What is the proper care for a dog bite wound?

Dog Bite Wound Care

Immediate Wound Management

The single most critical intervention is immediate and thorough wound cleansing with soap and water for approximately 15 minutes, followed by copious irrigation with sterile normal saline, as this markedly reduces both infection and rabies risk. 1, 2, 3

• Add povidone-iodine solution to the irrigation when available for additional virucidal effect 1, 2
• Explore the wound for tendon or bone involvement, periosteal penetration, and foreign bodies 2
• Remove all devitalized tissue and foreign material 4
• Assess and document neurovascular function including pulses, sensation, and range of motion of adjacent joints 4

Wound Closure Decision

Facial wounds should receive primary closure after thorough irrigation and debridement for optimal cosmetic outcomes. 2, 5

• Non-facial wounds generally should not be closed primarily but may be approximated rather than fully closed to reduce infection risk 2
• Hand wounds should specifically not be sutured due to high infection risk 6, 7
• Heavily contaminated wounds should not be closed regardless of location 6

Antibiotic Prophylaxis

Amoxicillin-clavulanate is the first-line antibiotic for all dog bite wounds, as it provides coverage against Pasteurella multocida (present in 50% of dog bites), staphylococci, streptococci, and anaerobes. 8, 2, 4, 5

• Prophylactic antibiotics reduce infection incidence with a relative risk of 0.56, preventing one infection for every 14 patients treated 9
• Antibiotic prophylaxis is particularly important for wounds presenting more than 8 hours after injury, hand injuries, immunocompromised patients, asplenic patients, and those with advanced liver disease 8, 2

Alternative Antibiotics for Penicillin Allergy

• Doxycycline 100 mg twice daily is the preferred alternative with excellent activity against Pasteurella multocida 8
• Moxifloxacin 400 mg daily as monotherapy covers both aerobes and anaerobes 8, 5
• Fluoroquinolones (ciprofloxacin, levofloxacin) plus metronidazole for anaerobic coverage 8

Antibiotics to Avoid

Do not use first-generation cephalosporins (cefalexina), penicillinase-resistant penicillins (dicloxacilina), macrolides, or clindamicina as monotherapy due to poor activity against Pasteurella multocida. 8, 2

Tetanus Prophylaxis

• Administer tetanus prophylaxis if vaccination is not current within the past 10 years 1, 2, 3

Rabies Risk Assessment

If the dog is healthy, domestic, and available for observation, confine and observe for 10 days without initiating rabies prophylaxis. 1, 2, 3

• Begin rabies post-exposure prophylaxis immediately at the first sign of rabies in the observed animal 3
• If the dog is stray, unwanted, cannot be observed, or shows signs of rabies, euthanize immediately and submit the head for rabies examination while initiating rabies prophylaxis 1, 3
• For previously unvaccinated persons, rabies post-exposure prophylaxis consists of one dose of rabies immunoglobulin (20 IU/kg body weight) infiltrated around and into the wound if anatomically feasible, plus rabies vaccine on days 0,3,7, and 14 1, 2, 3
• Rabies immunoglobulin can be administered up to day 7 if not given initially 1
• Exposures to dogs in rabies-endemic areas outside the United States carry high risk and may warrant immediate prophylaxis even if the dog appears healthy 1

Follow-up Care

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

Complications to Monitor

• Watch for cellulitis, abscess formation, septic arthritis, osteomyelitis, tendonitis, and rarely bacteremia or sepsis 8, 2
• Pain disproportionate to injury severity near a bone or joint suggests periosteal penetration 8
• Hand wounds are often more severe than wounds on other body parts 8
• Capnocytophaga canimorsus can cause fatal bacteremia and sepsis, especially in asplenic or cirrhotic patients 8
• Osteomyelitis and septic arthritis require prolonged therapy of 4-6 weeks 8