wound management.

Copious irrigation decreases the incidence of wound infection. Use normal saline, diluted Betadine, or diluted hydrogen peroxide to cleanse the wound thoroughly. This cleansing is best performed by using a 10-mL syringe with an 18-gauge angiocatheter sheath attached. Avoid the injected tissue and prevent additional trauma.

Careful debridement of obviously devitalized tissue, particulate matter, and clot is also necessary to reduce infection risk and improve cosmesis. Surgically created wound margins speed wound healing and decrease scarring.

Wound closure is a source of controversy. In general, do not close wounds that are older than 12 hours, infected, or due to puncture. Allow these wounds to heal by means of secondary intention, and consider secondary closure or revision at a later date.

Head and neck wounds occur in cosmetically important areas and may be closed if less than 12 hours old and not obviously infected. Closure of these wounds has a low incidence of infection, probably because of the excellent blood supply and infrequency of edema. However, several points deserve specific mention. Perform closure in a simple interrupted fashion, avoiding layered closure with buried sutures. The objective is to provide wound edge approximation that is not watertight, which allows for drainage. Antibiotic prophylaxis is mandatory in these patients.

• Bite wounds are often several days old and heavily contaminated or overtly infected on first presentation.
• On rare occasions, human bites have been shown to transmit Clostridium tetani. All patients should be assessed for tetanus immune status and updated appropriately. Administer tetanus toxoid or tetanus immunoglobulin when immunity is in question.
• Bites with no substantial skin penetration (eg, abrasions, contusions) and without injury to underlying structures require no further care.
• Human bite wounds at risk for transmission of disease (eg, hepatitis, HIV) require therapy individualization. A fully informed patient (ie, risks and benefits are clearly explained and understood) may be allowed to choose appropriate viral prophylaxis.
• Offer the patient a single dose of hepatitis B immunoglobulin (HBIG) and an accelerated course of hepatitis B vaccine with doses at 0, 1, and 2 months if the assailant is known to have hepatitis B, unless the patient is known to be immune.
• Offer the patient an accelerated course of hepatitis B vaccination if the assailant has unknown hepatitis B status, is considered at high risk, and is unavailable for testing.
• The accelerated course of hepatitis B vaccine may be offered to the patient if the assailant has an unknown hepatitis B status, is considered low risk, and is unavailable for testing, with the understanding that the likelihood of disease transmission is low.
• The Centers for Disease Control and Prevention recommend that patients be offered zidovudine and possibly lamivudine chemoprophylaxis if the assailant is known to be infected with HIV or considered at high risk and unavailable for testing.
• Draw a baseline specimen to determine preexposure HIV status. Retest at 3 and 6 months. Failure to seroconvert at 6 months makes the transmission of HIV highly unlikely.
• Considerable debate occurs over which patients require antibiotic therapy. Antibiotics cannot prevent or eradicate infections in the face of poor wound care, reflecting the importance of meticulous wound care as the cornerstone of therapy. Administering antibiotics is preferred when their use is in question; the risk of antibiotic therapy is minimal, whereas the potential complications of bite wound infections are considerable.
• Superficial noninfected wounds may be treated without antibiotics if left open to heal by secondary intention when evaluated early in compliant patients with no significant comorbidity.
• Infected wounds and wounds of the head and neck closed primarily require antibiotic therapy.
• Wounds managed on an outpatient basis may be treated with oral antibiotics, whereas wounds requiring admission to the hospital should be treated with intravenous antibiotics.
• Antibiotic prophylaxis is warranted if the wound is believed to be at higher risk for infection (eg, significant contamination is present; bone, tendon, or joint space is involved; the bite is on the hand; deep puncture wounds are present; or bites occurring in high-risk patients).
• Continue prophylaxis in the noninfected wound for 3-5 days. Administer therapeutic antibiotics for 10-14 days.
• Selection of the appropriate antibiotic involves multiple factors, including culture results, drug sensitivities, patient age, drug interactions, expected compliance, and renal and hepatic function.
• All patients should be re-examined in 48-72 hours in the emergency department or by the primary care provider.

Surgical Care

Surgical intervention is frequently necessary in treating human bite wounds. Surgical interventions range from simple wound exploration and debridement to the repair of complex structures under magnification. Certain patients (eg, children, those who are emotionally unstable or mentally disabled) may require anesthesia to permit adequate surgical examination of the wound.

Indications for surgical intervention include presence of the following:

• Severe soft tissue infection
• Abscess
• Joint penetration
• Underlying fracture
• Osteomyelitis
• Foreign body
• Neurovascular compromise or injury to a complex structure (eg, facial nerve, parotid duct)

The goal of treating human bites to the head and neck region is the restoration of the patient's facial appearance and function. Years ago, these wounds were routinely left open because of the high rate of wound infection. However, care of these patients has undergone marked changes with the introduction of broad-spectrum antibiotics and the evolution of microsurgical techniques. The development of broad-spectrum antibiotics gradually led to general acceptance of the idea that patients who presented early and without obvious infection were candidates for primary wound closure.

Once surgeons became familiar with and accepted this approach because of its good clinical results, aggressive reconstructive techniques evolved in the acute setting. These techniques have proven to be safe and effective, yielding an acceptably low rate of morbidity, and they do not leave the patient with a potentially significant facial deformity while awaiting reconstruction. More importantly, the ultimate results of primary reconstruction are clearly superior to those of delayed reconstruction.

Many options are available to the surgeon, including primary closure, skin grafting, composite grafting, use of local flaps, and microsurgical replantation.

• Lip wounds are among the most common facial bite wounds.  
• • Vermillion defects may be reconstructed with mucosal advancement flaps. Wounds measuring up to a third of the length of the lip may be closed by using a wedge or chevron excision and approximating the two cut edges. Perform muscular reapproximation of the orbicularis oris with interrupted buried absorbable sutures to assure continuity of the sphincteric muscular ring.
  • Small (<1.5 cm²) lip segments have been successfully replanted as composite grafts when a segment of lip has been amputated and is available for reattachment. However, the survival of such grafts is often questionable. Patients with small tissue loss may benefit more from primary wound closure or from using one of the available local flaps.
  • Larger defects may require a local flap (eg, Bernard advancement flap, Gillies fan flap, Karapandzic myocutaneous flap) or a lip switch procedure (eg, with an Abbé or Estlander flap).
  • Large amputated lip segments have been successfully replanted by using microvascular techniques, and successful results are unmatched by any other reconstructive technique. No other donor tissue matches replanted lip regarding symmetry, contour, shape, color, texture, or motion. Return of muscle function and protective sensation is fairly predictable. Although this approach is reliable, it is not universally applicable. The surgeon must have adequate experience in microvascular techniques, and the treating facility must have microsurgical equipment. Caution patients against smoking in the postoperative period to avoid the vasoconstrictive effects of nicotine.
  • An artery may be anastomosed to the remaining labial artery if it is identifiable in the severed lip.
  • Veins are small and often unidentifiable. Veins may be repaired primarily or by using a vein graft. When no vein is found and when 2 arteries are located in the severed segment, 1 of the arteries may be anastomosed to a facial vein; this creates an arteriovenous fistula that aids venous drainage of the amputated part through retrograde flow.
  • Venous congestion is the most likely cause of failure in lip replantation. In general, when no venous anastomosis is performed, patients require venous decompression for 4-6 days until the wound is adequately revascularized from surrounding tissue.
  • Venous drainage may be achieved in several ways. All methods involve notable bleeding and frequently require administration of blood transfusions, which increase the risk of disease transmission. Some recommend systemic anticoagulation with heparin, while others advocate local injection of heparin into reattached tissue. Bleeding occurs from the suture line, which should be kept free of clot or crusting to allow the egress of venous blood. Leeches actively remove blood and may be applied to the suture line. Passive oozing from the leech bite continues to provide artificial venous outflow after they are removed. An anticoagulant (hirudin) in leech saliva that is injected when it bites enhances venous egress. Give patients undergoing leech therapy appropriate antibiotic prophylaxis against infection by Aeromonas hydrophila, which is found in the GI tract of the leech.
• Ear wounds are also common facial bites because of the prominent position of the ears on the head.  
• • Coverage of exposed cartilage and restoration of shape are the primary concerns.
  • Similar to lip bites, small bites on the ears can be closed primarily and may require wedge excision.
  • Alternatives for covering exposed cartilage in the presence of skin deficits are the use of postauricular flaps or temporoparietal fascial flaps covered with thick split-thickness skin grafts. Helical advancement may be performed to reconstruct helical defects.
  • Small amputated parts may be replaced as composite grafts. If the composite graft fails, débride the wound, close the skin over the cartilage, and delay definitive reconstruction until infection or inflammation subsides.
  • Salvaged denuded cartilage can be preserved by placing it in an abdominal or cervical pocket or under postauricular skin.
  • Larger amputated segments may be replanted by using microvascular techniques similar to those described for the lip. However, these procedures tend to fail because of the small caliber of the vessels. Reanastomosing the veins may be difficult or impossible; alternative techniques for ensuring venous drainage may be needed.
  • In the absence of microvascular capabilities, amputated cartilage may be skeletonized and placed in a subcutaneous pocket for use during later reconstruction.
  • Delayed reconstruction may be performed by using a retroauricular flap, helical advancement, or cartilage or composite grafting, depending on the residual defect.
• Cheek wounds are frequently amenable to primary closure. Injuries with great tissue loss may be closed with cervicofacial, nasolabial, or other locoregional flaps.
• Bites to the eyelid are infrequent but pose a particular threat in terms of eye closure and corneal protection.  
• • A full-thickness graft from the contralateral lid may be used when only a skin deficit is encountered.
  • A composite graft from the contralateral lid may be used for defects of the tarsal plate.
• Nose wounds and resultant nose reconstruction can be challenging, and details of the procedure are beyond the scope of this discussion.  
• • Briefly, cartilaginous defects may require cartilage grafts from the septum, ear, or costal cartilages. A composite cartilage graft harvested from the ear may also be necessary.
  • Soft tissue coverage may require a dorsal nasal flap for small defects of the nasal dorsum.
  • A nasolabial flap (either pedicle or island), forehead flap, or Washio flap may be required for larger defects.

Consultations

A hand surgeon should be consulted for hand wounds involving bone, tendon, or joint space because of the higher risk for infection and potential need for admission and exploration. Likewise, consultation with either an otolaryngologist-head and neck surgeon or facial plastics and reconstructive surgeon should be obtained for all avulsion bites involving the face or neck. 

MEDICATION

Section 6 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Drug Category: Antibiotics

Several antibiotics are commonly used in cases of human bite wounds.

FOLLOW-UP

Section 7 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Some patients require hospitalization for the administration of intravenous antibiotics and observation or for surgical intervention. Inpatient observation facilitates prompt surgical intervention if no improvement is noted or the clinical situation deteriorates.
• Indications for hospitalization are as follows:
• • Injuries of severity requiring surgical exploration or complex wound closure; clinical situation dictates length of stay
  • Systemic manifestations of infection (eg, fever, chills, elevated WBC count)
  • Substantial comorbidity
  • Failure to improve with initial outpatient management
  • High likelihood of noncompliance (eg, emotionally disturbed, mentally handicapped, chronic alcoholism, homeless)

Further Outpatient Care

• Patients evaluated early and without evidence of infection may be treated as outpatients without antibiotics.
• Follow-up should be done within 48-72 hours for reassessment.
• Development of any signs or symptoms of infection indicate the need to seek immediate medical attention.
• Patients with mild-to-moderate infections who are likely to be compliant may be treated as outpatients with oral antibiotics. Instruct these patients to return for follow-up within 24-48 hours and to seek medical attention immediately if their clinical condition deteriorates.

Complications

• Complications may result from scarring or infection and include the following:  
• • Cosmetic deformity resulting from wound contraction
  • Osteomyelitis
  • Abscess formation
  • Transmission of disease (eg, hepatitis B or C, HIV) 

Patient Education

• Patients should be informed about and fully understand the following:
• • Signs and symptoms of wound infection that require immediate reevaluation (eg, fever, odor, drainage, purulence, swelling, cellulitis, warmth, pain, decreased range of motion, any other abnormal sign or symptom)
  • Importance of early and regular follow-up for this seemingly minor injury and the potential complications that may develop, even with complete compliance with the care plan
  • Rationale for providing antibiotics and the importance of compliance
• Inform patients that wound revision for cosmetic or functional purposes may be indicated at a later date.
• For excellent patient education resources, visit eMedicine's Bites and Stings Center. Also, see eMedicine's patient education article Human Bites.

MISCELLANEOUS

Section 8 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Cases of human bite wounds frequently involve the legal and judicial system, have an increased likelihood of infection, and have a significant rate of permanent functional or cosmetic deformity.
• The patient chart must appropriately document initial evaluation and treatment, a legitimate care plan, and evidence of relevant patient education.  Photographic documentation should also be considered.
• Most jurisdictions require medical professionals to report suspected child abuse.

REFERENCES

Section 9 of 9

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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17. Kos LK, Shwayder T. Cutaneous manifestations of child abuse. Pediatr Dermatol. Jul-Aug 2006;23:311-20. [Medline].
18. Menard P, Bertrand JC, Philippe B. [Reconstruction of the lip vermillion using a myo-mucosal advancement flap]. Rev Stomatol Chir Maxillofac. 1991;92(1):18-21. [Medline].
19. Presutti RJ. Bite wounds. Early treatment and prophylaxis against infectious complications. Postgrad Med. Apr 1997;101(4):243-4, 246-52, 254. [Medline].
20. Pretty IA. The barriers to achieving an evidence base for bitemark analysis. Forensic Sci Int. May 15 2006;159 Suppl 1:S110-20. [Medline].
21. Ruskin JD, Laney TJ, Wendt SV. Treatment of mammalian bite wounds of the maxillofacial region. J Oral Maxillofac Surg. Feb 1993;51(2):174-6. [Medline].
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24. Uchendu BO. Primary closure of human bite losses of the lip. Plast Reconstr Surg. Nov 1992;90(5):841-5. [Medline].
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Article Last Updated: May 21, 2008