What is the recommended management for a dog bite?

Dog Bite Management

The recommended management for dog bites includes thorough wound cleansing with copious irrigation, consideration of prophylactic antibiotics with amoxicillin-clavulanate as first-line therapy, and assessment for rabies and tetanus prophylaxis. 1

Initial Wound Management

1. Wound Cleansing and Irrigation

   • Thoroughly clean the wound with sterile normal saline
   • Perform copious irrigation with warm or room temperature potable water to remove foreign matter 1
   • Use a 20-mL or larger syringe or a 20-gauge catheter for effective irrigation 2
   • Remove superficial debris but avoid deeper debridement unless absolutely necessary 1

2. Wound Exploration and Assessment

   • Explore the wound 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 risk of infection 1
   • Consider consultation with a hand specialist if joint spaces or tendons are involved 1

3. Wound Closure

   • Do not close infected wounds 1
   • For clean wounds less than 8 hours old, approximation with Steri-Strips may be considered 1
   • Facial wounds or gaping wounds may be closed if cosmetically favorable 2
   • Primary closure results in better cosmetic appearance compared to non-closure, without increasing infection risk (mean VSS score 1.74 vs 3.05) 3

Antibiotic Therapy

1. Prophylactic Antibiotics

   • Consider prophylactic antibiotics, especially for:
     • High-risk wounds (hand wounds, puncture wounds)
     • Immunosuppressed patients 2
   • Prophylactic antibiotics reduce infection incidence (relative risk 0.56,95% CI 0.38-0.82) 4
   • First-line therapy: Amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days 1
   • This covers the polymicrobial nature of dog bite infections, including Pasteurella, Staphylococci, Streptococci, and anaerobes 1, 5

2. Alternative Regimens (for penicillin-allergic patients):

   • Doxycycline 100 mg twice daily
   • Fluoroquinolone plus metronidazole
   • Clindamycin plus TMP-SMZ 1
   • Clindamycin and a fluoroquinolone 6

Rabies and Tetanus Prophylaxis

1. Rabies Assessment

   • Assess need for rabies prophylaxis based on:
     • Vaccination status of the animal
     • Circumstances of the bite
     • Whether the animal can be observed for 10 days 1
   • Domestic animals with current rabies vaccinations should be observed for 10 days 1
   • For unknown vaccination status or stray animals, consult local health department 1

2. Rabies Prophylaxis Protocol (if indicated):

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

3. Tetanus Prophylaxis

   • Administer tetanus toxoid (0.5 mL intramuscularly) if:
     • Vaccination is outdated (>5 years)
     • Vaccination status is unknown 1
   • Tdap is preferred over Td if not previously given 1

Follow-up Care

1. 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
   • Consider hospitalization if infection progresses despite appropriate therapy 1

2. Potential Complications

   • Osteomyelitis, synovitis, nerve or tendon injury
   • Compartment syndromes, post-infectious arthritis
   • Fracture and bleeding 1

Important Considerations

• Timing is critical: Wounds treated within 8 hours of injury have significantly lower infection rates (4.5%) compared to those treated after 8 hours (22.2%) 3
• Location matters: Wounds on the head and neck generally have better outcomes regarding both infection rate and cosmetic appearance 3
• Wound size: Wounds >3 cm may have poorer cosmetic outcomes 3
• Reporting requirements: In most states, physicians are required by law to report animal bites 2

Prevention Strategies

• Avoid activities that might result in animal scratches or bites 1
• Do not allow animals to lick open cuts or wounds 1
• Consider flea control for animals to reduce risk of Bartonella infection 1
• Public education on animal safety and responsible pet ownership 6