What treatment should be given to a patient bitten by a cat with an unknown rabies status, who has swelling despite antibiotics, a clean wound, and whose last Tetanus Toxoid (TT) vaccination was more than 10 years ago?

Management of Cat Bite with Swelling Despite Antibiotics

Give TT (Tdap preferred) and observe the cat for 10 days. 1

Tetanus Prophylaxis

Since the last tetanus vaccination was more than 10 years ago and this is a contaminated wound (cat bite), administer tetanus toxoid immediately. 1, 2

• Cat bites are classified as contaminated wounds, which triggers the 5-year interval rule rather than the 10-year rule for tetanus boosters. 1, 3
• The CDC strongly prefers Tdap over Td if the patient has not previously received Tdap or Tdap history is unknown, as this provides additional protection against pertussis. 1, 3
• TIG is NOT required for patients with documented complete primary vaccination series (≥3 doses), even with contaminated wounds. 1, 3, 2
• The FDA label confirms that for patients with ≥3 previous doses, only tetanus toxoid is needed if >5 years since last dose for contaminated wounds—no TIG required. 2

Rabies Management

Observe the cat for 10 days for signs of rabies—this is the standard approach for domestic cat bites. 1

• The CDC recommends observing the cat for 10 days as the standard approach for domestic cat bites. 1
• The WHO states that rabies post-exposure prophylaxis is only initiated if:
  • The cat is unavailable for observation
  • The cat develops signs of rabies during observation
  • The cat tests positive for rabies
  • Local health officials determine the cat is high-risk based on epidemiologic factors 1
• Do NOT give rabies vaccine or immunoglobulin immediately if the cat is available for observation. 1
• If rabies prophylaxis becomes necessary (cat unavailable or develops signs), previously unvaccinated persons require both HRIG and rabies vaccine series. 1, 4, 5

Antibiotic Management for Persistent Swelling

Since swelling persists despite antibiotics, reassess wound management and antibiotic coverage. 1

• The IDSA recommends amoxicillin-clavulanate as first-line antibiotic for cat bites, covering Pasteurella multocida and other aerobic/anaerobic bacteria. 1
• The CDC suggests that persistent swelling despite appropriate antibiotics indicates:
  • Inadequate wound irrigation and debridement
  • Resistant organisms requiring culture-guided therapy
  • Deep space infection or abscess requiring surgical drainage 1
• The ACEP recommends immediate wound management with copious irrigation using water or dilute povidone-iodine solution, with cautious debridement. 1

Clinical Algorithm Summary

1. Administer Tdap immediately (or Td if Tdap previously received) 1, 2
2. Arrange 10-day observation of the cat for rabies signs 1
3. Optimize wound care: copious irrigation, debridement if needed 1
4. Ensure appropriate antibiotic coverage with amoxicillin-clavulanate 1
5. Consider surgical evaluation if deep space infection or abscess suspected 1
6. Initiate rabies PEP only if cat becomes unavailable, develops rabies signs, or tests positive 1

Critical Pitfalls to Avoid

• Do not give TIG for tetanus prophylaxis in patients with complete primary vaccination series (≥3 doses)—this is the most common error. 1, 3, 2
• Do not confuse the 10-year routine booster interval with the 5-year interval for contaminated wounds. 1, 3
• Do not initiate rabies prophylaxis if the cat is available for observation—this wastes resources and exposes patients to unnecessary interventions. 1
• Do not assume current antibiotics are adequate if swelling persists—reassess for resistant organisms or surgical complications. 1