What is the prophylaxis protocol for a dog bite?

Dog Bite Prophylaxis Protocol

For dog bite management, immediate wound cleaning with copious amounts of sterile saline or warm potable water for 15 minutes, followed by amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days, tetanus prophylaxis if needed, and rabies post-exposure prophylaxis assessment is the recommended protocol. 1

Immediate Wound Management

1. Thorough Wound Cleaning

   • Irrigate with copious amounts of sterile normal saline or warm potable water for about 15 minutes 1
   • Avoid iodine or antibiotic-containing solutions
   • Remove superficial debris but avoid deep debridement that could enlarge the wound
   • Examine neurovascular function and range of motion of adjacent joints 2

2. Wound Closure Considerations

   • Infected wounds should not be closed 1
   • Facial wounds may be closed primarily after meticulous wound care, irrigation, and with prophylactic antibiotics
   • For other wounds, consider:
     • Approximation with Steri-Strips
     • Delayed primary closure
     • Secondary intention healing
   • Avoid suturing when possible to reduce infection risk 1

Antibiotic Prophylaxis

1. First-line Regimen

   • Amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days 1
   • Provides coverage against both aerobic and anaerobic bacteria commonly found in dog bite wounds

2. Alternative Options for Penicillin-Allergic Patients

   • Doxycycline 100 mg twice daily
   • Fluoroquinolone plus metronidazole
   • Clindamycin plus TMP-SMZ 1

3. Indications for Preemptive Antibiotic Therapy

   • Immunocompromised patients
   • Asplenic patients
   • Advanced liver disease
   • Wounds with resultant edema
   • Moderate to severe injuries, especially to hand or face
   • Injuries that may have penetrated periosteum or joint capsule 1
   • Hand bites (NNT = 4) 3

Rabies Prophylaxis

1. Assessment

   • Consult local health officials to determine if rabies post-exposure prophylaxis (PEP) is indicated 1
   • In areas where canine rabies is not endemic, a healthy domestic dog that bites should be confined and observed for 10 days 4
   • Any illness in the animal during confinement should be evaluated by a veterinarian and reported to local health department 4
   • Stray or unwanted dogs that bite should be humanely killed and tested for rabies 4
   • Bites that do not break the skin generally do not require rabies PEP 2

2. If Rabies PEP is Indicated

   • Administer rabies immune globulin (RIG) at 20 IU/kg body weight
   • Infiltrate as much RIG as possible into and around the wound(s)
   • Administer any remaining volume intramuscularly at a site distant from vaccine administration
   • Administer first dose of rabies vaccine on day 0 (same day as RIG but at different site)
   • Follow with additional doses on days 3,7,14, and 28 (5-dose regimen) 1

Tetanus Prophylaxis

• Evaluate tetanus vaccination status
• Administer tetanus toxoid if status is outdated or unknown 1

Follow-up and Monitoring

• Follow up within 24-48 hours to assess for signs of infection
• Monitor for increasing redness, swelling, pain, warmth, or drainage
• Elevate affected area if inflammation is present to accelerate healing
• Consider hospitalization if infection progresses despite appropriate therapy 1

Special Considerations

• Dog bites may cause crush and soft-tissue avulsion injuries 2
• Children most often present with bites on head and neck, while adults usually have bites on extremities and hands 2
• The risk of infection from dog bites is approximately 16% without antibiotic prophylaxis 5
• Prophylactic antibiotics reduce the incidence of infection in dog bite wounds (relative risk 0.56) 5

Potential Complications to Monitor

• Osteomyelitis
• Synovitis
• Nerve or tendon injury
• Compartment syndromes
• Post-infectious arthritis
• Fracture
• Bleeding 1