What is the proper treatment for a dog bite?

Dog Bite Treatment

Immediate Wound Management

All dog bite wounds require immediate and thorough irrigation with soap and water followed by copious irrigation with sterile normal saline or dilute povidone-iodine solution, as this is the single most critical intervention to prevent both infection and rabies transmission. 1, 2

• Gentle irrigation using a 20-mL or larger syringe should be performed to adequately cleanse the wound without damaging tissue 3
• Careful debridement of devitalized tissue should be performed while preserving as much viable tissue as possible, especially for facial wounds 3
• Assess for potential nerve, tendon, or bone involvement, which may require specialized repair 3, 2

Wound Closure Decision

Facial lacerations should receive primary closure after thorough cleaning and debridement due to the rich vascular supply and cosmetic importance, unlike other body locations. 3, 2

• Non-facial wounds (especially hand wounds) should generally NOT be closed primarily but may be approximated rather than fully closed to reduce infection risk 2
• Wounds presenting with active discharge should not be closed until infection is controlled 3
• Primary closure of facial wounds yields better cosmetic outcomes and the facial vascularity helps prevent infection 3

Antibiotic Therapy

Amoxicillin-clavulanate 875/125 mg twice daily is the first-line antibiotic for dog bite wounds, providing essential coverage against Pasteurella multocida (present in 50% of dog bites), staphylococci, streptococci, and anaerobes. 3, 2

Indications for Prophylactic Antibiotics:

• All facial wounds 3
• Hand or foot wounds 2
• Puncture wounds (especially with bone, tendon, or joint penetration) 4
• Wounds requiring primary closure 4
• Moderate to severe wounds 4
• Presentation >8 hours after injury 2
• Immunocompromised, asplenic, or advanced liver disease patients 2

Duration and Alternatives:

• Prophylactic therapy: 3-5 days 3, 2
• Extended therapy (2-4 weeks) if complications like osteomyelitis or septic arthritis develop 3
• For penicillin-allergic patients: doxycycline 100 mg twice daily 3

Tetanus Prophylaxis

Administer tetanus toxoid if vaccination is not current within the past 5 years for dirty wounds like dog bites. 3

• Tdap is preferred over Td if not previously given 3

Rabies Risk Assessment and Prophylaxis

If the dog is healthy and domestic, confine and observe for 10 days without starting rabies prophylaxis; if the dog cannot be observed, is stray, or shows concerning behavior, initiate rabies post-exposure prophylaxis immediately. 1, 2

Rabies PEP Regimen for Previously Unvaccinated Persons:

• One dose of rabies immunoglobulin (HRIG) at presentation (infiltrated around the wound when feasible) 1
• Rabies vaccine on days 0,3,7,14, and 28 1
• Vaccine should be administered intramuscularly in the deltoid area for adults; anterolateral thigh is acceptable for children 1
• Never use the gluteal area for vaccine administration as it results in lower antibody titers 1

Previously Vaccinated Persons:

• Receive only vaccine (no immunoglobulin) on days 0 and 3 1

Circumstances Requiring Rabies Consideration:

• Unprovoked attacks are more likely to indicate rabies than provoked attacks 1
• Consult local health officials to determine rabies risk in your area 3, 2
• A fully vaccinated dog or cat is unlikely to become infected with rabies, though rare cases have been reported 1

Follow-up Care

All patients must be seen within 48-72 hours to assess for signs of infection and evaluate wound healing progress. 2

• Monitor for increasing pain, redness, swelling, or purulent discharge 3
• Elevate the injured area to reduce swelling 3

Critical Pitfalls to Avoid

• DO NOT close non-facial wounds primarily, especially hand wounds 2
• DO NOT use first-generation cephalosporins, macrolides, or clindamycin alone - they have poor activity against Pasteurella multocida 3, 2
• DO NOT rely on topical antibiotics alone - they are inadequate for bite wounds and cannot address the polymicrobial flora 3
• DO NOT close infected wounds - primary closure should only be performed on clinically uninfected wounds after thorough cleaning 3
• DO NOT delay wound irrigation - inadequate irrigation and debridement significantly increases infection risk 3
• DO NOT fail to consider rabies prophylaxis - it should be evaluated for all dog bites based on local epidemiology and animal observation status 3, 2