What is the recommended prophylaxis for a dog bite?

Dog Bite Prophylaxis

For dog bite prophylaxis, immediate wound cleansing with soap and water or povidone-iodine solution, tetanus prophylaxis, antibiotic prophylaxis with amoxicillin-clavulanate, and assessment for rabies risk are essential components of management. 1, 2, 3

Initial Wound Management

1. Wound Cleansing:

   • Immediate and thorough washing of all bite wounds with soap and water
   • Follow with irrigation using povidone-iodine solution
   • This step alone markedly reduces the risk of both rabies and bacterial infection 1

2. Wound Assessment:

   • Evaluate depth, location, and time elapsed since injury
   • Check for foreign bodies, nerve/tendon damage
   • Assess neurovascular function and joint movement 2
   • Avoid suturing when possible, especially for puncture wounds 1

Antibiotic Prophylaxis

Indications for prophylactic antibiotics:

• All dog bites to the hand
• Deep puncture wounds
• Wounds requiring surgical debridement
• Immunocompromised patients
• Wounds involving joints, tendons, or bones
• Moderate to severe injuries, especially to the face 2, 3

Recommended regimen:

• First-line: Amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days 2, 3
• Alternatives for penicillin-allergic patients: Doxycycline plus metronidazole or a fluoroquinolone plus metronidazole 3

Tetanus Prophylaxis

• Administer tetanus prophylaxis if vaccination is not current within 10 years
• For patients with unknown or incomplete tetanus vaccination history, administer tetanus immune globulin plus tetanus toxoid 2
• Tdap preferred over Td if not previously given 2

Rabies Prophylaxis

Assessment for rabies risk:

• Consider the geographic location, vaccination status of the dog, and circumstances of the bite (provoked vs. unprovoked) 1
• Unprovoked attacks are more likely to indicate rabid animals 1

For high-risk exposures:

• Administer human rabies immune globulin (HRIG) 20 IU/kg body weight
• Infiltrate the full dose around and into the wound if anatomically feasible
• Administer any remaining volume IM at a site distant from vaccine administration 1
• Begin rabies vaccine series (5 doses on days 0,3,7,14, and 28) 1

For previously vaccinated individuals:

• Administer only vaccine (no HRIG) 1

Follow-up Care

• Follow up within 24-48 hours to assess for signs of infection
• Monitor for increasing erythema, pain, swelling, purulent discharge, and systemic symptoms 2
• Consider surgical consultation for deep infections, abscess formation, or signs of compartment syndrome 2

Special Considerations

• Hand bites have higher infection rates and benefit significantly from prophylactic antibiotics (NNT = 4) 4
• Children are at higher risk for dog bites to the head and neck, requiring careful evaluation 3
• For bites from dogs in rabies-endemic areas outside the United States, consider immediate rabies post-exposure prophylaxis 1