What is the recommended treatment and discharge protocol for a dog bite?

Dog Bite Treatment and Discharge Protocol

The recommended treatment for dog bites includes thorough wound cleansing with normal saline 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

Initial Wound Management

• Perform copious irrigation with sterile normal saline using a 20-mL or larger syringe or a 20-gauge catheter to effectively reduce bacterial load and remove debris 1
• Carefully debride devitalized tissue while preserving viable tissue, especially important for facial wounds 1
• Examine and document neurovascular function (pulses, sensation) and range of movement of adjacent joints 2

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 1
• Non-facial wounds may be approximated rather than fully closed, especially if presenting >8 hours after injury 3, 1
• Hand wounds require special attention due to higher risk of infection and functional complications 3, 1

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 3, 1
• 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 3, 1
• Alternative options for penicillin-allergic patients include doxycycline (100 mg twice daily) and fluoroquinolones with additional anaerobic coverage 3, 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 1
• Tetanus, diphtheria, and pertussis (Tdap) is preferred over Tetanus and diphtheria (Td) if the former has not been previously given 3, 1

Rabies Prophylaxis

• 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 4, 1
• Consult with local health officials to determine if rabies post-exposure prophylaxis should be initiated 3, 1
• If rabies prophylaxis is indicated, it should include both rabies immunoglobulin and vaccine for previously unvaccinated individuals 3, 1
• Bites that do not break the skin generally do not require rabies post-exposure prophylaxis 2

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 3, 1
• Monitor for signs of infection, including increasing pain, redness, swelling, or purulent discharge 1
• Extended antibiotic therapy (2-4 weeks) may be necessary if complications such as osteomyelitis or septic arthritis develop 1

Common Pitfalls to Avoid

• Inadequate irrigation and debridement significantly increases infection risk 1
• Delaying primary closure of facial wounds can lead to poorer cosmetic outcomes 1
• Using first-generation cephalosporins, macrolides, or clindamycin alone has poor activity against Pasteurella multocida commonly found in dog bites 1
• Failing to consider rabies prophylaxis for all dog bites, especially from unknown or unvaccinated animals 1
• Overlooking the need for tetanus prophylaxis 1
• Neglecting to report animal bites as required by law in most states 5