Wound Infections from Taiwan Cobra (Naja atra) Bites: Determining Bacteriology, Antibiotic Susceptibility, and the Use of Antibiotics-A Cobra BITE Study

Round 1

Reviewer 1 Report

Author described the useful clinical tool to evaluate the infection risk after Taiwan cobra bites using some antibiotics such as Gentamicin, ceftriaxone, ciprofloxacin, and levofloxacin based on the enormous clinical data in Taiwan. This paper is interesting paper and include useful information for therapeutics of snakebite.

Although this paper is acceptable for publication in Toxins, some minor  and major points should be addressed;

There are some obscure description by XXXXX in text (page 2, line 61; page 8, line 246; page 10, lines 251, 255, 260, and 264). Should be defined these points with clarity.

Similar study was achieved for different snakes in Taiwan, Protobothrops mucrosquamatus and Viridovipera stejnegeri, and published by same authors (?) in Toxins (Toxins 2020, 12(9), 575). But there was little mention of this previous study. Author should be discussed more detail with comparison of data for Protobothrops mucrosquamatus and Viridovipera stejnegeri.

Author Response

Point to point response to Reviewer 1

There are some obscure descriptions by XXXXX in text (page 2, line 61; page 8, line 246; page 10, lines 251, 255, 260, and 264). Should be defined these points with clarity.

Response: all the XXXXX had been replaced by Chang Gung or CGMH (Line 141, 482, 487, 491, 495,499).

Similar study was achieved for different snakes in Taiwan, Protobothrops mucrosquamatus and Viridovipera stejnegeri, and published by same authors (?) in Toxins (Toxins 2020, 12(9), 575). But there was little mention of this previous study. Author should be discussed more detail with comparison of data for Protobothrops mucrosquamatus and Viridovipera stejnegeri.

Response: we added the comparison in discussion section 3.4 as following.

"As we described in the introduction section, there are six clinically medically important venomous snakes in Taiwan. Naja atra, Protobothrops mucrosquamatus, and Viridovipera stejnegeri accounted for more than 95 % of snakebites. In general, Naja atra bites had much higher wound infection than Protobothrops mucrosquamatus and Viridovipera stejnegeri associated wound infections. Only 7 cases in 163 victims who suffered from wound infection showed positive culture findings in our previous report [15]. However, the cultured microorganism species were similar. Enterococcus faecalis and Morganella morganii were still the most commonly found pathogens."

Author Response File: Author Response.docx

Reviewer 2 Report

Based on the local infection associated with the Taiwan Cobra bite, the authors derived from past treatment records the points of bite symptoms related to the bite treatment and the timing of antibiotic use to clinicians. As a whole, I get the impression that it is written in an easy-to-understand structure. As a reviewer, I think that the treatise will give a better understanding to the reader by correcting or adding the following points.

1. It is difficult to understand that the isolated bacteria from the locally infected swab associated with the Taiwanese cobra bite described in the paper are limited to almost two types of bacteria. In the discussion section, the authors state that the same two bacteria have been isolated from reports of local infections associated with snakebites in Taiwan. Since it is a local infection at the time of a snakebite, it is naturally expected that more environmental bacteria will be isolated, but I would like consideration to answer this question. For example, can we compare it with the types of bacteria that are isolated during local infection due to trauma in the field?
2.  Or 1. If the two bacteria listed in the above are isolated bacteria specific to the bite site of Taiwan Cobra, I think it is possible to propose to use them and add them to the Cobra bite score.
3. Since the isolated E. faecalis show antibiotic resistance from the data in Table S1, it may be VRE. I would like you to add some consideration about this.

minor point

Regarding the tables published in the treatise, please add explanations for the following items in the margins of each table.

1. Meaning of numbers listed in "culture sequence" in Table 1
2. Description of the numbers in parentheses in "No wound infection" in Table 3
3. Meaning of Beta and * in Table 4

Author Response

Reviewer 2

1. It is difficult to understand that the isolated bacteria from the locally infected swab associated with the Taiwanese cobra bite described in the paper are limited to almost two types of bacteria. In the discussion section, the authors state that the same two bacteria have been isolated from reports of local infections associated with snakebites in Taiwan. Since it is a local infection at the time of a snakebite, it is naturally expected that more environmental bacteria will be isolated, but I would like consideration to answer this question. For example, can we compare it with the types of bacteria that are isolated during local infection due to trauma in the field?

Response:

• In discussion 3.1, we stated that "snakebite wound infection is usually polymicrobial, with morganii and E. faecalis being the most often identified pathogens". Multiple pathogens were also observed and stated in Table 1 and 2. Therefore, the isolated pathogens were not just limited to 2 types of bacteria.
• We agree with you that environmental bacteria will be isolated in the snakebite's wounds. We made some changes of discussion 3.1.

 “Up to 14 different pathogens have been identified in this study. All of these isolated pathogens were skin commensals or opportunistic pathogens. When comparing pathogens isolated from necrosis and nonnecrosis wounds, we found that patients of the necrosis wound group were more easily to be prone to have polymicrobial and more complicated wound infection. We believed that patients with wound necrosis who requiring multiple surgical interventions were at risk of developing their complicated infections.

There are two factors we should consider in exploring the bacteriology of infected snakebites. First, the bacteriology of infected snakebite wounds reflects the polymicrobial flora of snakes’ oral cavities because of the direct inoculation of the pathogens from the snake’s oral cavity to the wound. For example, Morganella morganii, Aeromonas hydro-philia and E. faecalis are frequently isolated from the oral cavity of snakes [9,10,11,12,13,14]. It is thus not surprising that they are some of the most common pathogens found in infected snakebite wounds [3, 4 ,6 ,9]. Second, venom induced tissue damage allowing for the opportunistic colonization of the wound by snake oral cavity flora, skin commensals or environmental bacteria. This was demonstrated in a study regarding wound infection in Taiwan habu/ green bamboo viper snakebites patients [15]. Either Taiwan habu (Protobothrops mucrosquamatus) or green bamboo viper (Viridovipera stejnegeri) have their venom rich in metalloproteinases and phospholipase A2 which have cytotoxic, myotoxic, and pro-inflammatory properties and thus cause tissue damage [16,17].  Both in the previous study [15] and this study, we found that patients with infected snakebite wounds were administered more doses of antivenin compared to those without infected wounds. The more venom that is injected, the more severe the resultant tissue damage and con-sequent infection. It is accepted that more cytotoxin dose may induce tissue necrosis or to a more extensive degree of tissue necrosis [18]. In this study, all of the patients with tissue necrosis were highly infected and had more complicated bacteriology than the nonne-crosis wound infection patients. Thus, the degree of tissue destruction might be one of the contributing factors causing wound infection.”   

 

1.  Or 1. If the two bacteria listed in the above are isolated bacteria specific to the bite site of Taiwan Cobra, I think it is possible to propose to use them and add them to the Cobra bite score.

Response: Thank you for the suggestion, however, we don't think the two most commonly isolated bacteria should be added to the Cobra bite score. Instead, they should be considered in the choice of the antibiotics when treating wound infection od cobra bites.

1. Since the isolated E. faecalis show antibiotic resistance from the data in Table S1, it may be VRE. I would like you to add some consideration about this.

Response: Thank you and the following paragraph was added in the discussion 3.1. section.

“E. faecalis was one of the most isolated pathogens found in this study. We observed that antibiotic resistance existed in some of the bacteria cultures. Thus, reminding us the occurrence of Vancomycin-Resistant Enterococci (VRE) in the cobra bite wounds. Therefore, stick strictly to using antibiotics according to the above suggestions of choice of antibiotics according to local bacterial pattern and their drug susceptibility tests is paramount important in preventing the occurrence of VRE. Once VRE is cultured, the choice of antibiotics would be linezolid, daptomycin, or tigecycline [ 22, 23]. Other measurements such as washing hands, remove the possible VRE colonization site(such as the necrotic tissue, central lines or removing the unnecessary Foley catheter) should also be implanted to prevent its spread within the hospital.”

minor point

Regarding the tables published in the treatise, please add explanations for the following items in the margins of each table.

1. Meaning of numbers listed in "culture sequence" in Table 1

Response: "^@ 1/2= culture results of 1^st and 2^nd time culture; 1&2 =1^st and 2^nd time culture had the same culture result; * Yeast-like organism also cultured" was added at the bottom of Table 1, Line 189.

1. Description of the numbers in parentheses in "No wound infection" in Table 3.

Response: After I checked Table 3 and the corresponding sentences within the manuscript, I don't really understand what you mean. I think readers can understand the numbers in parentheses in "No wound infection" in Table 3.

1. Meaning of Beta and * in Table 4

Response: "^@β: vector of weights (or regression coefficients) corresponding to outcome. The β coefficient of each variable was divided by 0.4 and rounded off to the nearest integer to form the prediction rule. β=0.4= 1 point." was added at the bottom of Table 4. Line 247.

Author Response File: Author Response.docx

Reviewer 3 Report

Overall this is manuscript is interesting, it merits publication after improvements in the writing and  the signficance is clear. Moreover, this is a retrospective study and generation of a model/score. This should be validated  

Major comments: The figure captions do not explain the figure. Also the figures are low quality (very pixelated) . 

Minor comments:

“Respectively” is used 11 times in this paper in relation to listed information (Lines 18, 26, 69, 77, 81, 86, 88, 91, 132, 261, and 307).

Line 2: It is recommended to add the scientific name (Naja atra) after the common name of the Taiwan Cobra for clarity

 

Lines 5-6: Better flow would result from combining the sentences beginning in line 5 and ending in line 6 for better flow [“Taiwan cobra (Naja atra) bites account for approximately 20% of all venomous snakebites in Taiwan. In Taiwan, the rates of wound necrosis and secondary infection from Taiwan cobra bites are higher than those associated with other venomous snakebites.” could be “Taiwan cobra (Naja atra) bites account for approximately 20% of all venomous snakebites in Taiwan, where the rates of wound necrosis and secondary infection from N. atra bites are higher than those associated with other venomous snakebites.”].

 

Line 8: “Therefore” should be removed from the sentence beginning in line 8, as there is no precedent for it (“Therefore, in this study, we developed a useful 8 clinical tool to evaluate the infection risk after Taiwan cobra bites.”), and the sentence should begin at “In.”

 

Lines 9-22: Lines 9 through 22 contain jumbled language with runon sentences, and could be edited for clarity [“Moreover, we investigated wound infection bacteriology. We analyzed the data of patients bitten by N. atra who had undergone freeze-dried neurotoxic antivenin treatment in emergency rooms of the Chang Gung Memorial Hospital network, which comprises seven hospitals and the largest medical system in Taiwan, from January 2001 to May 2017. Because patients with wound necrosis required antibiotics for infection treatment, we included only patients with wound infection but without tissue necrosis in the development of 1our Cobra Bacteriology of Infections in Taiwanese snake Envenomation (Cobra BITE) score by using univariate and multiple logistic regression. In total, 8,295,497 emergency department visits occurred from January 2001 to May 2017, and 195 patients were diagnosed has having cobra bites. Among them, 23 and 30 patients had wound necrosis and wound infection, respectively. The wound infection rate was 27.2% (53/195). Regardless of whether the patients had necrosis, Enterococcus faecalis and Morganella morganii were the main bacteria identified in the culture report. Gentamicin, ceftriaxone, ciprofloxacin, and levofloxacin are the ideal first-line antibiotics for treating N. atra bite wounds in Taiwan.” could be “Furthermore, we investigated wound infection bacteriology through analysis of patients who had undergone treatment with freeze-dried neurotoxic antivenin within emergency departments of the Chang Gung Memorial Hospital (which comprises seven hospitals and is the largest medical system in Taiwan) spanning the period of January 2001 through May 2017. Only patients with wound infection lacking tissue necrosis were included in the development of our Cobra Bacteriology of Infections in Taiwanese snake Envenomation (Cobra BITE) score utilizing univariate and multiple logistic regression, as patients with wound necrosis require antibiotics for infection treatment. 8,295,497 emergency department visits occurred in the span of this study, with 195 of those patients being diagnosed as having cobra bites. Of these patients, 23 had wound necrosis and 30 had wound infection, resulting in a wound infection rate of 27.2% (53/195). Enterococcus faecalis and Morganella morganii were the main bacteria identified in the culture report regardless of whether patients wounds had necrosis.”]. Combine the sentences beginning in line 24 and ending in line 27 [“The area under the receiver operating characteristic curve for the Cobra BITE score system was 0.88. The ideal sensitivity and specificity were 0.89 and 0.76, respectively, and the optimal cutoff point for Cobra BITE score was 7. The Hosmer–Lemeshow p value was 0.4.” could be “The area under the receiver operating characteristic curve for the Cobra BITE score system was 0.88; ideal sensitivity and specificity were 0.89 and 0.76, respectively. The optimal cutoff point for Cobra BITE score was 7 and the Hosmer–Lemeshow p value was 0.4.”].

 

 

Line 39: The sentences beginning in line 39 could be combined [“Taiwan, a subtropical island, has many types of snakes. Clinically, six species of venomous snake are considered important, namely Naja atra (Taiwan cobra or Chinese cobra), Bungarus multicinctus, Protobothrops mucrosquamatus, Trimeresurus stejnegeri, Deinagkistrodon acutus, and Daboia siamensis.” could be “Taiwan, a subtropical island, has many types of snakes; of these, six species of venomous snakes are considered clinically important: Naja atra (Taiwan cobra or Chinese cobra), Bungarus multicinctus, Protobothrops mucrosquamatus, Trimeresurus stejnegeri, Deinagkistrodon acutus, and Daboia siamensis.”].

 

Line 40-42: Common names should be added in parentheses for the snakes listen in lines 40 through 42 (Bungarus multicinctus, Protobothrops mucrosquamatus, Trimeresurus stejnegeri, Deinagkistrodon acutus, and Daboia siamensis).

 

Line 43: The sentence beginning in line 43 (“Although Taiwan cobra bites do not cause neurological complications (bites from other cobra species do), they cause would tissue damage/necrosis and confer a high risk of wound infection [2-4]) could be edited to improve flow using a semicolon (“While other species of cobra cause neurological complications, Taiwan cobra bites do not; However, they cause wound tissue damage/necrosis, and confer a high risk of wound infection [2-4].).

 

Lines 49-51: Three transition phrases are used in sentences next to each other; “Therefore” is used to begin two of these sentences. The first “therefore” is in the sentence beginning on line 49 and the second is on line 51. Both “therefore”’s should be removed, and the sentences they precede should begin with the word following.

 

Subtitle names within study flow diagram in figure 1 are inconsistent.

Line 60: change “was” to “were”

Line 63: Replace period before “men” with a semicolon

Line 105: Change “because” to “due to”

Line 114: Remove “moreover” and begin sentence with “the”

Line 115: Replace period with semicolon

Figure 2: Capitalize first letter of all words within chart title “Wound Infection Rate”

Lines 140-142: Combine the following sentences: “Taiwan cobra bites account for 20% of venomous snakebites in Taiwan [1]. The incidence of cobra bites in our study was 21.03%. This was consistent with previous studies[1, 7, 8].”

Line 158: Replace “Taiwan cobra” with “N. atra”

Line 159: Replace “Taiwan cobra” with “this species of cobra”

Line 158-162: Reword the sentence beginning on line 158 and ending on line 162

Line 188: Sentence was begun with “second” with no precursor. Remove this word and begin with “Both”

 

Lines 226 and 228: Sentenced were begun with “however” back to back.

Author Response

Reviewer 3  

Major comments: The figure captions do not explain the figure. Also the figures are low quality (very pixelated). 

Response: We made some changes in the figure captions as following. We also replaced the original figures with high quality ones.

Line 127. Fig. 1 "Study flow diagram for Cobra BITE score. The enrolled cobra bites patients were dived into Wound tissue necrosis and nonnecrosis group. Patients were defined as wound necrosis if they met the criteria of positive wound/pus culture or admission diagnoses of cellulitis, abscess and necrotizing fasciitis. The nonnecrosis wound infection group was used to be compared with the no wound infection group to develop the Cobra BITE score. The bacteriology of necrosis wound group and nonnecrosis wound infection group were employed to provide clinical application of antibiotic administration for Taiwan cobra bites"

Line 261. Fig 2. "Cobra BITE scores and wound infection rates. The higher the score was, the higher the wound infection rate. With an optimal cutoff point of 7, the sensitivity and specificity of Cobra BITE score was 0.89 and 0.76, respectively.

Line 266. Fig 3. "The receiver operator characteristic curve of Cobra BITE score was 0.88."

 

Minor comments:

“Respectively” is used 11 times in this paper in relation to listed information (Lines 18, 26, 69, 77, 81, 86, 88, 91, 132, 261, and 307).

Response: Thank you for the reminding, we deleted most of "Respectively".

Line 2: It is recommended to add the scientific name (Naja atra) after the common name of the Taiwan Cobra for clarity

 Response: done as your suggestion.

Lines 5-6: Better flow would result from combining the sentences beginning in line 5 and ending in line 6 for better flow ["Taiwan cobra (Naja atra) bites account for approximately 20% of all venomous snakebites in Taiwan. In Taiwan, the rates of wound necrosis and secondary infection from Taiwan cobra bites are higher than those associated with other venomous snakebites." could be "Taiwan cobra (Naja atra) bites account for approximately 20% of all venomous snakebites in Taiwan, where the rates of wound necrosis and secondary infection from N. atra bites are higher than those associated with other venomous snakebites."].

Line 8: "Therefore" should be removed from the sentence beginning in line 8, as there is no precedent for it ("Therefore, in this study, we developed a useful 8 clinical tool to evaluate the infection risk after Taiwan cobra bites."), and the sentence should begin at "In."

Lines 9-22: Lines 9 through 22 contain jumbled language with runon sentences, and could be edited for clarity ["Moreover, we investigated wound infection bacteriology. We analyzed the data of patients bitten by N. atra who had undergone freeze-dried neurotoxic antivenin treatment in emergency rooms of the Chang Gung Memorial Hospital network, which comprises seven hospitals and the largest medical system in Taiwan, from January 2001 to May 2017. Because patients with wound necrosis required antibiotics for infection treatment, we included only patients with wound infection but without tissue necrosis in the development of 1our Cobra Bacteriology of Infections in Taiwanese snake Envenomation (Cobra BITE) score by using univariate and multiple logistic regression. In total, 8,295,497 emergency department visits occurred from January 2001 to May 2017, and 195 patients were diagnosed has having cobra bites. Among them, 23 and 30 patients had wound necrosis and wound infection, respectively. The wound infection rate was 27.2% (53/195). Regardless of whether the patients had necrosis, Enterococcus faecalis and Morganella morganii were the main bacteria identified in the culture report. Gentamicin, ceftriaxone, ciprofloxacin, and levofloxacin are the ideal first-line antibiotics for treating N. atra bite wounds in Taiwan." could be "Furthermore, we investigated wound infection bacteriology through analysis of patients who had undergone treatment with freeze-dried neurotoxic antivenin within emergency departments of the Chang Gung Memorial Hospital (which comprises seven hospitals and is the largest medical system in Taiwan) spanning the period of January 2001 through May 2017. Only patients with wound infection lacking tissue necrosis were included in the development of our Cobra Bacteriology of Infections in Taiwanese snake Envenomation (Cobra BITE) score utilizing univariate and multiple logistic regression, as patients with wound necrosis require antibiotics for infection treatment. 8,295,497 emergency department visits occurred in the span of this study, with 195 of those patients being diagnosed as having cobra bites. Of these patients, 23 had wound necrosis and 30 had wound infection, resulting in a wound infection rate of 27.2% (53/195). Enterococcus faecalis and Morganella morganii were the main bacteria identified in the culture report regardless of whether patients wounds had necrosis."]. Combine the sentences beginning in line 24 and ending in line 27 ["The area under the receiver operating characteristic curve for the Cobra BITE score system was 0.88. The ideal sensitivity and specificity were 0.89 and 0.76, respectively, and the optimal cutoff point for Cobra BITE score was 7. The Hosmer–Lemeshow p value was 0.4." could be "The area under the receiver operating characteristic curve for the Cobra BITE score system was 0.88; ideal sensitivity and specificity were 0.89 and 0.76, respectively. The optimal cutoff point for Cobra BITE score was 7 and the Hosmer–Lemeshow p value was 0.4."].

 Response: Thank you very much for the above suggestions in the abstract section. We re-write a shorter abstract version according to other reviewer's suggestion.

Line 39: The sentences beginning in line 39 could be combined ["Taiwan, a subtropical island, has many types of snakes. Clinically, six species of venomous snake are considered important, namely Naja atra (Taiwan cobra or Chinese cobra), Bungarus multicinctus, Protobothrops mucrosquamatus, Trimeresurus stejnegeri, Deinagkistrodon acutus, and Daboia siamensis." could be "Taiwan, a subtropical island, has many types of snakes; of these, six species of venomous snakes are considered clinically important: Naja atra (Taiwan cobra or Chinese cobra), Bungarus multicinctus, Protobothrops mucrosquamatus, Trimeresurus stejnegeri, Deinagkistrodon acutus, and Daboia siamensis."].

 Response: Thank you very much and done as your suggestion.

Line 40-42: Common names should be added in parentheses for the snakes listen in lines 40 through 42 (Bungarus multicinctus, Protobothrops mucrosquamatus, Trimeresurus stejnegeri, Deinagkistrodon acutus, and Daboia siamensis).

 Response: done as your suggestion, common names were added in line 33-35 as the following" Naja atra (Taiwan cobra or Chinese cobra), Bungarus multicinctus, Protobothrops mucrosquamatus (Taiwan habu), Trimeresurus stejnegeri(green bamboo viper), Deinagkistrodon acutus(hunder pacer viper), and Daboia siamensis(eastern Russell's viper)".

Line 43: The sentence beginning in line 43 ("Although Taiwan cobra bites do not cause neurological complications (bites from other cobra species do), they cause would tissue damage/necrosis and confer a high risk of wound infection [2-4]) could be edited to improve flow using a semicolon ("While other species of cobra cause neurological complications, Taiwan cobra bites do not; However, they cause wound tissue damage/necrosis, and confer a high risk of wound infection [2-4].).

  Response: Thank you very much and done as your suggestion.

Lines 49-51: Three transition phrases are used in sentences next to each other; "Therefore" is used to begin two of these sentences. The first "therefore" is in the sentence beginning on line 49 and the second is on line 51. Both "therefore"  's should be removed, and the sentences they precede should begin with the word following.

 Response: Thank you very much and done as your suggestion.

Subtitle names within study flow diagram in figure 1 are inconsistent.

Response: We made some changes of Subtitle names within study flow diagram of figure 1.

Line 60: change "was" to "were"

Response: done as your suggestion.

Line 63: Replace period before "men" with a semicolon

Response: done as your suggestion.

Line 105: Change "because" to "due to"

Response: done as your suggestion.

Line 114: Remove "moreover" and begin sentence with "the"

Response: done as your suggestion.

Line 115: Replace period with semicolon

Response: done as your suggestion.

Figure 2: Capitalize first letter of all words within chart title "Wound Infection Rate"

Response: done as your suggestion.

Lines 140-142: Combine the following sentences: "Taiwan cobra bites account for 20% of venomous snakebites in Taiwan [1]. The incidence of cobra bites in our study was 21.03%. This was consistent with previous studies[1, 7, 8]."

Response: the sentences were combined as "In this study, we had the cobra bites incidence of 21.03% which was consistent with previous studies [1, 7, 8]." (Line 273)

Line 158: Replace "Taiwan cobra" with "N. atra"

Response: done as your suggestion

Line 159: Replace "Taiwan cobra" with "this species of cobra"

Response: done as your suggestion

Line 158-162: Reword the sentence beginning on line 158 and ending on line 162

Response: we reword the sentence as following (Line 318-323)" Since N. atra bites cause considerable wound tissue swelling or necrosis [19,20] that may lead patients to receive multiple surgical procedures, therefore, using antibiotics such as metronidazole, augmentin, or piperacillin/tazobactam to cover both aerobic and anaerobic microorganisms was recommended [21]. However, unlike previous studies, Pseudomonas aeruginosa was not observed in this study [3,5,6]."

Line 188: Sentence was begun with "second" with no precursor. Remove this word and begin with "Both"

Response: done

Lines 226 and 228: Sentenced were begun with "however" back to back.

Response: we delete one "however".

Author Response File: Author Response.pdf

Reviewer 4 Report

The manuscripts titled “Wound Infections From Taiwan Cobra Bites: Determining Bacteriology, Antibiotic Susceptibility, and the Use of Antibiotics A Cobra BITE Study” reported developed a useful clinical tool to evaluate the infection risk after Taiwan cobra bites.  In general, I think I could not find a serious problem in this manuscript. Only there some minor points that need to be modification.

 

1. If the primary purpose of this study is to reduce secondary infections, it would be desirable to be able to determine the risk of secondary infection at an early stage of snake bite. Since the length of hospitalization is an outcome, not a cause, I am not sure whether the hospitalization is an appropriate factor or not. Please describe about this matter in discussion section.
2. There are some unclear expressions such as XXXX in lines 61, 246, 255, 260, and 264. Please change to the appropriate words instead of XXXX.
3. I could not understand the definition of “culture sequence”. What is difference of 1/2, 2/1, and 1 & 2“? And what did you indicate by “*” ? Further descriptions are necessary.
4. Please write the title of table S1. And because I could not understand the sensitivities such as 1S and 1R in this table, further descriptions are necessary. 

Author Response

Point to point response to Reviewer 4  

1. If the primary purpose of this study is to reduce secondary infections, it would be desirable to be able to determine the risk of secondary infection at an early stage of snake bite. Since the length of hospitalization is an outcome, not a cause, I am not sure whether the hospitalization is an appropriate factor or not. Please describe about this matter in discussion section.

Response: I agree with you we often treat hospitalization as an outcome, not a cause. In ED, we admit patients just a few hours after patients visiting. How could we do that? We judge the clinical severity by some parameters. We think severe swelling limbs or wound necrosis are more severe than the mild swelling limbs and administered more antivenom to those patients. This is what I believe is true, because I found there was higher serum venom level in the severe limbs swelling than those mild swelling limbs in my other studies (working on, not published yet.). Therefore, to admit patients who receive higher antivenom dose is reasonable. Thus, we think hospitalization could be a predictor of disease severity. The corresponding discussion was in the 3^rd paragraph in section 3.2. (Line 369-347)

 

1. There are some unclear expressions such as XXXX in lines 61, 246, 255, 260, and 264. Please change to the appropriate words instead of XXXX.

Response: all the XXXXX had been replaced by Chang Gung or CGMH (Line 141, 482, 487, 491, 495,499).

1. I could not understand the definition of "culture sequence". What is difference of 1/2, 2/1, and 1 & 2 "? And what did you indicate by "*"? Further descriptions are necessary.

Response: The meaning of the "culture sequence was added at the bottom of Table 1 in Line 189-190, 255.

"^@ 1/2= culture results of 1^st and 2^nd time culture; 1&2 =1^st and 2^nd time culture had the same culture result; * Yeast-like organism also cultured".

 

1. Please write the title of table S1. And because I could not understand the sensitivities such as 1S and 1R in this table, further descriptions are necessary. 

Response: Thank you for the suggestion.

The title of Table S1: Results of the antibiotic sensitivity tests.

S and R represent as sensitive and resistant strain. 1R25S in Enterococcus_faecalis means there were 26 times of culture results which only 1 E. faecalis strain was sensitive to ampicillin but 25 E. faecalis strain were resistant to ampicillin.

 

Author Response File: Author Response.docx

Reviewer 5 Report

The manuscript intitled “Wound Infections From Taiwan Cobra Bites: Determining Bacteriology, Antibiotic Susceptibility, and the Use of Antibiotics- A Cobra BITE Study” is a study where they investigate the antibiotic susceptibility in Taiwan  cobra snakebite wounds and developed a clinical scoring system (Cobra BITE score) to predict wound infection development and,  the necessity of antibiotic initiation. They suggest that physicians can use the Cobra BITE score to guide appropriate antibiotic use.

It is a retrospective study and to avoid local complications in envenoming mainly by Naja ssp severe and moderate envenoming  it was "developed a clinical scoring system (Cobra BITE score) to predict wound infection development and, hence the necessity of antibiotic initiation.

The introduction lacked a general description of the main biological activities of the venom and also some clinical signs, symptoms and laboratorial data of the patients bitten by these snakes that can define the severity of envenoming.  It was not clear in this manuscript in what conditions patients develop local lesions and worst with infection.  It is known that wound infections in some snake envenoming is caused by bacteria present in the mouth of the snake. This shows that the infection can be caused during the bite and the injury induced by snake bite propitiates the evolution of the secondary infection. Thus, it is important to well evaluate and monitor the patient's evolution, especially in local lesions before prescribing the antibiotic. What is the role of antivenom therapy in these cases? What is its efficacy?  It is interesting discuss about this point.

About the conclusions: I think these general conclusions may be acceptable, but when physicians treat patients he can assess the site of the infection, he can order hematological and biochemical parameters in addition to antibiogram and choose the antibiotic properly. This manuscript shows that WBC / NLR ratio is interesting to evaluate the patient for the possibility of developing serious infection.  Thus, physicians  may follow carefully up and  define specific treatment for each patient without a high cost.

 Finally, conclusions presented must be rewritten because in a medical service the particularity of each victim is more important than any pre-established recommendation that may incur unnecessary error or cause antibiotic resistence. This manuscript show important and useful results, but it  must be inserted in a context  of clinical  and laboratorial data of each patients.

Minor changes: Abstract longer than the journal recommended. Along the text, there is some space xxxx that need fill it. Line 61, 246,251,255,260 and 264.

Author Response

Point to point response to Reviewer 5

The introduction lacked a general description of the main biological activities of the venom and also some clinical signs, symptoms and laboratorial data of the patients bitten by these snakes that can define the severity of envenoming.  It was not clear in this manuscript in what conditions patients develop local lesions and worst with infection.  It is known that wound infections in some snake envenoming is caused by bacteria present in the mouth of the snake. This shows that the infection can be caused during the bite and the injury induced by snake bite propitiates the evolution of the secondary infection. Thus, it is important to well evaluate and monitor the patient's evolution, especially in local lesions before prescribing the antibiotic.

Response: We added the following sentences in the introduction section (Line 37-40) to describe the venom's main biological activities and the definition of the clinical severity. "While other species of cobra cause neurological complications, Taiwan cobra bites do not; however, they cause wound tissue damage/necrosis due to the actions of cytotoxins in the venom and confer a high risk of wound infection [2-4]. To our knowledge, there were no clinical parameters that can predict or assesses the clinical severity of the cobra bites patients."

What is the role of antivenom therapy in these cases? What is its efficacy?  It is interesting discuss about this point.

Response:  We added the following paragraph in discussion section 3.5.

"Antivenom is the fundamental treatment of cobra snakebites. Most of the cobra bites patients receive antivenom for the consequence of cobra bites of neurological or local limbs swelling. Antivenom itself is sufficient to treat the most less severe cobra-envenomated patients, and there are no further complications. In our study, all the nonnecrosis group patients received antivenom, and only a few of them had wound infection. On the other hand, whether antivenom can prevent the development of tissue necrosis is still in debate. Since we think all the necrotic wounds are infected, antivenom remains its role in neutralizing the venom but has no position in preventing wound infection in such kinds of patients."

 

About the conclusions: I think these general conclusions may be acceptable, but when physicians treat patients, he can assess the site of the infection, he can order hematological and biochemical parameters in addition to antibiogram and choose the antibiotic properly. This manuscript shows that WBC / NLR ratio is interesting to evaluate the patient for the possibility of developing serious infection.  Thus, physicians may follow carefully up and define specific treatment for each patient without a high cost.

 Finally, conclusions presented must be rewritten because in a medical service the particularity of each victim is more important than any pre-established recommendation that may incur unnecessary error or cause antibiotic resistance. This manuscript shows important and useful results, but it must be inserted in a context of clinical and laboratorial data of each patient.

Response: the conclusions were re-written as the following paragraph.

"We offer a treatment and study framework for cobra bite wound infections. When treating a cobra bites patient, we should assess the biting site if there are tissue necrosis and order hematological parameters such as WBC / NLR ratio in addition to antibiogram and choose the antibiotic properly. According to our study results, we recommend using antibiotics in a stepwise manner for all patients with infected wounds. Gentamicin, ceftriaxone, ciprofloxacin, and levofloxacin are reasonable first-line monotherapies. If patients receive multiple surgical procedures, the use of metronidazole, augmentin, and piperacillin/tazobactam is encouraged to cope with the possible anaerobic wound infection. However, ureidopenicillin should be reserved for patients at risk of Pseudomonas spp. infection. For those patients infected with VRE, the choice of antibiotics would be linezolid, daptomycin, or tigecycline. Washing hands, removing the possible VRE colonization site (such as the necrotic tissue, central lines, or removing the unnecessary Foley catheter) should also be implanted to prevent its spread within the hospital. Last, doctors could employ our Cobra BITE score in further studies regarding the Naja spp.-associated wound infections."

Minor changes: Abstract longer than the journal recommended. Along the text, there is some space xxxx that need fill it. Line 61, 246,251,255,260 and 264.

Response: all the XXXXX had been replaced by Chang Gung or CGMH (Line 141, 482, 487, 491, 495,499).

Author Response File: Author Response.pdf

Round 2

Reviewer 3 Report

My comments were addressed

minor revisions

Fix Table 1 BOLD bolder and No.1

Table 2 Caption is not aligned