Bite treatments

Mosquito

• Welt / itching

• May expand to large blisters or systemic symptoms

Fleas

• Redness / intense itching

• Usually multiple and grouped

• Primarily occur on the legs and ankles

Bed bugs

• Severe itching

• Exposed areas of skin

• Clusters or along straight-line

• May ssee small dermal hemorrhages

Spider

• Black widow

• Brown recluse

• Yellow sac spider

Ticks

• Intense itching papules

• Nodule if tick is still present

• Responsible for 75% of US vector borne illnesses

Routine check on where after being outdoors?

• Armpits

• Groin

• Under base of bra

• Hair

What to do when tick is identified and attached?

• Calm

• Need abt 12-72 hrs to infect and assumes the tick is a carrier of the disease

• Recommend use of tweezers

  • Pull straight out

  • Don’t use old wives’ tale remedies (nail polish, lit match, petrolatum)

Non-pharm self care

• Avoid scratching

  • Oral antihistamines if horrible itchiness

• Ice pack

  • Up to 10 mins with at least 10 min break between

Exclusions for self-treatment?

• Signs of secondary infection

• Hx of bite hypersensitivity

• < or = 2 yr old

What are pharmacologic treatment for bites?

• Local anesthetics

• Topical antihistamines

• Topical steroids

• Counter irritants

• Skin protectants

• Antiseptic/antibiotic

How many times and how long for creams, ointments, aerosols, and lotion should be applied?

3-4x daily for 7 days

Local anesthetics

• Benzocaine or ending in -caine

• Phenol or ending in -ol

• Use lowest concentrations

• Don’t place under compress or bandages

• Phenol avoid in pregnancy

Topical antihistamine

• Diphenhydramine HCl

• Continued use for 3-4 wks may cause contact dermatitis

• Can cause photosensitivity and hypersensitivity

• May use systemic antihistiamines for itching (off-label)

Topical steroids

• Hydrocortisone 1%

• Decreases itching and inflammation

• Avoid in pts with scabies, bacterial infections, or funcal infections - can worsen or mask these disorders

Counterirritants

• Camphor and menthol

• Camphor containing products can be very dangerous if ingested

Skin protectants

• Zinc oxide or -oxide

• Calamine

• Aquaphor

• Reduces inflammation and promote healing

• Zinc oxide and calamine absorb fluids from weeping wound

• Zinc/titanium - mild antiseptic properties

Antiseptics/antibiotics

• Bacitracin, neomycin etc

• To prevent localized secondary infection

Most common disease from tick?

• Lyme disease

• Majority occurs northeast and upper midwest US

Treatment for post tick bite?

Watch and wait for most cases

When is prophylaxis needed after a bite?

• Children or adults within 72 hrs of removal

• ONLY IF, a high risk based, in which ALL 3 criteria are met:

  • Tick bite was from an identified ixodes spp. vector species - lyme

  • It occured in a highly endemic area

  • Tick was attached for more than 36 hrs

Abx prophylaxis for all age groups

• A single dose of oral doxycycline within 72 hrs of removal

  • Adults: 200 mg

  • Children: 4.4 mg/kg (max of 200 mg)

Pt with erythema migrans and epidemiologic risk may be given a diagnosis of what disease w/o lab testing?

Lyme disease (Borrelia burgdoferi, B. mayonii)

Localized stage of lyme disease?

• Erythema migrans (EM): red ring-like or expanding rash

• Flu-like symptoms: malaise, headache

• Lymphadenopathy

Disseminated stage of lyme disease?

• Rashes

• Flu-like symptoms

• Chronic with relapsing symptoms

• Rheumatologic, cardiac, neurolgic and other manifestations

Treatment for lyme disease if (EM) is present?

• Adults: doxycycline 100 mg q12

• Peds: 2.2 mg/kg q12 (max 200 mg QD)

• treat for 10-14 days

What are alternative treatments for lyme disease?

• Amoxicillin

  • Adults: 500 mg po TID x 14 d

  • Peds: 50 mg/kg divided TID

• Ceftin

  • Adults: 500 mg po BID x 14 d

  • Peds: 30 mg/kg divided BID

Anaplasmosis Early illness symptoms

• Flu-like symptoms (mild-moderate)

Anaplasmosis cause?

Gram - bacteria anaplasma phagocytophilum

Anaplasmosis late stage illness symptoms

• Respiratory failure

• Bleeding problems

• Organ failure

• Death

Treatment for anaplasmosis?

• Adult: doxycycline 100 mg q12

• Peds: 2.2 mg/kg q12

• Treat for 10-14 days to cover potential co-infection or alternative infection w/ lyme

• If allergic to doxycycline, use Rifampin

Rocky mountain spotted fever rickettsiosis cause?

Gram - rickettsia

Rocky mountain spotted fever rickettsiosis symptoms?

• Non-specific fever

• Headache

• Stomach pain

• Rash develops 2-4 days after fever

Is there a chronic component to Rocky Mountain Spotted Fever rickettsiosis?

No, but can acutely cause serious problems including loss of limbs, hearing loss; paralysis or mental disability

Treatment for Rocky Mountain Spotted Fever?

• Adults: Doxycycline 100 mg q12

• Peds: 2.2 mg/kg q12

• Min course of treatment 5-7 days

• If true allergy to ddoxycyline: use Chloramphenicol

Chloramphenicol side effects?

• Bone marrow suppression

• Aplastic anemia

• Gray baby syndrome

  • Cardiac issues

  • Fussiness

  • Decreased appetite

  • Ashen appearance

What are self-protection against mosquitos and ticks?

• Prevention

• Use of recommended repellants

What are preventions for bites?

• Light colored

• Closed toe shoes

• Shower ASAP

• Perform tick checks after being outside

• Use oscillating fan to make mosquito lans more difficult

• Stay on center of path

• Pre-travel visits to determine vaccine rec

Reccommended repellants factors for effectiveness

• Product formulation

• Concentration

  • Higher = greater duration

• Environmental conditions

• Biting density

• User characteristics

  • Sweat and evaporation may decrease duration of protection

What does adult mosquitoes use to find hosts?

• Smell

• Specific chemical cues

• CO2

Clinical pearl regarding repellant

• Avoid combo products that contains sunscreen

• Apply sunscreen 1st as application then bug repellant to prevent systemic absorption of bug repellant

Permethrin

• Use on clothing, shoes, nets, or other fabrics

• DON’T apply DIRECTLY ON SKIN

• Acute toxicity: nausea, vomiting

• Lipophilic = may be transferred via breastmilk

Insect repellant agents

• DEET

• Picaridin

• PMD

• IR3535

DEET

Concentration:

• 20%-40%

• Use 30% or less in kids

Downfalls:

• Oily

• Dmg plastic and some fibers

• Foul odor

Other notes:

• Gold-standard repellant

• Efficacy plateau at 30%

Picaridin

Concentration:

• 20%

Downfalls

• Shorter duration of effect

PMD (oil of lemon eucalyptus)

Concentration

• 30%

Downfalls

• Shorter duration of effect

IR3535

Concentration

• 20%

Downfalls

• Does NOT protect against MALARIA (anopheles)

West Nile Virus

Culex mosquito

Treatment:

• OTC pain relievers

Dengue

Dengue virus 1,2,3,4

Aedes mosquito (also responsible for Zike and Chikungunya)

Initial:

• Fever w/ nausea, vomiting, rash, aches and pains

Treatment:

• Acetaminophen (not NSAID or ASA as platelets and steroids are not helpful)

Malaria

Caused by plasmodium parasite

Anopheles (responsible for yellow fever and Japanese encephalitis)

Symptoms:

• Fever and chills

• More severe: splenomegaly, anemia

Uncomplicated malaria:

• Non-specific

• Can be missed

Untreated severe:

• Can progress to severe that may be fatal consider in pt who have traveled