What is the proper management for a dog bite?

Dog Bite Management

Dog bite wounds should be thoroughly irrigated with soap and water or normal saline for at least 15 minutes, followed by appropriate antibiotic prophylaxis with amoxicillin-clavulanate, tetanus prophylaxis if needed, and consideration of rabies post-exposure prophylaxis based on the circumstances of the bite. 1

Initial Wound Management

1. Wound Cleaning and Irrigation:

   • Immediately wash and flush all bite wounds with soap and water or normal saline for at least 15 minutes 1
   • Use a 20-mL or larger syringe or a 20-gauge catheter for irrigation to remove foreign matter 2
   • Remove superficial debris but avoid deeper debridement unless absolutely necessary 1

2. Wound Assessment:

   • Examine for neurovascular function (pulses, sensation) and range of movement of adjacent joints 3
   • Explore for tendon or bone involvement and possible foreign bodies 2
   • Pay special attention to hand bites, particularly over joints or tendons, as they have higher infection risk 1

Wound Closure

• Facial wounds: May be closed primarily after thorough cleaning and with prophylactic antibiotics 4, 1
• Other wounds: Consider approximation with Steri-Strips or leave open 1
• Timing considerations: Avoid suturing wounds >8 hours old (except facial wounds) 1
• Infected wounds: Do not close 1

Antibiotic Prophylaxis

First-line antibiotic: Amoxicillin-clavulanate (875/125 mg twice daily for 3-5 days) 1, 3

Antibiotic prophylaxis is particularly important for:

• Bites to the hand or face
• Deep puncture wounds
• Immunocompromised patients
• Wounds with significant tissue damage 1

For patients allergic to penicillin, alternatives include:

• Doxycycline (100 mg twice daily) - not for children under 8 years
• Fluoroquinolone plus metronidazole
• Clindamycin plus TMP-SMZ 1

The meta-analysis by Cummings (1994) showed that prophylactic antibiotics reduce infection incidence in dog bite wounds (relative risk 0.56), with about 14 patients needing treatment to prevent one infection 5.

Tetanus Prophylaxis

• Administer tetanus toxoid if vaccination is outdated (>5 years) or status is unknown 4, 1
• Tetanus, diphtheria, and pertussis (Tdap) is preferred over Tetanus and diphtheria (Td) if the former has not been previously given 4

Rabies Post-Exposure Prophylaxis (PEP)

Consider rabies PEP based on:

• Vaccination status of the dog
• Circumstances of the bite
• Local rabies epidemiology 1

If indicated:

• Administer 20 IU/kg body weight of Rabies Immune Globulin (RIG), infiltrating around the wound
• For previously unvaccinated individuals, administer 5 doses of rabies vaccine on days 0,3,7,14, and 28 1
• Never delay rabies PEP while waiting for animal testing results if indicated 1

Follow-up and Monitoring

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

Special Considerations

• Hand bites: Consider consultation with a hand specialist if joint spaces or tendons are involved 1
• Children: Most dog bite victims are children, with bites commonly on the head and neck 3, 6
• Adults: Usually present with bites on extremities and hands 3

Potential Complications

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

Dog bites require prompt attention and proper management to prevent infection and other complications. The comprehensive approach outlined above addresses both immediate wound care and prevention of potential long-term consequences.