What is the protocol for managing a human bite?

Human Bite Management Protocol

The management of human bites requires immediate wound irrigation with copious amounts of water or saline, followed by amoxicillin-clavulanate as first-line antibiotic therapy, and consideration of tetanus prophylaxis. 1

Initial Wound Management

• Immediately irrigate the wound with copious amounts of water or saline to minimize bacterial infection risk 1
• Use gentle irrigation with water or dilute povidone-iodine solution to decrease bacterial infection risk 2
• Thoroughly clean the wound with sterile normal saline to remove superficial debris (avoid iodine or antibiotic-containing solutions directly in the wound) 1
• Use a 20-mL or larger syringe with a 20-gauge catheter for effective wound irrigation 3
• Explore the wound for potential tendon or bone involvement and possible foreign bodies 3

Wound Closure Considerations

• Do not close infected wounds; for non-infected wounds seen early (<8 hours), consider approximation with Steri-Strips rather than sutures 1
• Facial wounds are an exception and may be closed primarily after meticulous wound care, irrigation, and prophylactic antibiotics 1, 4
• Suturing should generally be avoided when possible to reduce infection risk 2
• Delay in presentation beyond 24 hours is not necessarily a contraindication to immediate repair of facial wounds, but excessive crushing or extensive edema may require delayed closure 4

Antibiotic Therapy

• Amoxicillin-clavulanate is the first-line oral antibiotic therapy for human bite wounds 1
• For patients allergic to penicillin, alternative oral therapies include:
  • Doxycycline 1
  • Penicillin VK plus dicloxacillin 1
  • Fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin) plus an anaerobic agent (metronidazole or clindamycin) 1
• For more severe infections requiring intravenous therapy, use:
  • β-lactam/β-lactamase combinations (ampicillin-sulbactam, piperacillin-tazobactam) as first-line 1
  • Second-generation cephalosporins (cefoxitin) or carbapenems (ertapenem, imipenem, meropenem) as alternatives 1

Special Considerations

• Clenched-fist injuries (fight bites) require expert hand evaluation for potential penetration into synovium, joint capsule, or bone 1
• These injuries are at higher risk of complications including septic arthritis and osteomyelitis 1, 5
• Human bites are particularly notorious due to the polymicrobial nature of human saliva inoculated in the wound 5

Tetanus and Rabies Prophylaxis

• Ensure tetanus prophylaxis is current; administer tetanus toxoid (0.5 mL intramuscularly) if outdated or unknown status 1, 2
• Although rare in human bites, consider rabies risk assessment based on the circumstances 6
• If rabies exposure is suspected, previously unvaccinated persons should receive both rabies immune globulin (HRIG) and vaccine 6
• The recommended regimen is 1 dose of HRIG and 5 doses of rabies vaccine administered on days 0,3,7,14, and 28 6

Follow-up Care

• Elevate the injured body part, especially if swollen, to accelerate healing 1
• Follow up within 24 hours either by phone or office visit for outpatients 1
• Consider hospitalization if infection progresses despite appropriate antimicrobial therapy 1
• For complicated infections (osteomyelitis, septic arthritis), extend treatment duration to 4-6 weeks for osteomyelitis and 3-4 weeks for synovitis 1
• Patient education is important for decreasing the incidence and morbidity of bite wounds 7