What is the recommended treatment for a dog bite?

Dog Bite Treatment

The recommended treatment for dog bites includes thorough wound cleansing with copious irrigation, assessment for rabies risk, 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. Clean and irrigate the wound thoroughly:

   • Use warm or room temperature potable water in large volumes 1
   • Consider povidone-iodine solution as a virucidal agent 1
   • Use a 20-mL or larger syringe with a 20-gauge catheter for irrigation 2

2. Wound exploration:

   • Examine for tendon or bone involvement 2
   • Check for foreign bodies 2
   • Remove superficial debris but avoid deeper debridement unless necessary 1

3. Wound closure considerations:

   • Facial wounds may be closed primarily after thorough cleaning with prophylactic antibiotics 1
   • Consider Steri-Strips for other wounds or leave open 1
   • Avoid suturing wounds >8 hours old (except facial wounds) 1
   • Puncture wounds and closed wounds have significantly higher infection rates (OR 4.1 and 3.1 respectively) 3

Antibiotic Prophylaxis

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

Antibiotic prophylaxis is particularly important for:

• Hand or face bites
• Deep puncture wounds
• Immunocompromised patients
• Wounds with significant tissue damage 1

For penicillin-allergic patients, consider:

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

The meta-analysis of randomized trials shows that prophylactic antibiotics reduce infection incidence with a relative risk of 0.56 (95% CI, 0.38 to 0.82) 4. About 14 patients need to be treated to prevent one infection.

Rabies Post-Exposure Prophylaxis (PEP)

1. Risk assessment:

   • Assess vaccination status of the dog
   • Evaluate if attack was provoked or unprovoked (unprovoked attacks more likely to indicate rabies) 1
   • Consider geographic location (higher risk along US-Mexico border and areas with wildlife rabies) 1

2. Management approach:

   • A healthy domestic dog should be confined and observed for 10 days 1
   • If the dog remains healthy during this period, it was not shedding rabies virus at the time of the bite 1

3. PEP regimen if indicated:

   • For previously unvaccinated individuals: 5 doses of rabies vaccine on days 0,3,7,14, and 28 1
   • Administer Rabies Immune Globulin (RIG) at 20 IU/kg body weight, infiltrating around and into the wound 1
   • For previously vaccinated individuals: vaccine alone without RIG 1

Tetanus Prophylaxis

• Administer tetanus toxoid if vaccination is outdated (>5 years) or status is unknown 1
• Tetanus, diphtheria, and pertussis (Tdap) is preferred over Tetanus and diphtheria (Td) if the former has not been previously given 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 are at higher risk of infection and complications, particularly over joints or tendons 1
• Consider consultation with a hand specialist if joint spaces or tendons are involved 1
• Potential complications include osteomyelitis, synovitis, nerve or tendon injury, compartment syndromes, post-infectious arthritis, fracture, and bleeding 1

Common Pitfalls to Avoid

1. Inadequate wound irrigation - ensure copious irrigation with appropriate pressure
2. Failing to consider rabies risk - always assess need for rabies prophylaxis
3. Inappropriate antibiotic selection - dog bites are polymicrobial and require broad-spectrum coverage
4. Closing high-risk wounds - puncture wounds and hand wounds should generally be left open
5. Neglecting tetanus status - always verify and update tetanus immunization as needed