What is the recommended prophylaxis for a neonate scratched by a cat?

Prophylaxis for a Neonate Scratched by a Cat

For a neonate scratched by a cat, immediate wound cleansing with soap and water is the primary intervention, with azithromycin being the recommended prophylactic antibiotic if needed due to concerning wound characteristics or immunocompromise. 1

Initial Management

1. Immediate wound care:

   • Thoroughly wash the scratch with soap and water 1
   • Do not allow the wound to be licked by cats 1
   • Keep the area clean and monitor for signs of infection

2. Risk assessment factors:

   • Depth and severity of the scratch
   • Whether the cat is a kitten (higher risk) or older cat
   • Whether the cat is domestic or feral
   • Presence of cat fleas (vector for Bartonella transmission)
   • Neonate's overall health status

Antibiotic Prophylaxis Decision

When prophylaxis is indicated:

• Deep or severe scratches
• Signs of local infection
• Scratches from kittens or feral cats
• Scratches near sensitive areas (face, eyes)

Recommended antibiotic regimen:

• First-line: Azithromycin 1

  • For neonates: 10 mg/kg on day 1, followed by 5 mg/kg for 4 additional days
  • Azithromycin has been shown to speed recovery in cat scratch disease 2

• Alternative (if azithromycin unavailable):

  • Erythromycin: 40-50 mg/kg/day in 4 divided doses 3
  • Important caution: Erythromycin in neonates <1 month carries risk for infantile hypertrophic pyloric stenosis (IHPS) 3
  • Parents should be counseled about signs of IHPS if erythromycin is used 3

Special Considerations for Neonates

• Neonates may be more susceptible to infections due to immature immune systems
• Monitor closely for signs of systemic infection (fever, irritability, poor feeding)
• Lower threshold for prophylaxis compared to older children
• Avoid doxycycline due to potential effects on bone and teeth development

Follow-up Recommendations

• Clinical reassessment within 24-48 hours to evaluate wound healing 1
• Watch for signs of cat scratch disease:
  • Regional lymphadenopathy (typically develops ~3 weeks after inoculation)
  • Fever
  • Malaise
• Return immediately if:
  • Fever develops
  • Redness, swelling, or drainage from the wound site increases
  • Lymph node enlargement occurs
  • Neonate becomes irritable or feeds poorly

Prevention of Future Incidents

• Consider risks of cat ownership with a neonate in the household 1
• If keeping cats:
  • Implement flea control measures 1
  • Keep cats' nails trimmed 1
  • Supervise all interactions between cats and the neonate 1
  • Consider adopting older cats (>1 year) rather than kittens 1

Common Pitfalls

• Underestimating risk: Cat scratch disease can be more severe in very young or immunocompromised patients
• Delayed treatment: Prompt wound cleansing is essential to prevent infection
• Inappropriate antibiotic selection: Penicillins and first-generation cephalosporins have no in vivo activity against Bartonella and should not be used 1
• Overlooking flea control: Cat fleas are the primary vector for horizontal transmission between cats and can occasionally transmit to humans 2

While most cases of cat scratch disease are self-limited in immunocompetent hosts 4, neonates represent a vulnerable population where prophylaxis may be warranted when risk factors are present.