What is the management for a human bite in a child?

Management of Human Bites in Children

All children with human bite wounds should receive prophylactic antibiotics regardless of wound appearance, with amoxicillin-clavulanate as first-line therapy, and wounds should undergo thorough irrigation but generally not be closed primarily except for facial injuries managed by specialists. 1, 2

Immediate Wound Care

• Irrigate the wound immediately with copious amounts of sterile normal saline or running tap water to remove visible debris and reduce bacterial load 2, 3
• Clean thoroughly but avoid iodine or antibiotic-containing solutions, which offer no additional benefit 1, 2
• Perform only superficial debridement to remove debris; avoid aggressive deep debridement that enlarges the wound or impairs closure 1
• Do not close infected wounds under any circumstances 1, 2

Wound Closure Strategy

The approach to wound closure differs significantly from animal bites and depends on timing and location:

• For wounds presenting <8 hours after injury: Approximate margins with Steri-Strips rather than sutures, allowing for delayed primary or secondary closure 1, 2
• For wounds presenting >8 hours after injury: Leave open for healing by secondary intention 2, 3
• Facial wounds are the critical exception: These may be closed primarily by a plastic surgeon after meticulous wound care, copious irrigation, and administration of prophylactic antibiotics 1, 2
• Recent evidence from a 9-year retrospective study of 660 children demonstrates that delayed closure achieves significantly lower infection rates (12.6%) compared to primary closure (29.0%), while maintaining optimal wound healing rates of 76.4% 4

Antibiotic Prophylaxis (Universal for Human Bites)

Unlike animal bites where prophylaxis is selective, all human bite wounds require prophylactic antibiotics regardless of appearance because human oral flora is particularly pathogenic 1, 2:

First-Line Oral Therapy

• Amoxicillin-clavulanate 875/125 mg twice daily (or weight-based dosing for children) 1, 2
• This covers the polymicrobial flora including viridans streptococci (80% of wounds), staphylococci, Haemophilus species, Eikenella corrodens, and anaerobes (60% of cases) 1

Alternative Oral Regimens for Penicillin Allergy

• Doxycycline 100 mg twice daily (avoid in children <8 years due to tooth staining) 1, 2
• Penicillin VK plus dicloxacillin 500 mg four times daily each 1, 2
• Fluoroquinolones (ciprofloxacin, levofloxacin, or moxifloxacin) plus metronidazole or clindamycin for anaerobic coverage 1, 2

Intravenous Therapy for Severe Infections

• First-line: Ampicillin-sulbactam 1.5-3.0 g every 6-8 hours or piperacillin-tazobactam 3.37 g every 6-8 hours 1, 2
• Alternative: Carbapenems (ertapenem, imipenem, meropenem) for broader coverage 1, 2
• Note that all these regimens miss MRSA; add vancomycin if MRSA is suspected or present 1

Critical Antibiotic Pitfalls to Avoid

• Never use first-generation cephalosporins, penicillinase-resistant penicillins alone, or clindamycin monotherapy as they have poor activity against Eikenella corrodens, a key pathogen in human bites 1, 3

Special High-Risk Scenarios

Clenched-Fist Injuries

• Require immediate evaluation by a hand surgery specialist to assess for penetration into synovium, joint capsule, or bone 1, 2
• These carry exceptionally high risk for septic arthritis and osteomyelitis 2, 3
• Duration of therapy extends to 4 weeks for septic arthritis and 6 weeks for osteomyelitis 1

Child Abuse Consideration

• Bite wounds in children should alert clinicians to possible child abuse, particularly when the injury pattern is inconsistent with the reported mechanism 1
• Look for embedded teeth fragments in sports-related injuries versus intentional biting patterns 1

Tetanus Prophylaxis

• Administer tetanus toxoid 0.5 mL intramuscularly if vaccination status is outdated or unknown 1, 2
• Give booster if >5 years since last dose for contaminated wounds 3

Rabies Considerations

• Rabies transmission from human bites is extraordinarily rare in the United States and typically not a concern 2
• Consider rabies prophylaxis only in exceptional circumstances where the biting person has suspected rabies exposure or compatible clinical signs 2
• If indicated, previously unvaccinated persons should receive both rabies immune globulin (HRIG) and vaccine series on days 0,3,7,14, and 28 2

Supportive Care and Follow-Up

• Elevate the injured extremity, especially if swollen, using a sling for outpatients or tubular stockinet for inpatients 1, 2
• Mandatory follow-up within 24 hours either by phone or office visit 1, 2
• Consider hospitalization if infection progresses despite appropriate antimicrobial therapy 1, 2
• A single initial dose of parenteral antimicrobial may be administered before starting oral therapy for moderate wounds 1

Evidence Regarding Antibiotic Necessity

While older pediatric data from 1985 suggested that superficial human bites in children rarely become infected without antibiotics (0/13 untreated children developed infection) 5, current guidelines universally recommend prophylactic antibiotics for all human bites given the polymicrobial nature of human oral flora and potential for serious complications 1, 2. The risk-benefit analysis favors prophylaxis given the devastating consequences of missed deep infections, particularly in clenched-fist injuries.

Risk Factors for Infection

Multivariate analysis identifies three independent predictors of wound infection 4:

• Advanced age (RR 1.195 per year increase)
• Primary closure technique (RR 4.375 compared to delayed closure)
• Delayed presentation (RR 1.029 per additional hour)

Human bites have infection rates of 10-20% overall, significantly higher than dog bites (15-20%) but comparable to cat bites (50%) 3, 5.