Personal Formulary for a Mild Skin Infection Secondary to an Animal Bites Nearly 18% of dog bites and 50% and 80% of cat bites become infected. Infections are often polymicrobial with the most common organism being Pasteurella multocida(Bower, 2003; Dendle & Looke, 2008; Morgan, 2005; Norton, 2008; Sheff, 2002) Diagnosis Diagnoses following an animal bite include actual soft tissue injury;
actual infection, usually apparent within 12-48 hours and characterized by inflammation and serosanguineous or purulent drainage; and potential infection in bites requiring primary closure, puncture wounds, all cat bites, clenched fist, and crush wounds with devitalized tissue (Bower, 2003; Morgan, 2005; Sheff, 2002). Therapeutic Objectives The therapeutic objectives are promote wound healing, prevent an infection is one has not yet occurred (prophylaxis); and cure the infection if one has developed (De Vries, Henning, Hogerzeil, & Fresle, 1994). Drugs of Choice First Line Drug (No Contraindications)
Amoxicillin-clavulanate 500/125 mg three times a day (TID) or 875/125 mg twice a day (BID) taken orally. Duration of therapy is 3-5 days for prophylaxis and 7-14 days for a confirmed infection (Anti-infective Review Panel, 2012; Blondel-Hill & Fryters, 2006; Bower, 2003; Dendle & Looke, 2008; Joint Formulary Committee, 2012; Morgan, 2005; Sheff, 2002; Stuart, Kouimtzi, & Hill, 2009). Contraindications. Contraindications include hypersensitivity to penicillins, renal disease, or mononucleosis (Canadian Pharmacists Association, 2012; Joint Formulary Committee, 2012; Skidmore-Roth, 2012; Stuart et al. , 2009).
Use cautiously in pregnancy (class B), breastfeeding, neonates and children, hypersensitivity to cephalosporins, gastrointestinal disease, or viral infection (Skidmore-Roth, 2012). Side effects. Common side effects include nausea, vomiting, diarrhea (most common), vaginitis, and rash. Potentially life-threatening side effects include anaphylaxis, bone marrow depression, glomerulonephritis, pseudomembranous colitis, respiratory distress, seizures, Stevens-Johnson syndrome, superinfection, and toxic epidermal necrolysis (Canadian Pharmacists Association, 2012; Joint Formulary Committee, 2012; Skidmore-Roth, 2012; Stuart et al., 2009).
Drug related health teaching. The drug should be not crushed or chewed and may be taken with or without regard food; however absorption is promoted when taken with food (Canadian Pharmacists Association, 2012; Skidmore-Roth, 2012). Patients should report sore throat, fever, fatigue (suggestive of superinfection or agranulocytosis), diarrhea, cramping, blood in the stool (suggestive of pseudomembranous colitis), or changes in urinary habits including hematuria or oliguria(Skidmore-Roth, 2012).
Amoxicillin-clavulanate has a number of drug interactions includingincreased serum levels if taken concurrently with probenecid; increased anticoagulation effects of warfarin; skin rash if taken with allopurinol; and decreased effectiveness of oral contraceptives (Canadian Pharmacists Association, 2012; Skidmore-Roth, 2012). First Line Drug (If Contraindications Exist) Doxycycline 200 mg first dose then 100 mg BID taken orally for 3-5 days for prophylaxis and 7-10 days for treatment of a confirmed infection (Anti-infective Review Panel, 2012; Blondel-Hill & Fryters, 2006; Bower, 2003; Dendle & Looke, 2008).
Limits on Nurse Practitioner Prescribing. In Alberta, Nurse Practitioners (NPs) are authorized to prescribe Schedule 1 drugs (College and Association of Registered Nurses of Alberta, 2011). Both amoxicillin-clavulanate and doxycycline are Schedule 1 drugs (National Association of Pharmacy Regulatory Authorities, 2009), there are no restrictions on Alberta NPs in prescribing these drugs or requirements for consultation. Monitoring Parameters Wound cultures should be taken and sensitivities requested for bites which are clinically infected.
X-rays should be obtained to exclude fractures or embedded teeth (Bower, 2003; Dendle & Looke, 2008; Morgan, 2005). Health Teaching Patients should monitor the bite for worsening infection and return in 24-48 hours for reassessment (Bower, 2003; Dendle & Looke, 2008). Related to Drug Patients should be advised of the purpose and duration of therapy, drug interactions, medications, administration considerations, and side effects.
Patients should be advised on methods to alleviate discomfort (e.g. dimenhydrinate for nausea) for tolerable side effects and to discontinue the medication and seek medical assistance if side effects are not tolerable or an allergic reaction occurs. Complementary Health Strategies Wound care should involve cleaning, irrigation, and debridement of wound. The need for tetanus prophylaxis should be determined and vaccination provided as required. For human bites, follow local guidelines to determine if HIV or hepatitis post-exposure prophylaxis is required.
This may require consulting public health officials (Anti-infective Review Panel, 2012; Blondel-Hill & Fryters, 2006; Bower, 2003; Dendle & Looke, 2008; Morgan, 2005; Norton, 2008). Patient Resources Available Patients can be directed to reputable health websites such as MyHealth. Alberta. ca (Healthwise Staff, 2010) for details on their condition. Additional medication information can be obtained from the dispensing pharmacist or their local poison and drug information service. Evidence Selection of these drugs was based on peer reviewed articles and current international, national, and provincial guidelines.
Details on the drugs were obtained from published formularies, nursing drug references, and the Compendium of Pharmaceuticals and Specialties. The reference list details these various sources of evidence. Review Date This personal formulary should be reviewed every 3-5 years as new guidelines are released. Various guidelines (Anti-infective Review Panel, 2012; Blondel-Hill & Fryters, 2006) are revised within this timeframe. The practitioner should be aware of local infection trends and review the personal formulary if an increased frequency of infections is found to be resistant to the described therapy. References
Anti-infective Review Panel. (2012). Anti-infective guidelines for community-acquired infections (2012 ed. ). Toronto, ON: MUMS Guideline Clearinghouse. Blondel-Hill, E. , & Fryters, S. (Eds. ). (2006). Bugs & drugs (Capital Health ed. ). Edmonton, AB: Capital Health. Bower, M. G. (2003). An update on managing dog, cat, and human bite wounds. Physician Assistant, 27(8), 38-43, 45. Retrieved from http://0-ovidsp. tx. ovid. com. aupac. lib. athabascau. ca/ Canadian Pharmacists Association. (2012). CPS 2012: Compendium of pharmaceuticals and specialties: The trusted Canadian drug reference for health professionals.
Ottawa, ON: Author. College and Association of Registered Nurses of Alberta. (2011). Scope of practice for nurse practitioners (NPs). Retrieved from http://www. nurses. ab. ca/Carna-Admin/Uploads/2011_NP_Scope_of_Practice. pdf De Vries, T. P. G. M. , Henning, R. H. , Hogerzeil, H. V. , & Fresle, D. A. (1994). Guide to good prescribing: A practical manual. Retrieved from http://apps. who. int/medicinedocs/pdf/whozip23e/whozip23e. pdf Dendle, C. , & Looke, D. (2008). Animal bites: An update for management with a focus on infections. Emergency Medicine Australasia, 20(6), 458-467. doi: 10. 1111/j. 1742-6723.
2008. 01130. x Healthwise Staff. (2010). Animal and human bites. MyHealth. Alberta. ca. Retrieved from https://myhealth. alberta. ca/health/pages/conditions. aspx? hwId=anlbt Joint Formulary Committee. (2012). British national formulary (63 ed. ). London: BMJ Group and Pharmaceutical Press. Morgan, M. (2005). Hospital management of animal and human bites. Journal of Hospital Infection, 61(1), 1-10. doi: 10. 1016/j. jhin. 2005. 02. 007 National Association of Pharmacy Regulatory Authorities. (2009). National drug schedules. Retrieved from http://napra. ca/pages/Schedules/Search. aspx Norton, C. (2008).
Animal and human bites. Emergency Nurse, 16(6), 26-29. Retrieved from http://emergencynurse. rcnpublishing. co. uk/ Sheff, B. (2002). Microbe of the month. Pasteurella multocida. Nursing, 32(11), 72. Retrieved from http://www. nursingcenter. com/library/ Skidmore-Roth, L. (2012). Mosby’s 2012 nursing drug reference (25th ed. ). St. Louis, MO: Elsevier Mosby. Stuart, M. C. , Kouimtzi, M. , & Hill, S. R. (Eds. ). (2009). WHO model formulary 2008. Geneva: World Health Organization. Word Counts Excluding title and reference page: 836 words. Excluding title and reference page and in text “(Author, year)” citations: 667 words.