Diseases, Disorders information

I’ll briefly talk about prevention of RSV, respiratory syncytial virus. There are two products available and these are both passive immunization. These can be given to children less than 2 years of age. Those with chronic lung disease – and that’s defined as medical therapy for the chronic lung disease in the past six months. These are preemies, kids born less than 32 weeks. One product is palivizumab, also known as Synagis. It’s a monoclonal RSV antibody, purified antibody, and it’s given intramuscularly. We give it monthly during the RSV season because one dose only lasts a month. It does result in a 50% reduction in hospitalization due to RSV. A precaution is don’t give it to children with cyanotic congenital heart disease. That’s due to experience with the next product, which is RespiGam, or RSV-IGIV. This is a hyperimmune globulin, so it’s not a purified monoclonal antibody and this needs to be given monthly during RSV season. It’s given intravenously, not intramuscularly, so you have to start an IV to give it. It also results in about a 50% reduction in hospitalization due to RSV. But the drawback is that you do need to start an IV and that can be cumbersome. Contraindication is, a definite contraindication due to cyanotic congenital heart disease. Administration of RSV-IGIV in that situation, in children with cyanotic congenital heart disease, results in increased risk of death and that’s why as a precaution the monoclonal antibody is not given in that situation. Since this is a polyclonal antibody, it may result in vaccine interference as well because it does contain antibodies against measles and varicella so you need to pay attention to that vaccine interference and give additional doses of MMR and varicella vaccine after the antibody has worn off.
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Finally I’m just going to talk briefly about bite wounds and some specific situations in that regard. In general, with a bite wound, you need to clean the wound and debride the wound of any devitalized tissue, update routine immunizations such as tetanus and hepatitis B for human bites only, and assess HIV risk for human bites. Then you need to assess the rabies risk. And in terms of assessing the rabies risk, those animal bites that are high risk for transmitting rabies are any bat bite or bat contact, a rabid or suspected rabid dog or cat – that’s obvious – and any skunk, raccoons, foxes, most other carnivores or woodchucks in rabies-endemic areas may transmit rabies virus. In terms of unknown risk in an escaped dog or cat, a bite from those animals may result in rabies and for that you should contact the local public health authorities. They would know whether there is any rabies in the area, whether that would be a risk. Low-risk animal bites would be those from livestock, ferrets, rodents or rabbits or hares. Low risk. Bunnies are low risk.
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In terms of rabies prophylaxis there are two things to do in addition to cleaning the wound and local wound care and that’s giving the rabies immune globulin; giving as much as possible of the dose, infiltrating the wound area, and then giving the rabies vaccines. There are three different vaccines from different manufacturers. They are not important to know, but it is important to know the time that you should give rabies vaccine, when it’s indicated. It’s a five dose series and there’s the schedule.
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In terms of antibiotic therapy after bite wounds, you should give antibiotics as prophylaxis when it’s indicated, following a bite wound. That would be with increased infection risk. That would be when there has been a moderate or severe wound, you get devitalized tissue which can serve as a possible nidus of infection where host defenses can’t get into. Puncture wounds; this will inoculate areas deep in areas that may not be easily cleansed, facial, hand, foot or genital bite, these key areas, immunocompromised subjects would be at increased risk of infection. And the organisms that you would suspect as causing infection from a dog or cat bite would include staph aureus, strep, Pasteurella, and Capnocytophaga. From human bites, strep, staph aureus. So the recommended antibiotics would be either amoxicillin clavulanic acid or Augmentin, cefuroxime or the combination of trimethoprim-sulfa and clindamycin.