What is the recommended treatment for a dog bite?

Dog Bite Treatment

Immediate Wound Management

The single most critical intervention is immediate and thorough wound cleansing with soap and water, followed by copious irrigation with sterile normal saline, which markedly reduces the risk of both infection and rabies transmission. 1, 2

• Perform wound irrigation immediately upon presentation, using high-volume sterile normal saline or adding povidone-iodine solution as a virucidal agent 2, 3
• Explore the wound carefully for tendon or bone involvement, periosteal penetration, and foreign bodies 2
• Debride superficial devitalized tissue cautiously without enlarging the wound 3

Wound Closure Decision Algorithm

Facial wounds should receive primary closure after thorough irrigation and debridement for optimal cosmetic outcomes, ideally by a plastic surgeon. 2, 3

Non-facial wounds should NOT be closed primarily—they may be approximated but not fully sutured to reduce infection risk. 2, 4

Absolute Contraindications to Primary Closure:

• Infected wounds at presentation 3
• Puncture wounds (high risk for deep infection) 3
• Hand wounds (significantly higher infection risk) 2, 4
• Wounds in immunocompromised, asplenic, or advanced liver disease patients 3
• Wounds with pre-existing edema of the affected area 3
• Presentation >8 hours after injury (except facial wounds) 2

Antibiotic Prophylaxis

Amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days is the first-line antibiotic, providing essential coverage against Pasteurella multocida (present in 50% of dog bites), staphylococci, streptococci, and anaerobes. 2, 4, 3

Mandatory Antibiotic Prophylaxis Indications:

• Immunocompromised patients 2, 4
• Asplenic patients 2, 4
• Advanced liver disease 2, 4
• Hand injuries 2
• Moderate to severe injuries 4
• Wounds with potential periosteal or joint capsule penetration 4
• Presentation >8 hours after injury 2
• Edema of the affected area 4

Alternative Antibiotic Regimens:

• Oral alternatives: Doxycycline (excellent Pasteurella activity) or fluoroquinolones with anaerobic coverage 4
• IV options (for severe infections): Ampicillin-sulbactam, piperacillin-tazobactam, second-generation cephalosporins, or carbapenems 4

Critical Pitfall to Avoid:

Never use first-generation cephalosporins or penicillinase-resistant penicillins alone—they have poor activity against Pasteurella multocida. 2

Tetanus Prophylaxis

Administer tetanus toxoid 0.5 mL IM if the patient has not been vaccinated within the past 10 years, preferring Tdap over Td if the patient has not previously received Tdap. 2, 4, 3

Rabies Risk Assessment and Prophylaxis

For Healthy Domestic Dogs (U.S. and non-enzootic areas):

Confine and observe the dog for 10 days without initiating rabies prophylaxis. 1, 2, 4

• If the dog remains healthy during the 10-day observation period, no rabies prophylaxis is needed 1, 2
• If signs suggestive of rabies develop, euthanize the animal immediately, submit the head for examination, and initiate rabies post-exposure prophylaxis (PEP) 1, 4

For Stray, Unwanted, or Unobservable Dogs:

Euthanize the dog immediately, submit the head for rabies examination, and initiate rabies PEP without delay. 2, 4

For Exposures in Rabies-Enzootic Areas (Asia, Africa, Central/South America):

Initiate rabies PEP immediately after dog bite exposures, as dogs are the major rabies vector in these regions and >50% of U.S. rabies cases result from dog exposures abroad. 1

• Treatment can be discontinued if the dog remains healthy during the 10-day observation period 1

Rabies PEP Regimen (for previously unvaccinated persons):

Administer one dose of human rabies immunoglobulin (HRIG) at presentation plus rabies vaccine on days 0,3,7, and 14. 2

• The complete regimen consists of five 1-mL doses of vaccine given intramuscularly in the deltoid area (never the gluteal area, which produces lower antibody titers) 1
• Additional vaccine doses should be given on days 3,7,14, and 28 after the first vaccination 1
• Critical timing: Begin treatment within 24 hours when possible, though rabies PEP remains indicated even with delayed presentation, as incubation periods >1 year have been documented 1, 4

Follow-up Care

All patients must be seen within 48-72 hours to assess for signs of infection and evaluate wound healing progress. 2, 4, 3

Infectious Complications to Monitor:

• Cellulitis, abscess formation, septic arthritis, osteomyelitis, tendonitis, and rarely bacteremia or sepsis 2, 4

Treatment Duration for Established Infections:

• Septic arthritis: 4 weeks of antibiotic therapy 4
• Osteomyelitis: 6 weeks of antibiotic therapy 4
• If infection progresses despite appropriate therapy: Consider hospitalization 4

Special Considerations for High-Risk Wounds

Hand Wounds:

Hand wounds require particularly aggressive management due to higher infection risk and potential for functional complications. 2, 4

• Never close hand wounds primarily 2, 3
• Evaluate deep wounds near joints or bones for periosteal or joint capsule penetration 4
• Maintain high suspicion for deep structure injury if pain is disproportionate to the visible injury 3

Immunocompromised Patients:

Require more aggressive follow-up and mandatory antibiotic prophylaxis due to substantially higher infection risk. 4, 3

Additional Supportive Care

• Elevate the injured body part, especially if swollen, during the first few days to accelerate healing 3
• Consult local health officials to determine specific rabies risk in your geographic area 2, 4