What is the recommended treatment for a stray cat scratch?

Treatment for a Stray Cat Scratch

Immediately wash the scratch thoroughly with soap and water, apply a topical antibiotic, cover with a clean dressing, ensure tetanus is up to date, and monitor closely for signs of infection or cat scratch disease—but do not routinely start antibiotics unless infection develops. 1

Immediate Wound Care (First Priority)

• Irrigate the wound immediately and thoroughly with copious amounts of soap and water to reduce bacterial load and prevent both bacterial infection and Bartonella henselae transmission 2, 1
• Use high-volume irrigation (100-1000 mL of tap water), which is more effective than lower volumes at reducing infection rates 1
• Povidone-iodine solution can be added as a virucidal agent, particularly important for stray animal exposures where rabies risk exists 2

Post-Cleaning Wound Management

• Apply a topical antibiotic ointment to keep the wound moist and promote faster healing 1
• Cover with a clean occlusive dressing, which significantly shortens healing time compared to leaving wounds open 1
• Change dressings daily and inspect for signs of infection 1

Tetanus and Rabies Considerations

• Verify and update tetanus immunization status as indicated 3
• For stray cat scratches specifically, rabies risk assessment is critical: if the cat cannot be observed for 10 days or tested, rabies postexposure prophylaxis with both rabies immune globulin (RIG) and vaccine series should be initiated immediately 2
• The stray status makes this a high-risk exposure since the animal's vaccination status is unknown and observation is typically not possible 2

Antibiotic Therapy Decision

Do not routinely prescribe antibiotics for uncomplicated cat scratches 2, 1, 4, 5. This is a critical point where clinical practice often diverges from evidence:

• Most cat scratch disease cases in immunocompetent hosts are self-limited and resolve without antibiotics 4, 5
• Only 12.5% of clinicians correctly choose monitoring over antibiotics for uncomplicated cases, despite this being the guideline recommendation 6
• Reserve antibiotics for documented infection or high-risk scenarios 2, 1

When to Prescribe Antibiotics

If cat scratch disease develops (lymphadenopathy appearing 1-3 weeks after scratch):

• Azithromycin is the first-line treatment 2
• For patients >45 kg: 500 mg on day 1, then 250 mg daily for 4 additional days 2
• For patients <45 kg: 10 mg/kg on day 1, then 5 mg/kg daily for 4 additional days 2
• This is the only antibiotic with placebo-controlled evidence showing benefit (80% lymph node regression at 30 days, P=0.02) 2

Alternative antibiotics if azithromycin is contraindicated (based on lower-quality evidence):

• Rifampin (87% efficacy in retrospective study) 7
• Ciprofloxacin (84% efficacy) 7
• Trimethoprim-sulfamethoxazole (58% efficacy) 7
• Gentamicin IM (73% efficacy, reserve for severe cases) 7, 8

Red Flags Requiring Immediate Medical Evaluation

Seek urgent medical attention if any of the following develop:

• Increasing redness, swelling, warmth, or pain around the wound 1
• Red streaks extending from the wound (lymphangitis) 1
• Fever or systemic symptoms 1, 3
• Lymph node enlargement (typically appears 1-3 weeks post-scratch) 1, 4
• Immunocompromised status (risk of bacillary angiomatosis) 1, 4

Common Pitfalls to Avoid

• Do not allow cats to lick the wound, as saliva is the primary vector for Bartonella transmission 3
• Do not close or suture cat scratches if any signs of infection are present, as this promotes abscess formation 3
• Do not prescribe antibiotics reflexively—71.4% of clinicians incorrectly prescribe antibiotics for uncomplicated cases when monitoring is appropriate 6
• Do not dismiss stray cat exposures without rabies assessment—this is the most critical mortality risk and requires immediate action if the animal cannot be observed 2

Special Considerations for Stray Cats

• Stray cats have higher rates of Bartonella infection and unknown rabies vaccination status 2
• If the stray cat cannot be captured for 10-day observation, initiate rabies postexposure prophylaxis immediately 2
• Flea control in cats reduces Bartonella transmission risk, but this is obviously not applicable to stray exposures 1