What is the appropriate management for a patient who has been bitten by a monkey?

Management of Monkey Bites

Immediately wash the wound thoroughly with soap and copious amounts of water for at least 15 minutes, then initiate rabies post-exposure prophylaxis (PEP) with both rabies immunoglobulin and vaccine, and strongly consider antiviral prophylaxis against herpes B virus if the monkey is a macaque species. 1, 2

Immediate Wound Care (First Priority)

• Irrigate the wound with copious amounts of water and soap for approximately 15 minutes as soon as possible after the bite. 3, 2
• Apply an iodine-containing or similarly viricidal topical preparation to the wound if available. 2
• Remove superficial debris with sterile normal saline; avoid deep debridement that could enlarge the wound or impair closure. 3
• Do not close infected wounds or wounds presenting late (>8 hours after injury). 3
• Elevate the injured body part, especially if swollen, to accelerate healing. 3

Rabies Post-Exposure Prophylaxis (Mandatory)

Nonhuman primates, including monkeys, are considered high-risk rabies reservoir species requiring immediate PEP. 1, 2

For Previously Unvaccinated Patients:

• Administer human rabies immunoglobulin (RIG) at 20 IU/kg body weight, infiltrating the full dose around and into the wound if anatomically feasible, with any remaining volume injected intramuscularly at a site distant from the vaccine. 2
• Simultaneously administer rabies vaccine at a different anatomical site on day 0. 2
• Complete the 5-dose vaccine series on days 0,3,7,14, and 28. 1, 2
• Do not delay prophylaxis while awaiting animal testing results. 1, 2

For Previously Vaccinated Patients:

• Administer rabies vaccine alone (no RIG needed) if the patient has documented prior complete vaccination with cell culture vaccine or documented rabies antibody titers. 2

Herpes B Virus Prophylaxis (Critical for Macaque Bites)

Herpes B virus is endemic in 80-90% of adult macaque monkeys and causes potentially fatal meningoencephalitis in humans. 4, 5

High-Risk Exposures Requiring Antiviral Prophylaxis:

• Any bite that breaks the skin from a macaque monkey 1
• Scratches that penetrate the epidermis 1
• Contact of macaque saliva, mucous membranes, or neural tissue with open wounds or mucous membranes 1

Antiviral Protocol:

• Initiate antiviral prophylaxis (acyclovir or valacyclovir) immediately for all macaque exposures meeting high-risk criteria. 1, 4
• Never delay antiviral prophylaxis while awaiting test results or attempting to determine the macaque's infection status—assume all macaques are herpes B positive. 1

Antimicrobial Prophylaxis

• Administer prophylactic antibiotics to cover polymicrobial oral flora, including aerobic and anaerobic bacteria. 3, 6
• Appropriate intravenous options include β-lactam/β-lactamase combinations (ampicillin-sulbactam, piperacillin-tazobactam), second-generation cephalosporins (cefoxitin), or carbapenems (ertapenem, imipenem, meropenem). 3
• Consider a single initial dose of parenteral antimicrobial before starting oral therapy. 3

Tetanus Prophylaxis

• Verify tetanus immunization status and administer tetanus toxoid (0.5 mL intramuscularly) if outdated or unknown. 3, 2

Follow-Up and Monitoring

• Arrange follow-up within 24 hours either by phone or office visit. 3
• Monitor for signs of infection, including pain disproportionate to injury severity (suggesting periosteal penetration, septic arthritis, or osteomyelitis). 3
• Hand wounds require particularly close monitoring as they are often more serious than wounds to fleshy body parts. 3
• If infection progresses despite appropriate antimicrobial and ancillary therapy, hospitalization should be considered. 3

Reporting Requirements

• Report the incident immediately to the local health department for epidemiologic tracking and public health guidance. 3, 1

Critical Pitfalls to Avoid

• Never assume a monkey is herpes B negative—all macaques must be considered positive until proven otherwise. 1
• Never delay rabies PEP for monkey bites, as nonhuman primates cannot be observed like domestic dogs, cats, or ferrets. 3, 2
• Do not suture wounds early or close infected wounds, as this increases infection risk. 3
• Do not underestimate hand wounds, which can lead to serious complications including septic arthritis, osteomyelitis, and tendonitis requiring 3-6 weeks of therapy. 3

Special Considerations

• Children are more than three times as likely to be bitten by monkeys than adults, often during attempts to pet or feed the animals. 6, 5
• Most monkey bites to travelers occur in India, Thailand, Indonesia, and Bali, typically involving macaque or capuchin species. 6
• Workers at tourist sites, temples, or facilities with macaque contact face ongoing exposure risk and should implement strict barrier precautions. 1