What are the follow-up management steps for a dog bite?

Dog Bite Management Follow-up

Follow-up management of dog bite wounds should include antibiotic therapy for 3-5 days for high-risk patients, tetanus prophylaxis if not vaccinated within 10 years, rabies prophylaxis consultation with local health officials, and appropriate wound care based on location and severity. 1

Antibiotic Management

• Preemptive antimicrobial therapy for 3-5 days is recommended for patients who are immunocompromised, asplenic, have advanced liver disease, have edema of the affected area, have moderate to severe injuries (especially to the hand or face), or have injuries that may have penetrated the periosteum or joint capsule 1
• Amoxicillin-clavulanate is the preferred antibiotic as it provides coverage against both aerobic and anaerobic bacteria commonly found in dog bite wounds 1
• Alternative oral options include:
  • Doxycycline (100 mg twice daily) - excellent activity against Pasteurella multocida 1
  • Fluoroquinolones (with additional anaerobic coverage) 1
  • For patients unable to take oral medications, IV options include ampicillin-sulbactam, piperacillin-tazobactam, second-generation cephalosporins, or carbapenems 1

Wound Management

• Primary closure is generally not recommended for dog bite wounds except for facial wounds 1
• Facial wounds should receive:
  • Copious irrigation with sterile normal saline 1
  • Cautious debridement of devitalized tissue 1
  • Preemptive antibiotics 1
  • Primary closure for optimal cosmetic results 2, 3
• Non-facial wounds may be approximated rather than fully closed 1
• Wounds treated within 8 hours of injury show significantly lower infection rates (4.5%) compared to those treated after 8 hours (22.2%) 3

Tetanus Prophylaxis

• Tetanus toxoid should be administered to patients without vaccination within the past 10 years 1
• Tetanus, diphtheria, and pertussis (Tdap) is preferred over Tetanus and diphtheria (Td) if the former has not been previously given 1

Rabies Prophylaxis

• Consultation with local health officials is recommended to determine if rabies post-exposure prophylaxis should be initiated 1
• If indicated, rabies prophylaxis should include both rabies immunoglobulin and vaccine for previously unvaccinated individuals 1
• Rabies post-exposure prophylaxis is a medical urgency, not an emergency, but decisions should not be delayed regardless of the time since exposure 1

Follow-up Evaluation

• All patients should be seen in follow-up within 48-72 hours to:
  • Assess for signs of infection (increasing pain, erythema, swelling, purulent discharge) 1
  • Evaluate wound healing progress 1
  • Consider additional wound care if needed 1
• Patients should be instructed to return sooner if signs of infection develop 1

Special Considerations

• Hand wounds require special attention due to higher risk of infection and functional complications 1
• Deep wounds near joints or bones should be evaluated for potential penetration of periosteum or joint capsule 1
• Immunocompromised patients require more aggressive follow-up due to higher infection risk 1

Potential Complications

• Infectious complications include cellulitis, abscess formation, septic arthritis, osteomyelitis, and rarely bacteremia 1
• Non-infectious complications include nerve or tendon injury, compartment syndrome, post-traumatic arthritis, and scarring 1
• Pain disproportionate to the wound severity near a bone or joint may suggest periosteal penetration 1

Remember that while prophylactic antibiotics reduce infection risk (relative risk 0.56), good local wound care remains the most important factor in preventing infection 4, 5.