What's the next step for a dog bite wound with light sutures, finishing 10 days of Augmentin (amoxicillin/clavulanate), that still doesn't appear to be healing?

Management of Persistent Dog Bite Wound After Augmentin

For a dog bite wound that still doesn't look good after 10 days of Augmentin, surgical consultation and wound debridement is needed, followed by a change in antibiotic therapy to a different regimen such as doxycycline or a fluoroquinolone plus metronidazole. 1

Assessment of the Non-Healing Wound

When a dog bite wound fails to respond to initial antibiotic therapy with amoxicillin-clavulanate (Augmentin), several factors need to be considered:

1. Wound characteristics:

   • Presence of deep abscess
   • Necrotic tissue
   • Foreign material
   • Inadequate initial debridement
   • Sutures acting as foreign bodies

2. Potential resistant organisms:

   • Pasteurella multocida
   • Anaerobes
   • Staphylococcus aureus (including MRSA)
   • Capnocytophaga species

Immediate Management Steps

1. Wound Care

• Remove sutures if present, as they may be impeding drainage 1
• Perform thorough wound cleansing with sterile normal saline 1
• Debride any necrotic tissue or slough 1
• Consider surgical consultation, especially if there's evidence of:
  • Deep abscess
  • Substantial necrosis
  • Crepitus
  • Extensive involvement of bone or joint 1

2. Antibiotic Change

Since Augmentin (amoxicillin-clavulanate) for 10 days has failed, switch to an alternative regimen:

Oral options: 1

• Doxycycline 100 mg twice daily (excellent activity against Pasteurella multocida)
• Fluoroquinolone (ciprofloxacin 500-750 mg twice daily or moxifloxacin 400 mg daily) plus metronidazole 500 mg three times daily

For severe infections requiring IV therapy: 1

• Ampicillin-sulbactam 1.5-3.0 g every 6-8 hours
• Piperacillin-tazobactam 3.37 g every 6-8 hours
• Carbapenem (ertapenem, imipenem, or meropenem)

3. Duration of Therapy

• For moderate infections: continue antibiotics for 2-4 weeks 1
• For infections with bone involvement (osteomyelitis): at least 4-6 weeks 1

Special Considerations

Wound Closure

• Primary wound closure is generally not recommended for dog bite wounds except for facial wounds 1
• For the current non-healing wound, leave it open to allow drainage and healing by secondary intention 1

Tetanus Prophylaxis

• Ensure tetanus prophylaxis is current
• If >5 years since last dose for this "dirty wound," administer tetanus toxoid booster
• Tdap is preferred over Td if not previously given 1

Follow-up

• Early and careful follow-up within 24-48 hours is essential to ensure the new treatment regimen is effective 1
• If infection persists despite the change in antibiotics, consider:
  • Obtaining wound cultures after discontinuing antibiotics for a few days 1
  • Imaging studies to evaluate for deeper infection or foreign body
  • Hospitalization if systemic symptoms develop

Pitfalls to Avoid

1. Don't continue the same antibiotic regimen when there's clear evidence of failure after 10 days
2. Don't close a non-healing infected wound as this may worsen the infection
3. Don't overlook the possibility of resistant organisms or unusual pathogens in dog bite wounds
4. Don't neglect proper wound care - antibiotics alone are often insufficient without appropriate debridement 1
5. Don't miss bone involvement - consider imaging if there's pain near a bone or joint

The failure of Augmentin after 10 days suggests either resistant organisms, inadequate wound care, or deeper infection requiring more aggressive management. Changing the antibiotic regimen and ensuring proper wound debridement are the critical next steps.