What Physicians Need to Know to Treat Fight Bites

When should antibiotics be given after a bite (tooth punctured the skin) from punching someone in the mouth? What are the exceptions to the guidelines on prophylactic (preventive) antibiotics? What are the potential complications for such bites? How often do they happen? Can they be prevented?

These are just some of the questions posed in this educational article for emergency department (and other) physicians treated acute fight bites. To help answer these questions, the case of a 26-year-old man with a laceration (cut) on the back of his hand is presented. He came to the emergency department a few hours after a bar fight. The cut was his only injury as X-rays showed there was no fracture or other lesions observed on the radiograph.

Now the emergency physician must decide on the best plan-of-care to manage this acute fight bite injury. All of the questions posed above must be considered. Even a small skin opening from such an injury can allow bacteria to enter the body. The joint can become infected to the point that finger amputation is the end-result.

Not all complications from infection following an acute fight bite of the hand are as drastic as finger amputation. But loss of motion, decreased grip strength, tenosynovitis, osteomyelitis, and septic arthritis occur in up to one-third of all cases. With up to 50 different types of bacteria in the human mouth, the concern for infection is very real.

Antibiotics are given prophylactically to prevent infection in almost all cases. The only two exceptions are: 1) patients with minimal superficial wounds (skin is not broken) and 2) those individuals who come for care 72 hours or more after the injury and have no signs of infection. The physician may also surgically debride the wound (open the hand down to the bone/joint and clean out any microbes present).

Without knowing what may happen in those early hours after the contact with someone’s tooth, a wide-spectrum antibiotic is given. This type of medication covers most of the common bacteria (Staphylococcus, Streptococcus, Corynebacterium, Eikenella corrodens). Anyone with clinical signs of infection (fever; red, swollen, tender or painful skin/joint) should receive additional medications including intravenous antibiotics.

The biggest concern is for patients who do not seek care immediately and wait up to a week before getting treatment. The risk of amputation from infection increases dramatically with longer delays between injury and care. Patients whose tetanus shots are out-of-date and who have not had hepatitis vaccinations (or for whom hepatitis B status is unknown) will require additional treatment.

Research in the area of acute fight bites is limited by a number of factors. First, many individuals in this situation do not seek medical care. They are often young men who do not have insurance or money to pay for treatment. Second, the only data really available is for those people who do seek medical treatment because of a problem. Information on how often these injuries occur without infection (with self-healing) is virtually unknown.

In summary, current concepts for acute fight bites based on available evidence are presented in this article. The authors propose future studies to help physicians recognize risk factors for serious consequences of fight bites (e.g., osteomyelitis, septic arthritis, amputation). A way to evaluate joint involvement would also be helpful in planning treatment.