What is the appropriate management for a patient presenting to the emergency room (ER) with a cat bite, potentially exposed to rabies and tetanus, and possibly requiring antibiotic prophylaxis?

Management of Stray Kitten Bite with Rabies and Tetanus Risk

This patient requires immediate rabies post-exposure prophylaxis with BOTH rabies immune globulin (RIG) and rabies vaccine series, plus tetanus prophylaxis and antibiotic therapy—begin treatment urgently without delay. 1, 2

Immediate Wound Management

• Thoroughly wash and flush both hand wounds with soap and water for approximately 15 minutes immediately, as this single intervention markedly reduces rabies transmission risk even without other prophylaxis 1, 2
• Apply povidone-iodine solution or other virucidal agent to the wounds after cleansing 3, 1
• Avoid suturing the puncture wounds to prevent trapping virus in deeper tissues 1
• Evaluate for signs of infection given that cat bites create deep puncture wounds with high contamination risk 1

Rabies Post-Exposure Prophylaxis (Critical - Do Not Delay)

Since this is a stray kitten that cannot be observed and is presumed unvaccinated, begin immediate prophylaxis. Stray cats represent significant rabies risk in the United States, with more cats than dogs reported rabid during most of the 1980s 1. The animal's unavailability for 10-day observation mandates immediate treatment 1, 2.

Rabies Immune Globulin (RIG) - Day 0

• Administer 20 IU/kg body weight of RIG immediately 1, 2
• Infiltrate the full dose thoroughly into and around BOTH hand puncture wound sites—this is critical as inadequate wound infiltration has been associated with rare prophylaxis failures 1
• Any remaining volume after wound infiltration should be injected intramuscularly at a site distant from vaccine administration 1, 2
• RIG can be administered up to day 7 if not given initially, but should ideally be given immediately 1

Rabies Vaccine Series

• Administer 5 doses of rabies vaccine intramuscularly on days 0,3,7,14, and 28 3, 1, 2
• Give the vaccine in the deltoid area—never use the gluteal area 1
• Administer the vaccine at a different anatomical site than the RIG 1, 2

Tetanus Prophylaxis

• Administer tetanus toxoid (0.5 mL intramuscularly) immediately since the patient's tetanus immunization status is unknown or potentially outdated 1, 2
• For patients with unknown or incomplete tetanus vaccination history, consider tetanus immunoglobulin in addition to tetanus toxoid 2
• Note that even patients with documented vaccination can develop tetanus if prophylaxis is not administered after high-risk wounds, particularly if the last booster was more than 5 years ago 4

Antibiotic Prophylaxis

Prescribe amoxicillin-clavulanate as first-line oral antibiotic therapy for cat bite wounds, particularly for hand bites which have significantly higher infection risk 1, 5. Cat bites create deep puncture wounds with high bacterial inoculation.

• Prophylactic antibiotics are associated with statistically significant reduction in infection rates for hand bites (NNT = 4) 5
• Alternative regimens for penicillin-allergic patients include doxycycline or fluoroquinolones plus metronidazole 6
• Duration typically 3-5 days for prophylaxis 7

Critical Pitfalls to Avoid

• Do not delay prophylaxis attempting to locate the escaped stray kitten—begin treatment immediately as this is a medical urgency 1, 2
• Do not rely on the kitten's healthy appearance—rabid animals may appear normal early in infection 1
• Do not fail to infiltrate RIG directly into the wound—this is associated with prophylaxis failures 1
• Do not exceed the recommended RIG dose (20 IU/kg) as this can suppress active antibody production 1
• Do not administer RIG and vaccine in the same syringe or anatomical site 1, 2
• Do not dismiss tetanus risk even in previously vaccinated patients if prophylaxis timing is uncertain 4

Timing Considerations

• Rabies post-exposure prophylaxis is a medical urgency—begin as soon as possible after exposure 1, 2
• Even delays of months do not preclude prophylaxis if clinical rabies signs are absent, as incubation periods exceeding 1 year have been documented 3, 1
• Treatment can be discontinued only if the animal is later captured and proven negative by laboratory testing 1, 2

Follow-Up

• Arrange follow-up within 24 hours to assess for signs of wound infection 6
• Ensure completion of the full 5-dose rabies vaccine series over 28 days 3, 1, 2
• Monitor hand wounds closely as hand bites have higher complication rates including septic arthritis and osteomyelitis 5