Given the circumstances surrounding the patient’s wounds and the length of time since the injury, clinicians decided to close the wound at 24 hours; although the clinicians do admit that had the wounds become infected, opening the sutures and draining would have been required. For some patients, allowing the wounds to heal by secondary intention or waiting 3–4 days to suture may be more appropriate. The authors add that “the decision to heal the wounds by delayed primary intention led to a more speedy recovery and, likely, better cosmesis.”
While low-risk wounds and small abrasions in an immunocompetent patient would not require prophylactic antibiotics, in this patient, the wounds were considered high-risk because of their size and the duration of time they were open. Ciprofloxacin and cephalexin were chosen as appropriate therapy for this patient given the marine environment and the flora of the shark’s mouth; tetanus vaccination was also administered as Clostridium tetani has been cultured in sea water.
One potentially lethal pathogen that was considered when making the treatment decision was Vibrio vulnificus; infection with this bacteria can cause necrotizing fasciitis, myositis, sepsis and death, therefore Vibrio bacteria required adequate coverage. Treatment of V. vulnificus infection can include doxycycline (oral or IV) 100mg twice daily for 1–2 weeks plus a 3rd-generation cephalosporin (e.g. ceftazidime 1–2g every 8 hours), although fluoroquinolones have also been proven effective. For this patient, ciprofloxacin was used as prophylaxis for Vibrio bacteria. In addition to Vibrio pathogens, Staphylococcus and Streptococcus species also need to be considered when making treatment decisions. Since methicillin-resistant Staphylococcus aureus is unlikely to occur in this scenario, both cephalexin and doxycycline would be appropriate choices.
Although this is a rare occurrence, several factors must be considered when treating a patient who has suffered a shark bite. Radiography, irrigation and a comprehensive examination are key (since radiographs may not be sensitive for tooth fragments, as was the case in this patient). Treatment for high-risk wounds should include prophylactic antibiotics as well as tetanus vaccination (if status is unknown). With regards to wound closure, the authors add that “delayed primary closure of similar wounds can be a viable option if the patient is sufficiently reliable to follow up closely.”
1. Popa, D. Van Hoesen K. A ‘Shark Encounter’: Delayed Primary Closure and Prophylactic Antibiotic Treatment of a Great White Shark Bite. Journal of Emergency Medicine. September 9, 2016. DOI: 10.1016/j.jemermed.2016.06.066.