What is the recommended management for a dog bite?

Dog Bite Management

Immediate Wound Care

All dog bite wounds require immediate copious irrigation with sterile normal saline or dilute povidone-iodine solution using a 20-mL or larger syringe, followed by careful debridement of devitalized tissue—this is the single most important intervention to prevent infection and reduce rabies risk. 1

• Gentle irrigation is critical; avoid high-pressure irrigation as it may force bacteria deeper into tissue planes 1
• Explore wounds for tendon or nerve laceration, bone involvement, and foreign bodies 1, 2
• Avoid suturing most wounds when possible, as closure increases infection risk 1

Exception for Facial Wounds

• Facial lacerations should receive primary closure after thorough irrigation and debridement due to superior cosmetic outcomes and the face's rich vascular supply that reduces infection risk 1, 2, 3
• Facial wounds require meticulous technique with tissue preservation 3

Antibiotic Management

Preemptive antibiotic therapy for 3-5 days is indicated for high-risk wounds: hand/foot/face/genital locations, deep wounds, wounds near joints or bones, puncture wounds, immunocompromised patients, asplenic patients, those with advanced liver disease, or wounds with significant edema. 1, 2

First-Line Antibiotic

• Amoxicillin-clavulanate (875/125 mg twice daily) is the preferred agent, providing coverage against Pasteurella multocida (present in 50% of dog bites), Staphylococcus, Streptococcus, and anaerobes 1, 2, 3

Alternative Oral Options

• Doxycycline 100 mg twice daily (excellent Pasteurella coverage) 1, 2, 3
• Fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin) plus metronidazole or clindamycin for anaerobic coverage 1

Intravenous Options (for severe infections)

• Ampicillin-sulbactam, piperacillin-tazobactam, second-generation cephalosporins (cefoxitin), or carbapenems (ertapenem, imipenem, meropenem) 1, 2

Critical Pitfall to Avoid

• Never use first-generation cephalosporins (cephalexin), penicillinase-resistant penicillins (dicloxacillin), macrolides (erythromycin), or clindamycin alone—these have poor activity against Pasteurella multocida and will fail 1, 3

Tetanus Prophylaxis

• Administer tetanus toxoid if not vaccinated within the past 5-10 years 1, 2, 3
• Tdap is preferred over Td if the patient has not previously received pertussis vaccination 2

Rabies Prophylaxis

Consult local health officials immediately to determine if rabies post-exposure prophylaxis is needed—this decision depends on the animal's vaccination status, behavior, and local rabies epidemiology. 1, 2, 3

• If indicated, administer both rabies immunoglobulin (HRIG) and vaccine on days 0,3,7, and 14 for previously unvaccinated individuals 1, 2, 3
• Previously vaccinated individuals require vaccine only (no immunoglobulin) 1
• Rabies prophylaxis is a medical urgency, not an emergency, but should not be delayed regardless of time elapsed since exposure 1

Follow-Up Care

• All patients must be evaluated within 48-72 hours to assess for infection signs: increasing pain, erythema, swelling, purulent drainage, fever, or lymphangitis 2
• Hand wounds require particularly close monitoring due to higher complication rates 1, 2
• Elevate injured extremities to reduce swelling and accelerate healing 1, 2

High-Risk Scenarios Requiring Aggressive Management

• Hand wounds have the highest infection risk and may require 4-6 weeks of antibiotics if complications develop 1, 2
• Deep wounds near joints or bones require evaluation for septic arthritis or osteomyelitis 1, 2
• Immunocompromised, asplenic, or patients with advanced liver disease are at risk for Capnocytophaga canimorsus sepsis and require immediate broad-spectrum antibiotics 1, 2

Common Infectious Complications

• Cellulitis, abscess formation (requiring incision and drainage), septic arthritis, osteomyelitis, tendonitis, and rarely bacteremia 1, 2
• Dog bite wounds yield an average of 5 bacterial species, with 60% containing mixed aerobic and anaerobic organisms 1
• Pain disproportionate to injury severity suggests periosteal penetration or deep infection 1