1
|
Hung YL, Chen YC, Tsai TS, Chang YI, Chuang PC. Incidence and Risk Factors for Wound Infections after Trimeresurus stejnegeri Snakebites in Taiwan. Am J Trop Med Hyg 2024; 110:295-302. [PMID: 38109772 PMCID: PMC10859800 DOI: 10.4269/ajtmh.23-0302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 09/30/2023] [Indexed: 12/20/2023] Open
Abstract
Snakebite envenomation is a neglected tropical disease. Taiwan, with its subtropical and Southeast Asian environment, provides suitable habitat for several venomous snake species. Trimeresurus stejnegeri, an arboreal pit viper, is the most common cause of venomous snakebite in Taiwan. Trimeresurus stejnegeri envenomation can cause local swelling, occasional ecchymosis, and wound infection. The primary treatment of T. stejnegeri envenomation is the binary antivenom, vacuum freeze-dried F(ab')2 fragments of equine antibodies, against T. stejnegeri and Protobothrops mucrosquamatus. This study aimed to analyze the incidence of post-envenomation wound infections caused by T. stejnegeri based on data collected over a decade from institutions affiliated with the Chang Gung Memorial Hospital in Taiwan. A total of 254 patients were enrolled in this study. Clinical and laboratory data, treatment information, and patient outcomes were extracted from electronic medical records. Wound infection was associated with delay in antivenom initiation (adjusted odds ratio: 3.987; 95% CI: 1.406-11.302). The infection rates were 20.5%, 12.5%, 31.3%, and 48.1% for antivenom administration within 2 hours, 2-4 hours, 4-6 hours, and > 6 hours, respectively. Therefore, early initiation of antivenom treatment (within 6 hours) is recommended. Morganella morganii was cultured from wounds of the patients, whereas Enterobacter cloacae and Enterococcus faecalis were cultured from both the oral cavity of snakes and the wounds of the patients. For post-envenomation patients who develop a local infection, empiric antibiotics such as third-generation cephalosporins, quinolones, and piperacillin/tazobactam are recommended because snakebite wound infections are often polymicrobial in nature.
Collapse
Affiliation(s)
- Yu-Lun Hung
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yi-Chun Chen
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Tein-Shun Tsai
- Department of Biological Science and Technology, National Pingtung University of Science and Technology, Pingtung, Taiwan
| | - Ye-In Chang
- Department of Computer Science and Engineering, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Po-Chun Chuang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Department of Computer Science and Engineering, National Sun Yat-sen University, Kaohsiung, Taiwan
| |
Collapse
|
2
|
Lin CC, Shih CP, Wang CC, Ouyang CH, Liu CC, Yu JS, Lo CH. The Clinical Usefulness of Taiwan Bivalent Freeze-Dried Hemorrhagic Antivenom in Protobothrops mucrosquamatus- and Viridovipera stejnegeri-Envenomed Patients. Toxins (Basel) 2022; 14:toxins14110794. [PMID: 36422968 PMCID: PMC9699225 DOI: 10.3390/toxins14110794] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 10/18/2022] [Accepted: 11/03/2022] [Indexed: 11/16/2022] Open
Abstract
Snakebites from Protobothrops mucrosquamatus (Taiwan habus) and Viridovipera stejnegeri (green bamboo vipers) account for the most venomous snakebites in Taiwan. The bivalent freeze-dried hemorrhagic (FH) antivenom is employed to treat these two snakebite patients without a strict clinical trial. We evaluated the clinical usefulness of Taiwan bivalent freeze-dried hemorrhagic (FH) antivenom in Taiwan habu- and green bamboo viper-envenomed patients. We checked ELISA- based serum venom antigen levels before and after FH antivenom to evaluate FH's ability to neutralize patients' serum snake venom and its usefulness in reducing limb swelling after snakebites. Patients who had higher serum venom antigen levels had more severe limb swelling. Of the 33 enrolled patients, most of their snake venom antigen levels were undetected after the appliance of antivenom. Most enrolled patients (25/33) had their limb swelling subside within 12 h after antivenom treatment. The failure to reduce limb swelling was probably due to an inadequate antivenom dose applied in more severely envenomated patients. Our data indicate the feasibility of the FH antivenom in effectively eliminating venom and resolving the affected limb swelling caused by Taiwan habu and green bamboo viper bites.
Collapse
Affiliation(s)
- Chih-Chuan Lin
- Department of Emergency Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Correspondence:
| | - Chia-Pang Shih
- Department of Nursing, Yuanpei University of Medical Technology, Hsinchu 300, Taiwan
| | - Chia-Cheng Wang
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Chun-Hsiang Ouyang
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Chien-Chun Liu
- Molecular Medicine Research Center, Chang Gung University, Taoyuan 33302, Taiwan
| | - Jau-Song Yu
- Molecular Medicine Research Center, Chang Gung University, Taoyuan 33302, Taiwan
- Department of Cell and Molecular Biology, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Liver Research Center, Chang Gung Memorial Hospital, Linkou, Taoyuan 33305, Taiwan
| | - Chih-Hong Lo
- Department of General Surgery, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| |
Collapse
|
3
|
Chuang PC, Lin WH, Chen YC, Chien CC, Chiu IM, Tsai TS. Oral Bacteria and Their Antibiotic Susceptibilities in Taiwanese Venomous Snakes. Microorganisms 2022; 10:microorganisms10050951. [PMID: 35630396 PMCID: PMC9147925 DOI: 10.3390/microorganisms10050951] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/15/2022] [Accepted: 04/28/2022] [Indexed: 12/07/2022] Open
Abstract
Wound infections after venomous snakebites are clinically important. Information regarding the nature and antibiotic susceptibilities of snake oral bacterial flora could support empiric antibiotic therapy. Wild venomous snakes were collected from southern Taiwan: a total of 30 each of Bungarus multicinctus, Naja atra, Protobothrops mucrosquamatus, and Trimeresurus stejnegeri; 3 Deinagkistrodon acutus; and 4 Daboia siamensis. The species and antibiotic susceptibilities of their oral bacteria were determined. Aerobic gram-negative bacteria, especially Pseudomonas aeruginosa and Proteus vulgaris, were the most abundant. Proteus vulgaris were more abundant in B. multicinctus, N. atra, and P. mucrosquamatus than in T. stejnegeri (40%, 43.3%, and 40% vs. 13.3%, respectively). The gram-negative species were less susceptible to first- and second-generation cephalosporins and ampicillin-sulbactam than to third-generation cephalosporins, fluoroquinolones, carbapenems, or piperacillin-tazobactam. The most abundant aerobic gram-positive species cultured was Enterococcus faecalis, which was more abundant in N. atra than in other snakes (p < 0.001) and was highly susceptible to ampicillin, high-level gentamicin, penicillin, teicoplanin, and vancomycin. Bacteroides fragilis and Clostridium species were the most common anaerobic bacteria. The anaerobic organisms were highly susceptible to metronidazole and piperacillin. As a reference for empiric antimicrobial therapy, third-generation cephalosporins, fluoroquinolones, carbapenems, or piperacillin-tazobactam can be initiated in venomous snakebites wound infections.
Collapse
Affiliation(s)
- Po-Chun Chuang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833401, Taiwan; (P.-C.C.); (I.-M.C.)
- College of Medicine, Chang Gung University, Taoyuan 333323, Taiwan
| | - Wen-Hao Lin
- Institute of Wildlife Conservation, National Pingtung University of Science and Technology, Pingtung 912301, Taiwan;
| | - Yi-Chun Chen
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833401, Taiwan;
| | - Chun-Chih Chien
- College of Medicine, Chang Gung University, Taoyuan 333323, Taiwan
- Department of Laboratory Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833401, Taiwan;
| | - I-Min Chiu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833401, Taiwan; (P.-C.C.); (I.-M.C.)
- College of Medicine, Chang Gung University, Taoyuan 333323, Taiwan
| | - Tein-Shun Tsai
- Department of Biological Science and Technology, National Pingtung University of Science and Technology, Pingtung 912301, Taiwan
- Correspondence: or
| |
Collapse
|
4
|
Abstract
SNAKE ENVENOMATION REPRESENTS AN IMPORTANT HEALTH PROBLEM IN much of the world. In 2009, it was recognized by the World Health Organization (WHO) as a neglected tropical disease, and in 2017, it was elevated into Category A of the Neglected Tropical Diseases list, further expanding access to funding for research and antivenoms. However, snake envenomation occurs in both tropical and temperate climates and on all continents except Antarctica. Worldwide, the estimated number of annual deaths due to snake envenomation (80,000 to 130,000) is similar to the estimate for drug-resistant tuberculosis and for multiple myeloma., In countries with adequate resources, deaths are infrequent (e.g., <6 deaths per year in the United States, despite the occurrence of 7000 to 8000 bites), but in countries without adequate resources, deaths may number in the tens of thousands. Venomous snakes kept as pets are not rare, and physicians anywhere might be called on to manage envenomation by a nonnative snake. Important advances have occurred in our understanding of the biology of venom and the management of snake envenomation since this topic was last addressed in the Journal two decades ago. For the general provider, it is important to understand the spectrum of snake envenomation effects and approaches to management and to obtain specific guidance, when needed.
Collapse
Affiliation(s)
- Steven A Seifert
- From the Department of Emergency Medicine and the New Mexico Poison and Drug Information Center, University of New Mexico Health Sciences Center, Albuquerque (S.A.S.); the Department of Internal Medicine, University of Nebraska Medical Center, Omaha (J.O.A.); and the National Natural Toxins Research Center and the Department of Chemistry, Texas A&M University-Kingsville, Kingsville (E.E.S.)
| | - James O Armitage
- From the Department of Emergency Medicine and the New Mexico Poison and Drug Information Center, University of New Mexico Health Sciences Center, Albuquerque (S.A.S.); the Department of Internal Medicine, University of Nebraska Medical Center, Omaha (J.O.A.); and the National Natural Toxins Research Center and the Department of Chemistry, Texas A&M University-Kingsville, Kingsville (E.E.S.)
| | - Elda E Sanchez
- From the Department of Emergency Medicine and the New Mexico Poison and Drug Information Center, University of New Mexico Health Sciences Center, Albuquerque (S.A.S.); the Department of Internal Medicine, University of Nebraska Medical Center, Omaha (J.O.A.); and the National Natural Toxins Research Center and the Department of Chemistry, Texas A&M University-Kingsville, Kingsville (E.E.S.)
| |
Collapse
|
5
|
Personal Experience of Daboia siamensis Envenomation. Case Rep Med 2022; 2021:3396373. [PMID: 34976069 PMCID: PMC8719983 DOI: 10.1155/2021/3396373] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/08/2021] [Indexed: 11/24/2022] Open
Abstract
Reports of envenomation induced by Daboia siamensis, a medically important venomous snake in Taiwan, are rare, and species identification might not be definitive. This article reports the complete course of a definite D. siamensis bite. The patient in this report was one of the authors who was bitten on the right palm near the base of the index finger by D. siamensis. The patient experienced local effects, neurological manifestations, and acute kidney injury. The laboratory analysis revealed elevated D-dimer and coagulopathy. The patient was administered 8 vials of antivenom and did not undergo surgical intervention or endotracheal tube intubation, but serum sickness occurred 8 days after antivenom administration. The horse immunoglobulin produced by the Centers for Disease Control, R. O. C. (Taiwan), against D. siamensis was effective and safe in the treatment of the patient. However, the best antivenom administration strategy remains unclear and requires further study.
Collapse
|