Antibiotic Recommendations for Puncture Dog Bite Wounds
Amoxicillin-clavulanate 875/125 mg twice daily is the first-line antibiotic for puncture dog bite wounds, particularly for high-risk injuries requiring preemptive therapy. 1, 2
When to Initiate Antibiotics for Puncture Wounds
Puncture dog bite wounds warrant preemptive antibiotic therapy for 3-5 days in the following situations 1:
- Immunocompromised patients 1
- Asplenic patients (at risk for Capnocytophaga canimorsus sepsis) 1, 2
- Advanced liver disease 1
- Moderate to severe injuries, especially to the hand or face 1
- Injuries that may have penetrated the periosteum or joint capsule 1
- Preexisting or resultant edema of the affected area 1
Puncture wounds specifically carry higher infection risk than superficial lacerations and generally meet criteria for antibiotic prophylaxis. 3, 4
First-Line Antibiotic Regimen
Amoxicillin-clavulanate is the antimicrobial agent of choice because it provides activity against both aerobic and anaerobic bacteria commonly found in dog bite wounds. 1, 2
Dosing 1, 5:
- Adults: 875/125 mg orally twice daily 1
- Alternative adult dosing: 500/125 mg orally three times daily 1
- Children ≥3 months: 45 mg/kg/day divided every 12 hours (based on amoxicillin component) 5
Microbiologic Rationale 2:
- Dog bite wounds are polymicrobial with an average of 5 bacterial isolates per wound 2
- Pasteurella species isolated in approximately 50% of dog bites 2
- Staphylococci and streptococci found in approximately 40% 2
- The amoxicillin-clavulanate combination effectively addresses beta-lactamase-producing organisms 2
Alternative Regimens for Penicillin Allergy
For patients with penicillin allergy, doxycycline 100 mg twice daily is the preferred alternative, with excellent activity against Pasteurella multocida. 1, 2
Other alternatives include 1, 2:
- Fluoroquinolone plus metronidazole (e.g., ciprofloxacin or levofloxacin with metronidazole for anaerobic coverage) 2
- Moxifloxacin 400 mg daily as monotherapy (covers both aerobes and anaerobes) 2
Intravenous Options for Severe Infections
For severe infections requiring hospitalization 1, 2:
- Ampicillin-sulbactam 1.5-3.0 g every 6-8 hours 1
- Piperacillin-tazobactam 3.37 g every 6-8 hours 1
- Carbapenems (ertapenem, imipenem, meropenem) 1, 2
- Second-generation cephalosporins (e.g., cefoxitin) 2
Antibiotics to AVOID
Do not use the following as monotherapy for dog bite wounds 2:
- First-generation cephalosporins (e.g., cephalexin) - inadequate coverage of Pasteurella 2
- Penicillinase-resistant penicillins (e.g., dicloxacillin alone) 2
- Macrolides (e.g., erythromycin) 2
- Clindamycin as monotherapy 2
Essential Wound Management
Beyond antibiotics, proper wound care is critical 1, 2:
- Copious irrigation with normal saline using a 20-mL or larger syringe is essential and may significantly reduce infection risk 2, 3
- Primary wound closure is NOT recommended for puncture wounds 1, 2
- Facial wounds are an exception and may be closed after copious irrigation, cautious debridement, and preemptive antibiotics 1, 2
- Explore the wound for tendon, bone, or joint involvement 3
Additional Prophylaxis
Tetanus prophylaxis should be administered if vaccination is not current within the last 10 years (or 5 years for dirty wounds). 1, 2
Rabies postexposure prophylaxis may be indicated - consult local health officials to determine if vaccination should be initiated. 1
Critical Complications to Monitor
Hand puncture wounds warrant particular vigilance 2, 3:
- Hand wounds are often more severe than wounds to other body parts 2
- Pain disproportionate to injury severity near bone or joint suggests periosteal penetration 2
- Complications include septic arthritis, osteomyelitis, subcutaneous abscess formation, and tendinitis 2
- These complications require prolonged therapy (4-6 weeks for osteomyelitis) 2
Capnocytophaga canimorsus bacteremia can cause fatal sepsis, especially in asplenic or cirrhotic patients. 2