Transmission of HIV-1 by human bite

Human bite wounds as a portal of entry for infective endocarditis and purulent pericarditis: a very rare association

Human bites are an infrequent cause of emergency department visits and hospital admissions. There are rarely published cases of complicated infection, such as infective endocarditis. We present a rare case of a patient with acute infective endocarditis in a healthy native valve and purulent pericarditis from a human bite. A 40-year-old man with obesity suffered deep human bites by an adult woman, with two deep lesions in the anterior thorax and one superficial lesion in the upper abdomen and admitted in intensive care unit with septic shock and a persistent aortic murmur. Echocardiography described evidence of vegetation, perforation and severe regurgitation of aortic valve. Scanner described moderate pericardial effusion. Cardiac surgery was performed, with evidence of purulent pericardial effusion after pericardiotomy, and subsequently aortic valve replacement with a 25 mm bioprosthesis. The patient showed positive progress.

HIV transmission by human bite: a case report and review of the literature-implications for post-exposure prophylaxis

We report a case of a probable HIV-1 transmission by human bite. The analyzed data from ten previously reported  suspected or allegedly confirmed HIV transmissions revealed a deep bleeding bite wound as the primary risk factor. A high HIV plasma viral load and bleeding oral lesions are present most of the time during HIV transmission by bite. HIV post-exposure prophylaxis (PEP) should be recommended in case of a bleeding wound resulting from a bite of an HIV-infected person. PEP was missed in this presented case.

Human bite facial wounds in Bouaké (Côte d'Ivoire): development of a therapeutic algorithm in underdeveloped countries

Introduction: The treatment of facial wounds by human bites is difficult, especially in under-developed countries. We aimed to distinguish the epidemiological and clinical aspects to describe the therapeutic methods and evaluate their effectiveness. Materials and methods: This was a descriptive and retrospective study over a period of 6 years. Patients who consulted regarding a human bite wound and were surgically treated were included. Results: Eighteen patients with a hospital prevalence of 0.008% were enrolled. The ratio of men to women was 2 (12 men for every 6 women). The average age was 32.77 years (range, 23–45 years). The lesions were labial in 11 cases (61.11%). The wounds were type III in eight cases (44.44%) and type II in nine cases (50%). Surgical treatment was primary in 12 cases (66.67%) and delayed in 6 cases (33.33%). The evolution was favorable in 16 cases (88.89%). Discussion: The wounds on the face created by human bite can be effectively treated via primary repair while reserving systematic secondary closure to an initially necrotic wound.

Transmission of HIV infection by severe bites

A 56-year-old man acquired HIV infection as the result of bites that caused severe tissue injuries. The features of the biting episode that led to transmission of infection were very similar to those in four other patients reported to have acquired HIV infection as the result of bites. Post-exposure prophylaxis should be recommended for people who have suffered bites that caused significant tissue injuries, inflicted by a person with known HIV infection, who had visible blood staining of their saliva at the time of biting, and an HIV viral load known or presumed to be greater than 3.0 log10 copies/ml.

Pediatric Considerations for Postexposure Human Immunodeficiency Virus Prophylaxis

Exposures that carry risk of transmission of blood-borne disease are rare in pediatrics, but expose patients and families to great anxiety. Specialists in pediatric infectious diseases are often asked about initial antimicrobial prophylaxis in these cases. Guidelines for nonoccupational postexposure prophylaxis for human immunodeficiency virus have evolved as new formulations and medications become available and greater experience obtained in assessing relative risks of different exposures and relative costs and benefits for different interventions. This article discusses the evidence behind recent updates to Centers for Disease Control and Prevention guidelines for nonoccupational postexposure prophylaxis for human immunodeficiency virus, focusing on application in the pediatric population.

A systematic review of risk of HIV transmission through biting or spitting: implications for policy

OBJECTIVES

The perceived threat of HIV transmission through spitting and biting is evidenced by the increasing use of "spit hoods" by Police Forces in the UK. In addition, a draft parliamentary bill has called for increased penalties for assaults on emergency workers, citing the risk of communicable disease transmission as one justification. We aimed to review literature relating to the risk of HIV transmission through biting or spitting.

METHODS

A systematic literature search was conducted using Medline, Embase and Northern Lights databases and conference websites using search terms relating to HIV, AIDS, bite, spit and saliva. Inclusion and exclusion criteria were applied to identified citations. We classified plausibility of HIV transmission as low, medium, high or confirmed based on pre-specified criteria.

RESULTS

A total of 742 abstracts were reviewed, yielding 32 articles for full-text review and 13 case reports/series after inclusion and exclusion criteria had been applied. There were no reported cases of HIV transmission related to spitting and nine cases identified following a bite, in which the majority occurred between family (six of nine), in fights involving serious wounds (three of nine), or to untrained first-aiders placing fingers in the mouth of someone having a seizure (two of nine). Only four cases were classified as highly plausible or confirmed transmission. None related to emergency workers and none were in the UK.

CONCLUSIONS

There is no risk of transmitting HIV through spitting, and the risk through biting is negligible. Post-exposure prophylaxis is not indicated after a bite in all but exceptional circumstances. Policies to protect emergency workers should be developed with this evidence in mind.

A Human Bite on the Scrotum: Case Report and Review of Management in the Emergency Department

BACKGROUND

Human bites involving the genitalia rarely present to the emergency department (ED). They have the potential to cause life-threatening secondary infections as well as serious physical and functional damage.

CASE REPORT

We report a case of an adult male who sustained a human bite to the scrotum, resulting in a ragged laceration on the anterior scrotum, with a devascularized flap and necrotic edges overlying the wound. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Human bites to the scrotum are rare and, hence, the experience of emergency physicians treating patients presenting with these injuries may be minimal. This puts patients at risk of underevaluation or suboptimal treatment. The rapid initiation of antibiotics in the ED and thorough wound debridement will prevent infections, aid healing, and lead to improved outcomes by preserving organ function and integrity. We therefore present a systematic approach to the management of patients with human bite to the scrotum in the ED.

Human bite injuries to the head and neck: current trends and management protocols in England and Wales

INTRODUCTION

Human bite injuries can be challenging in their presentation to the examining physician. In a study by Merchant et al., 18% of patients presenting with a human bite injury had suffered wounds to the head and neck region. Current trends in their initial management at presentation to emergency departments throughout England and Wales will be discussed in this paper.

MATERIALS AND METHOD

A postal survey was sent out to 100 A&E lead clinicians. This was followed up by telephone enquiries to improve the response rate. The collated results of the survey were entered onto a spreadsheet (Microsoft Excel©) for the purpose of statistical review.

RESULTS

A 68% response rate from A&E departments throughout England and Wales demonstrated a lack of consensus in the initial management and subsequent treatment of human bite injuries. Written protocols are in place for human bite injuries in 54.4% of units. In 100% of units, initial management involves irrigation +/- debridement of the wound, though there is a lack of agreement on the surgical management of the wound. 77.9% of units follow 'needle stick protocols' when stratifying risk for blood-borne viruses.

CONCLUSION

Human bites pose a number of unique problems, ranging from cellulitis to the transmission of communicable diseases. The maxillofacial surgeon has the added dilemmas surrounding subsequent repair and reconstruction. Appreciation of the complexity of human bite injuries will ensure optimal care for the patient. We propose a set of guidelines developed 'in-house' to assist in the management of human bite injuries.

Genital injuries acute evaluation and management

Genital trauma may result in external injuries to the labia, vulva or vagina, urethra and anus and internal injuries to the bony pelvis, bladder, bowels and reproductive organs. Worldwide, the most common cause of genital trauma in reproductive age women is injury sustained during childbirth, but in this chapter we will focus on accidental genital injuries as well as those arising from sexual violence, and female genital mutilation. While genital injuries alone rarely result in death; if not properly managed, chronic discomfort, dyspareunia, infertility, or fistula formation may result. Clinicians need to be able to recognize these injuries and provide initial management, and assure that the patient's mental, emotional and physical needs are addressed.

Pathogenesis of oral FIV infection

Feline immunodeficiency virus (FIV) is the feline analogue of human immunodeficiency virus (HIV) and features many hallmarks of HIV infection and pathogenesis, including the development of concurrent oral lesions. While HIV is typically transmitted via parenteral transmucosal contact, recent studies prove that oral transmission can occur, and that saliva from infected individuals contains significant amounts of HIV RNA and DNA. While it is accepted that FIV is primarily transmitted by biting, few studies have evaluated FIV oral infection kinetics and transmission mechanisms over the last 20 years. Modern quantitative analyses applied to natural FIV oral infection could significantly further our understanding of lentiviral oral disease and transmission. We therefore characterized FIV salivary viral kinetics and antibody secretions to more fully document oral viral pathogenesis. Our results demonstrate that: (i) saliva of FIV-infected cats contains infectious virus particles, FIV viral RNA at levels equivalent to circulation, and lower but significant amounts of FIV proviral DNA; (ii) the ratio of FIV RNA to DNA is significantly higher in saliva than in circulation; (iii) FIV viral load in oral lymphoid tissues (tonsil, lymph nodes) is significantly higher than mucosal tissues (buccal mucosa, salivary gland, tongue); (iv) salivary IgG antibodies increase significantly over time in FIV-infected cats, while salivary IgA levels remain static; and, (v) saliva from naïve Specific Pathogen Free cats inhibits FIV growth in vitro. Collectively, these results suggest that oral lymphoid tissues serve as a site for enhanced FIV replication, resulting in accumulation of FIV particles and FIV-infected cells in saliva. Failure to induce a virus-specific oral mucosal antibody response, and/or viral capability to overcome inhibitory components in saliva may perpetuate chronic oral cavity infection. Based upon these findings, we propose a model of oral FIV pathogenesis and suggest alternative diagnostic modalities and translational approaches to study oral HIV infection.

Development of a clinical path for the emergency care of hand bite injuries without signs of infection

HYPOTHESIS

The care of bite injuries has not currently reached a consensus, including in our department. The goal of this study was to evaluate our current care of bite injuries by an assessment of professional practices (APP), then formulate and validate a flowchart to standardize our practices.

MATERIAL AND METHODS

During a first round of file reviewing, 30 files were randomly selected and then evaluated using a 15 item auditing form (group 1). A flowchart was then designed to standardize the care of hand bite injuries and released in our department. Six months later, 30 new files were randomly selected and evaluated using the same auditing form (group 2).

RESULTS

When comparing the results of the 15 items before and after the release of the flowchart, 7 items reached 100% in group 2. The wounds were described more precisely, signs of severity were systematically researched and the antibiotic treatment was standardized. Two items decreased but did not reach 0%: systematic prescription of bacteriologic swabs and X-rays. Using these results the flowchart was improved.

DISCUSSION AND CONCLUSION

Our results showed an improvement of the care of hand bites for 11 items, including 5 that were statistically significant. This flowchart enabled to standardize our practices and could be used in other emergency departments.

[Consensus Document on post-exposure prophylaxis against HIV, HBV and HCV in adults and children]

OBJECTIVE

This consensus document is an update of occupational and non-occupational prophylaxis guidelines in HIV-patients, promoting appropriate use of them, from the standpoint of care.

METHODS

This document has been approved by expert panel of SPNS, GESIDA, SEMST and different scientific societies related, after reviewing the results of efficacy and safety clinical trials, cohort and pharmacokinetic studies published in biomedical journals (PubMed and Embase) or presented at conferences and different guidelines. The strength of the recommendation and gradation of their evidence are based on the GRADE system.

RESULTS

We have developed recommendations for assessing the risk of transmission in different types of exposure situations in which post-exposure prophylaxis should be recommended, special circumstances to consider, patterns of antiretroviral with the start and duration of early monitoring of tolerance and adherence to treatment, the subsequent monitoring of exposed persons regardless of whether they received post-exposure prophylaxis or not, and the need of psychological support.

CONCLUSIONS

These new guidelines updated previous recommendations regarding occupational post-exposure prophylaxis and non-occupational, in adults and children.

Bite injuries to the hand: microbiology, virology and management

Bites to the human hand, be it from a pet, a stray animal or even a fellow human, may often have dire consequences for the person suffering the insult. Bites by mammals are a common problem and they account for up to 1% of all visits to hospital emergency rooms, in the UK. Clenched fist injuries to the mouth ('fight bite') are notorious for being the worst human bites. Bite injuries of the hand and their related infections must be monitored vigilantly and managed proactively, by experts in this field of surgery. In this review article we discuss the associated microbiology and virology of these injuries as well as their management.

Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis

This report updates US Public Health Service recommendations for the management of healthcare personnel (HCP) who experience occupational exposure to blood and/or other body fluids that might contain human immunodeficiency virus (HIV). Although the principles of exposure management remain unchanged, recommended HIV postexposure prophylaxis (PEP) regimens and the duration of HIV follow-up testing for exposed personnel have been updated. This report emphasizes the importance of primary prevention strategies, the prompt reporting and management of occupational exposures, adherence to recommended HIV PEP regimens when indicated for an exposure, expert consultation in management of exposures, follow-up of exposed HCP to improve adherence to PEP, and careful monitoring for adverse events related to treatment, as well as for virologic, immunologic, and serologic signs of infection. To ensure timely postexposure management and administration of HIV PEP, clinicians should consider occupational exposures as urgent medical concerns, and institutions should take steps to ensure that staff are aware of both the importance of and the institutional mechanisms available for reporting and seeking care for such exposures. The following is a summary of recommendations: (1) PEP is recommended when occupational exposures to HIV occur; (2) the HIV status of the exposure source patient should be determined, if possible, to guide need for HIV PEP; (3) PEP medication regimens should be started as soon as possible after occupational exposure to HIV, and they should be continued for a 4-week duration; (4) new recommendation-PEP medication regimens should contain 3 (or more) antiretroviral drugs (listed in Appendix A ) for all occupational exposures to HIV; (5) expert consultation is recommended for any occupational exposures to HIV and at a minimum for situations described in Box 1 ; (6) close follow-up for exposed personnel ( Box 2 ) should be provided that includes counseling, baseline and follow-up HIV testing, and monitoring for drug toxicity; follow-up appointments should begin within 72 hours of an HIV exposure; and (7) new recommendation-if a newer fourth-generation combination HIV p24 antigen-HIV antibody test is utilized for follow-up HIV testing of exposed HCP, HIV testing may be concluded 4 months after exposure ( Box 2 ); if a newer testing platform is not available, follow-up HIV testing is typically concluded 6 months after an HIV exposure.

An uncommon case of HIV-1 transmission due to a knife fight

This article describes a case of human immunodeficiency virus type 1 (HIV-1) infection transmission caused by a bloody knife fight in a robbery. The victim was a 69-year-old man who was not infected with HIV-1, and his wife was HIV-antibody negative. A robber, a 42-year-old man, was HIV antibody-positive since December 2005 and had not taken antiretroviral therapy. The BED IgG Capture incidence EIA (BED-CEIA assay) data showed that the specimens from the victim were compatible with a recent seroconversion. Phylogenetic analysis of fragments of pol, encompassing protease and a portion of reverse transcriptase, and of env genes isolated from the victim, the robber, and a local population samples of HIV-1 positive individuals showed that the victim's HIV-1 sequences were most closely related to and nested within a lineage comprised of the robber's HIV-1 sequences. We provide HIV-1 seroconversion data and phylogenetic analysis as evidence that the HIV-1 transmission likely occurred from contact during the robbery.

Prevention of post-operative infections after surgical treatment of bite wounds

After reviewing the literature about the microbial spectrum, the risk factors of post-operative infections, and the results of surgical interventions, the following recommendation can be made for the management of bite wounds:

fresh, open wounds: surgical debridement, if appropriate, then an antiseptic lavage with a fluid consisting of povidone iodine and ethanol (e.g., Betaseptic^®), no antibiotics, primary wound closure

nearly closed fresh wounds (e.g., cat bites): surgical debridement, if appropriate, dressing with an antiseptic-soaked compress for ~60 minutes with repeated soaking (e.g., Betaseptic^®), no antibiotics

older wounds after ~4 hours: surgical debridement, if appropriate, dressing with an antiseptic-soaked compress or bandage for ~60 minutes with repeated soaking (e.g., Betaseptic^®), at the same time intravenous or dose-adapted oral antibiotics (Amoxicillin and/or clavulanic acid)

older wounds after ~24 hours: surgical debridement, then antiseptic lavage (Betaseptic^®), in case of clinically apparent infection or inflammation surgical revision with opening of wound and treatment with antibiotics according to resistogram (empirical start with Amoxicillin and/or clavulanic acid).

For each kind of bite wound, the patient’s tetanus immunization status as well as the risk of exposure to rabies have to be assessed. Similarly, the possibility of other infections, such as lues (Syphilis), hepatitis B (HBV), hepatitis C (HBC), hepatitis D (HDV) and HIV, in the rare case of a human bite wound, has to be taken into account.

Autologous saliva transfusion: treatment for HIV?

The HIV-1 pandemic is a complex mix of diverse epidemics within and between countries and regions of the world, and is undoubtedly the defining public-health crisis of our time. Any therapeutic or prophylactic measure which holds promise or provides clues of eliminating or inhibiting the infection is worthy of investigation. As our body's own saliva is suspiciously escaping from the infection and providing clues regarding the resistance/inhibition of HIV; in this paper, a treatment approach is suggested with the rationale of in vitro effective antiviral action of autogenous saliva may also have a better therapeutic potential by its intravenous administration along with dextran.

A 4-year review of human bite injuries presenting to emergency medicine and proposed evidence-based guidelines

Human bite injuries are a common injury, roughly accounting for around 0.1% of attendances to Emergency Medicine departments. Morbidities associated with such injuries are legion. Of paramount importance is the potential for infection of the wound site, both bacterial and viral. A retrospective 4-year review of 3136 case notes was conducted, identifying 421 human bites. This amounts to one every 3 days! The majority of those bitten were young males (male:female ratio=3:1; 44% comprising the age group 16-25 years). The management of these wounds was found to be poor. 17% of patients did not receive any antibiotic cover; 21% of patients either did not have tetanus prophylaxis administered when required or had a tetanus booster when they were already covered; 34% of patients either did not receive a hepatitis B booster when one was required or received one when they were already covered. This lack of effective documentation, along with errors in addressing prophylaxis of the infective agents, may have profound medico-legal consequences. The author believes that the findings will be reproduced in other centres and in view of the inadequacies highlighted by this work, it is necessary to introduce an evidence-based protocol for the comprehensive management of the human bite. Using United Kingdom Department of Health evidence-based guidelines, the author proposes such a pathway.

Oral transmission of HIV, reality or fiction? An update

Human immunodeficiency virus (HIV) and many other viruses can be isolated in blood and body fluids, including saliva, and can be transmitted by genital-genital and especially anal-genital sexual activity. The risk of transmission of HIV via oral sexual practices is very low. Unlike other mucosal areas of the body, the oral cavity appears to be an extremely uncommon transmission route for HIV. We present a review of available evidence on the oral-genital transmission of HIV and analyse the factors that act to protect oral tissues from infection, thereby reducing the risk of HIV transmission by oral sex. Among these factors we highlight the levels of HIV RNA in saliva, presence of fewer CD4+ target cells, presence of IgA antibodies in saliva, presence of other infections in the oral cavity and the endogenous salivary antiviral factors lysozyme, defensins, thrombospondin and secretory leucocyte protease inhibitor (SLPI).

Hospital management of animal and human bites

The management of bites severe enough to warrant hospital admission is complex. This review includes the epidemiology, clinical management, investigations, microbiology and role of antimicrobials for all types of animal and human bites likely to be encountered in UK hospitals.

Facial bite wounds: management update

Bite wounds are frequently located on the face; injuries inflicted by dogs are most common, especially in children. Bacteriology of infected dog and cat bite wounds includes Pasteurella multocida, Staphylococcus aureus, viridans streptococci, Capnocytophaga canimorsus, and oral anaerobes. Infected human bites yield a similar spectrum of bacteria except for Pasteurellae and C. canimorsus; instead human bites are frequently complicated by Eikenella corrodens. Antibiotic therapy against these bacteria is indicated both for infected bite wounds and fresh wounds considered at risk for infection. Amoxicillin-clavulanate (and other combinations of extended-spectrum penicillins with beta-lactamase inhibitors) and moxifloxacin offer the best in vitro coverage of the pathogenic flora. Initial wound management consisting in irrigation and debridement is at least equally important with antibiotics for prevention of infection. The need for prophylaxis against systemic infectious complications, particularly tetanus, should also be evaluated. Primary surgical repair is the treatment of choice for most clinically uninfected facial bite wounds, whereas delayed closure should be reserved for certain high risk or already infected wounds. Avulsive injuries with significant tissue loss represent the most difficult cases for definitive management and are also those most likely to require hospitalization.

Human retroviruses in leukaemia and AIDS: reflections on their discovery, biology and epidemiology

The study of retroviruses has had a profound impact by unveiling an unusual form of viral replication: the multiplication of RNA viruses via a proviral DNA, for which Jan Svoboda provided the experimental model over forty years ago. In 1970 Temin, Mizutani and Baltimore discovered that this group of viruses contains a unique enzyme catalysing the synthesis of a DNA copy of the viral RNA: reverse transcriptase (RT). The discovery of RT has itself had an enormous impact on molecular biology in general, but also stimulated many premature claims of its detection in human disease. Claims by Gallo's laboratory that the cytoplasm of human leukaemia cells contained RT proved to be unfounded, as did his report in collaboration with Weiss that myeloid leukaemia contained HL23 virus, this organism proving not to be human but a laboratory contaminant of three monkey viruses. Conclusive demonstration of a retroviral involvement in human leukaemia was first provided in 1981 by Hinuma and his associates, showing that adult T-cell leukaemia (ATL), a rare form of leukaemia endemic to south-west Japan, is caused by a new retrovirus (ATLV). Other publications in December 1980 and through 1981 claimed the discovery of a new human T-cell leukaemia virus involved in mycosis fungoides (MF) and Sézary's syndrome (SS). This virus was termed HTLV by Gallo. The nucleotide sequence of ATLV is strongly conserved, that of my 1983 isolate from a black British ATL patient being practically identical with the Japanese virus isolates. After AIDS was recognised in 1981 by Gottlieb and coworkers as a new human disease, several papers were published by Gallo and his associates during 1983-4, invoking the oncovirus responsible for adult T-cell leukaemia as the cause of AIDS. In 1983 the French scientist Barré-Sinoussi and her colleagues succeeded in isolating a new agent in the disease, a lentivirus, which they named LAV. The French immunologist Klatzmann and his colleagues discovered that LAV killed CD4+ T-cells, furnishing an explanation for the pathogenesis of AIDS and providing a mechanism for how AIDS developed. For some time Gallo continued to suggest leukaemia virus involvement, claiming that his independent isolate of the AIDS virus, termed HTLV-III, was closely related to HTLV-I (the Japanese ATLV). Although this created considerable confusion among researchers for a period, the relationship was eventually disproved. Unlike ATLV, whose nucleic acid sequence is very stable, the AIDS virus (now termed HIV by international agreement) is extraordinarily unstable, the sequences of independent HIV isolates being quite unique: this made it possible to establish conclusively that both HTLV-III and another independent isolate CBL-1, from Weiss' laboratory, were actually LAV isolates from the French laboratory. It has been shown by Hayami and his associates that only African primates are infected with similar lentiviruses to HIV which explains why AIDS started in Africa. Further research has clarified the origin of HIV-1 to be a chimpanzee lentivirus and HIV-2 to be the sooty mangabey lentivirus, which began to spread in humans perhaps no more than fifty years ago. The infection has spread rapidly, primarily through sexual intercourse, but also by transmission through blood and its products as well as contaminated needles and syringes. Sexual intercourse has now spread the virus around the World; and there are probably some 70 million infected. 90% of those infected with HIV develop the deadly disease of AIDS within ten years of infection: the death toll from the disease has been enormous. By contrast, HTLV-1 has been infecting man in isolated areas probably for hundreds of years; but it has not spread widely. HTLV causes leukaemia in only less than 1% of those infected. The prime mode of transmission of HTLV-1 is between mother and neonate; infections can be reduced by stopping breast-feeding by infected mothers. The isolation of HIV enabled screening tests to be developed for contaminated blood. However, due to the peculiar biology of HIV infection, unfortunately all efforts to develop an effective vaccine have so far failed.

A human bite to the scrotum: a case report and review of the literature

Human bites to the scrotum are rare and can be associated with a high morbidity rate if poorly managed. We report a case of a human bite to the scrotum that was successfully treated with a 5-day course of antibiotics, surgical debridement and healing by secondary intention.

Bite Wound Infections

Patients with mammalian bite wounds account for hundreds of thousands of emergency department, urgent care center, and physician office visits in the United States each year. The types of wounds encountered by physicians range from insignificant scratches to life-threatening neck and facial injuries. Infectious complications of bite wounds are common, and the consequences of these infections are significant and sometimes disabling. This article reviews the infectious complications of cat, dog, and human bite wounds. The prevention of tetanus and rabies virus infection, the appropriate antimicrobial treatment of bacterial infections, and the frequent need for surgical consultation and intervention are emphasized.

Postexposure prophylaxis in children and adolescents for nonoccupational exposure to human immunodeficiency virus

Exposure to human immunodeficiency virus (HIV) can occur in a number of situations unique to, or more common among, children and adolescents. Guidelines for postexposure prophylaxis (PEP) for occupational and nonoccupational (eg, sexual, needle-sharing) exposures to HIV have been published by the US Public Health Service, but they do not directly address nonoccupational HIV exposures unique to children (such as accidental exposure to human milk from a woman infected with HIV or a puncture wound from a discarded needle on a playground), and they do not provide antiretroviral drug information relevant to PEP in children. This clinical report reviews issues of potential exposure of children and adolescents to HIV and gives recommendations for PEP in those situations. The risk of HIV transmission from nonoccupational, nonperinatal exposure is generally low. Transmission risk is modified by factors related to the source and extent of exposure. Determination of the HIV infection status of the exposure source may not be possible, and data on transmission risk by exposure type may not exist. Except in the setting of perinatal transmission, no studies have demonstrated the safety and efficacy of postexposure use of antiretroviral drugs for the prevention of HIV transmission in nonoccupational settings. Antiretroviral therapy used for PEP is associated with significant toxicity. The decision to initiate prophylaxis needs to be made in consultation with the patient, the family, and a clinician with experience in treatment of persons with HIV infection. If instituted, therapy should be started as soon as possible after an exposure-no later than 72 hours-and continued for 28 days. Many clinicians would use 3 drugs for PEP regimens, although 2 drugs may be considered in certain circumstances. Instruction for avoiding secondary transmission should be given. Careful follow-up is needed for psychologic support, encouragement of medication adherence, toxicity monitoring, and serial HIV antibody testing.

Pharmacologic management of HIV/STD exposure

Emergency physicians must be familiar with management of occupational exposures to HIV-infected bodily fluids. Victims of sexual assault also may be exposed to HIV and other sexually transmitted diseases. The Centers for Disease Control and Prevention guidelines for the management of occupational exposures include recommendations for administration of combination antiretroviral therapy to reduce the risk for HIV transmission. Antiretroviral therapy also may be indicated for certain types of sexual exposure to HIV. Drugs that are used to treat sexually transmitted diseases also may be given to prevent infection after possible exposures. This article reviews current recommendations for prophylaxis against HIV and other sexually transmitted diseases and the scientific basis for these recommendations.

Proviral HIV-1 DNA in gingival crevicular fluid of HIV-1-infected patients in various stages of HIV disease

The oral cavity is rarely reported to be a site of human immunodeficiency virus (HIV) transmission, despite detectable virus in saliva and relatively frequent prevalence of periodontal disease in HIV-infected persons yielding increased excretion of mononuclear-cell-enriched gingival fluid. To search for possible sources of HIV in saliva, and using the polymerase chain-reaction technique, we sought the presence and shedding patterns of proviral HIV-1 DNA in gingival crevicular fluid in a group of patients previously determined as HIV-1-seropositive. Periodontal status at the collection sites was monitored by several clinical parameters, including Plaque Index, Gingival Index, probing depth, and clinical attachment loss. Gingival crevicular fluid samples were collected by means of paper points. Proviral HIV-1 DNA was detected in the gingival fluid of 17 out of 35 HIV-1-infected patients. Its detection correlated significantly with higher plasma HIV-1 RNA viral load (p = 0.03) and not with peripheral blood CD4+ cell count, the presence of blood in gingival fluid, or oral lesions. There was a significant correlation between clinical attachment loss at the sites of fluid collection and plasma HIV-1 RNA viral load (p = 0.002), and borderline correlation between the latter and probing depth (p = 0.54) in the group of patients harboring proviral HIV-1 DNA in gingival crevicular fluid. The results of our study suggest that mononuclear cells present in gingival crevicular fluid and harboring proviral HIV-1 DNA could represent a potential source of HIV-1 in the presence or absence of local bleeding, especially in persons with advanced HIV infection and increased loss of clinical attachment.

HIV topic update: oro-genital transmission of HIV

Several viruses, including the human immunodeficiency virus (HIV), can be found in blood and many body fluids including saliva, and are transmissible sexually across genital and particularly anal mucosae. A persisting concern has been the question of transmission of HIV by oral sexual practices. This review discusses the evidence for oro-genital transmission of HIV, detailing the presence and infectivity of HIV in genital fluids and saliva, the case reports and epidemiology of oro-genital HIV transmission, and the evidence from animal studies. Oral intercourse is not risk-free. The evidence suggests that the risk of HIV transmission from oro-genital sexual practices is substantially lower than that from penile-vaginal or penile-anal intercourse, that exposure to saliva presents a considerably lower risk than exposure to semen, and that oral trauma and ulcerative conditions might increase the risk of HIV transmission.

Emergency department management of blood and body fluid exposures

Exposure to blood and body fluids that may be contaminated with infectious agents is a common occupational hazard for health care workers. Health care workers in the emergency department or out-of-hospital setting are at especially high risk for exposure to blood or body fluids. Nonemergency health care workers are frequently referred to hospital EDs for immediate treatment of occupation exposures. A series of recommendations by the Centers for Disease Control and Prevention evolved over the past decade, and changes are expected to continue. This state-of the-art article reviews current recommendations for management of persons exposed to blood or body fluids and discusses the scientific basis for recommendations regarding hepatitis B virus, hepatitis C virus, and HIV.

Genital ulcer caused by human bite to the penis

BACKGROUND AND OBJECTIVES

Human bite injuries, while less frequent than cat or dog bites, usually stem from aggressive behavior, sports, or sexual activity. It has been thought that human bites have a higher rate of infection than animal bites, but this view is likely skewed because of the frequency of closed fist injuries presenting to emergency rooms. Human bites to the genitalia also occur, but are not often reported because of embarrassment.

GOAL OF THE STUDY

We report a genital ulceration after a human bite to the penis and review appropriate diagnostic and therapeutic maneuvers.

STUDY DESIGN

This article reports the development of a severe genital ulcer associated with a human bite to the penis secondarily infected, as verified by culture, with an oral flora organism Eikenella corrodens.

RESULTS

The genital ulceration healed after appropriate antibiotic therapy.

CONCLUSIONS

Treatment of human bites focuses on obtaining an accurate history and performing a salient physical examination, as well as early irrigation and debridement. Transmission of communicable disease should be considered as a possible consequence. Prophylactic antibiotic treatment and primary closure of wounds continue to be areas of controversy.

Human bites and the risk of human immunodeficiency virus transmission

The risk of human immunodeficiency virus (HIV) transmission following a bite injury is important to many groups of people. The first are those who are likely to be bitten as an occupational risk, such as police officers and institutional staff. Another group are represented by the victims and perpetrators of crimes involving biting, both in attack and defense situations. The possibility of these bites transmitting a potentially fatal disease is of interest to the physicians who treat such patients and the legal system which may have to deal with the repercussions of such a transmission. Bite injuries represent 1% of all emergency department admissions in the United States, and human bites are the third most common following those of dogs and cats. The worldwide epidemic of HIV and acquired immunodeficiency syndrome (AIDS) continues, with >5 million new cases last year and affecting 1 in 100 sexually active adults. A review of the literature concerning human bites, HIV and AIDS, HIV in saliva, and case examples was performed to examine the current opinion regarding the transmission of HIV via this route. A bite from an HIV-seropositive individual that breaks the skin or is associated with a previous injury carries a risk of infection for the bitten individual.

Molecular evidence for transmission of human T-lymphotropic virus type II infection by a human bite

Investigation of a human T-lymphotropic virus type II (HTLV-II) infection in a female Australian blood donor identified a human bite as the likely mode of transmission, confirmed by nucleotide sequencing of the proviral tax/rex from both donor and contact. We believe this to be the first report of the transmission of an HTLV by a human bite.

The role of the oral environment in HIV-1 transmission

Human immunodeficiency virus type 1, or HIV-1, is infrequently transmitted through the mouth, unlike other mucosal sites. Factors such as low salivary viral titers, low numbers of CD4-positive target cells, anti-HIV antibodies and endogenous salivary antiviral factors work in concert to protect oral tissues from infection and reduce the risk of viral transmission through salivary secretions. This review summarizes the various factors thought to influence oral transmission HIV-1, focusing on the mucosal protein secretory leukocyte protease inhibitor, or SLPI.

Managing animal bite wounds

A review of specific features associated with bite wounds occurring as a result of human fights or attacks by dogs and other animals

Occupational risk of human immunodeficiency virus infection in healthcare workers: an overview

Healthcare workers (HCWs) are at risk for occupational acquisition of human immunodeficiency virus (HIV) infection, primarily due to percutaneous exposure to infected blood. As of June 1996, 51 documented cases and 108 possible cases of occupationally acquired HIV infection in HCWs in the United States had been reported to the Centers for Disease Control and Prevention. The frequency of blood exposure among HCWs varies according to occupation, procedures performed, and use of preventive measures. Based on limited data, it has been estimated that approximately 500,000 percutaneous blood exposures may occur annually among hospital-based HCWs in the United States. Of these, approximately 5,000 may involve exposures to blood that is known to be HIV infected. The average risk of HIV transmission after percutaneous exposure to HIV-infected blood is approximately 0.3%; however, the risk is believed to be higher for exposures involving an increased volume of blood and/or high viral load.

Risks and issues for the health care worker in the human immunodeficiency virus era

The perception of degree of risk can vary markedly from actual risk. About 5% of the cases of AIDS and HIV infection in the United States have occurred in health care workers, a percentage that has remained stable over time. Nearly all of these infections are related to lifestyle factors, not occupational risk. The rise of occupational transmission is greatest with parenteral injuries. If there is an HIV risk to patients, it appears to be very much smaller than the risk to workers although it has received even more publicity. Apprehension exists concerning the future framework of the medical care delivery system and who will care for whom. The sensitive handling of legitimate fears and the balancing of conflicting risks will continue to be a challenging task in the decades ahead.