What is the proper treatment for a dog bite in an urgent care setting?

Treatment of Dog Bites in an Urgent Care Setting

Dog bite wounds should be managed with thorough wound cleansing, irrigation, appropriate antibiotic therapy with amoxicillin-clavulanate, tetanus prophylaxis if needed, and consideration of rabies post-exposure prophylaxis based on the circumstances of the bite. 1, 2

Initial Wound Management

• Perform copious irrigation with sterile normal saline using a 20-mL or larger syringe or a 20-gauge catheter to reduce bacterial load and remove debris 2, 3
• Carefully debride devitalized tissue while preserving viable tissue, especially important for facial wounds 2
• Explore the wound for potential tendon or bone involvement and possible foreign bodies 4
• Assess neurovascular function (pulses, sensation) and range of movement of adjacent joints 3

Wound Closure Considerations

• Facial wounds should receive primary closure after thorough cleaning and debridement for optimal cosmetic results due to the rich vascular supply of the face 2
• Non-facial wounds may be approximated rather than fully closed, especially if presenting >8 hours after injury 1
• Hand wounds require special attention due to higher risk of infection and functional complications 1
• Avoid primary closure for heavily contaminated wounds or those located on the hand 5

Antibiotic Therapy

• Amoxicillin-clavulanate (875/125 mg twice daily for adults) is the preferred antibiotic as it provides coverage against both aerobic and anaerobic bacteria commonly found in dog bite wounds 1, 2, 3
• Preemptive antibiotic therapy for 3-5 days is recommended for:
  • Immunocompromised patients
  • Asplenic patients
  • Patients with advanced liver disease
  • Wounds with edema
  • Moderate to severe injuries
  • Injuries that may have penetrated periosteum or joint capsule
  • Hand wounds 1
• Alternative options for penicillin-allergic patients include:
  • Doxycycline (100 mg twice daily), which has excellent activity against Pasteurella multocida
  • Fluoroquinolones with additional anaerobic coverage 1, 2
• For patients unable to take oral medications, IV options include ampicillin-sulbactam, piperacillin-tazobactam, second-generation cephalosporins, or carbapenems 1

Tetanus Prophylaxis

• Administer tetanus toxoid to patients without vaccination within the past 10 years 1
• For dirty wounds, tetanus prophylaxis is recommended if vaccination is not current within the past 5 years 2
• Tetanus, diphtheria, and pertussis (Tdap) is preferred over Tetanus and diphtheria (Td) if the former has not been previously given 1

Rabies Prophylaxis

• Consult with local health officials to determine if rabies post-exposure prophylaxis should be initiated 1, 2
• A healthy dog that bites a person should be confined and observed daily for 10 days; rabies vaccine administration is not recommended during this observation period 6
• If rabies prophylaxis is indicated, it should include both rabies immunoglobulin and vaccine for previously unvaccinated individuals 1, 2
• Bites that do not break the skin generally do not require rabies post-exposure prophylaxis 3

Follow-up Care

• All patients should be seen in follow-up within 48-72 hours to assess for signs of infection and evaluate wound healing progress 1
• Monitor for signs of infection, including increasing pain, redness, swelling, or purulent discharge 2
• Extended antibiotic therapy (2-4 weeks) may be necessary if complications such as osteomyelitis or septic arthritis develop 2

Common Pitfalls to Avoid

• Inadequate irrigation and debridement increases infection risk 2
• Delaying primary closure of facial wounds can lead to poorer cosmetic outcomes 2
• Using first-generation cephalosporins, macrolides, or clindamycin alone has poor activity against Pasteurella multocida commonly found in dog bites 2
• Failing to consider rabies prophylaxis for all dog bites, especially from unknown or unvaccinated animals 2
• Overlooking the need for tetanus prophylaxis 2