Bacteriology of Naja atra Snakebite Wound and Its Implications for Antibiotic Therapy

Yan-Chiao Mao Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan; School of Medicine, National Defense Medical Center, Taipei, Taiwan; Division of Infection, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Division of Toxicology, Trauma and Emergency Center, China Medical University Hospital, Taichung, Taiwan; Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan; Division of Nephrology, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Institute of Public Health, School of Medicine, National Yang-Ming University, Taipei, Taiwan

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Po-Yu Liu Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan; School of Medicine, National Defense Medical Center, Taipei, Taiwan; Division of Infection, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Division of Toxicology, Trauma and Emergency Center, China Medical University Hospital, Taichung, Taiwan; Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan; Division of Nephrology, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Institute of Public Health, School of Medicine, National Yang-Ming University, Taipei, Taiwan

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Dong-Zong Hung Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan; School of Medicine, National Defense Medical Center, Taipei, Taiwan; Division of Infection, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Division of Toxicology, Trauma and Emergency Center, China Medical University Hospital, Taichung, Taiwan; Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan; Division of Nephrology, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Institute of Public Health, School of Medicine, National Yang-Ming University, Taipei, Taiwan

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Wei-Cheng Lai Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan; School of Medicine, National Defense Medical Center, Taipei, Taiwan; Division of Infection, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Division of Toxicology, Trauma and Emergency Center, China Medical University Hospital, Taichung, Taiwan; Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan; Division of Nephrology, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Institute of Public Health, School of Medicine, National Yang-Ming University, Taipei, Taiwan

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Shih-Ting Huang Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan; School of Medicine, National Defense Medical Center, Taipei, Taiwan; Division of Infection, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Division of Toxicology, Trauma and Emergency Center, China Medical University Hospital, Taichung, Taiwan; Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan; Division of Nephrology, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Institute of Public Health, School of Medicine, National Yang-Ming University, Taipei, Taiwan

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Yao-Min Hung Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan; School of Medicine, National Defense Medical Center, Taipei, Taiwan; Division of Infection, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Division of Toxicology, Trauma and Emergency Center, China Medical University Hospital, Taichung, Taiwan; Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan; Division of Nephrology, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Institute of Public Health, School of Medicine, National Yang-Ming University, Taipei, Taiwan

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Chen-Chang Yang Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan; School of Medicine, National Defense Medical Center, Taipei, Taiwan; Division of Infection, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Division of Toxicology, Trauma and Emergency Center, China Medical University Hospital, Taichung, Taiwan; Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan; Division of Nephrology, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Institute of Public Health, School of Medicine, National Yang-Ming University, Taipei, Taiwan

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DOI:
https://doi.org/10.4269/ajtmh.15-0667
Volume/Issue:
Volume 94: Issue 5
Page(s):
1129–1135
Restricted access
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A total of 112 cases of Naja atra envenomation were examined at two referring hospitals: Taichung Veterans General Hospital in central Taiwan and Taipei Veterans General Hospital (VGH-TP) in northern Taiwan. Overall, 77% (86/112) of cases developed clinically suspected wound infections and 54% (61/112) required surgery secondary to tissue necrosis, finger or toe gangrene, and/or necrotizing fasciitis. Morganella morganii was the most abundant gram-negative bacterial strain isolated from bite wounds, followed by Proteus spp., Aeromonas hydrophila, Pseudomonas aeruginosa, and Providencia spp. in descending order; Enterococcus spp. were the most common gram-positive bacteria and Bacteroides spp. were the only anaerobic bacteria. A few episodes of bacteremia were caused by Bacteroides and Shewanella spp. There were no significant variations in the distribution of bacterial species between these two hospitals except for a higher incidence of M. morganii, Enterococcus spp., and polymicrobial infection observed at VGH-TP, which may have been related to variations in the fecal flora of prey and oral flora of individual snakes in different geographic areas in Taiwan. According to the susceptibility test involving various pathogens, first-line drug options for the management of N. atra snakebite wound infections may include monotherapy with ureidopenicillin or combination therapy with aminopenicillin and a third-generation cephalosporin or fluoroquinolone. A prospective evaluation of empiric antibiotic therapy for the management of N. atra snakebite should be considered.

Author Notes

* Address correspondence to Chen-Chang Yang, Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, 201 Sec. 2, Shipai Road, Taipei 112, Taiwan. E-mail: ccyang@vghtpe.gov.tw

Authors' addresses: Yan-Chiao Mao, Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan, and School of Medicine, National Defense Medical Center, Taipei, Taiwan, E-mail: doc1385e@gmail.com. Po-Yu Liu, Division of Infection, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, E-mail: idfellow@gmail.com. Dong-Zong Hung, Division of Toxicology, Trauma and Emergency Center, China Medical University Hospital, Taichung, Taiwan, and Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan, E-mail: dzhung0224@gmail.com. Wei-Cheng Lai, Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, E-mail: sprite93@gmail.com. Shih-Ting Huang, Division of Nephrology, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, E-mail: kitheroborn@hotmail.com. Yao-Min Hung, Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, and Institute of Public Health, School of Medicine, National Yang-Ming University, Taipei, Taiwan, E-mail: ymhung1@gmail.com. Chen-Chang Yang, Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, and Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan, E-mail: ccyang@vghtpe.gov.tw.

Copyright:
© The American Society of Tropical Medicine and Hygiene 2016
Received:
13 Sep 2015
|
Accepted:
29 Jan 2016
|
Published Online:
04 May 2016
Cover The American Journal of Tropical Medicine and Hygiene
The American Journal of Tropical Medicine and Hygiene
Print ISSN:
0002-9637
Online ISSN:
1476-1645
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