What is the immediate management for a patient presenting with an animal bite?

Immediate Management for Animal Bite

Immediately wash the wound thoroughly with soap and water for approximately 15 minutes, as this is the single most effective measure to prevent rabies and bacterial infection. 1, 2

Step 1: Immediate Wound Care (First Priority)

• Copious irrigation with soap and water for 15 minutes is the most critical initial step and markedly reduces risk of both rabies and bacterial infection 1, 2
• Gently irrigate with water or dilute povidone-iodine solution, taking care not to damage skin or tissues 3, 1
• Avoid suturing when possible to allow drainage, particularly for puncture wounds, hand wounds, and high-risk bites 3, 1
• Explore the wound for nerve or tendon laceration and foreign bodies 3
• Facial wounds may be sutured for cosmetic reasons even in delayed presentations 4

Step 2: Assess Rabies Risk and Initiate Prophylaxis

High-Risk Animals (Immediate Prophylaxis Required):

• Wild carnivores (bats, skunks, foxes, raccoons, coyotes), primates, and unvaccinated/stray domestic animals require immediate rabies prophylaxis without waiting for observation 1, 2, 5

For Previously Unvaccinated Patients:

• Administer both human rabies immune globulin (HRIG) 20 IU/kg AND rabies vaccine simultaneously on day 0 at different anatomical sites 1, 2
• Infiltrate the full HRIG dose around and into the wound if anatomically feasible; inject any remaining volume intramuscularly at a distant site 1
• Rabies vaccine regimen: 5 doses over 28 days (days 0,3,7,14,28) 1, 2
• HRIG can be given up to day 7 if not administered initially, but NEVER after day 7 as it interferes with active immunity 1, 2

For Previously Vaccinated Patients:

• Administer vaccine only (no HRIG) in a 2-dose regimen on days 0 and 3 1, 2

Domestic Dogs/Cats/Ferrets (Observation Protocol):

• If the animal is healthy and available, confine and observe for 10 days without administering rabies vaccine during observation 3, 2
• Initiate prophylaxis immediately if the animal shows any signs of illness, is unavailable, or is a stray 3, 2
• Euthanize and test the brain if rabies signs develop during observation 3

Critical caveat: Rabies prophylaxis is a medical urgency—do not delay decisions, but it is not a medical emergency requiring immediate administration within minutes 3, 2

Step 3: Tetanus Prophylaxis

• Assess tetanus immunization status and administer booster if indicated 3, 1

Step 4: Antibiotic Prophylaxis

Indications for prophylactic antibiotics (high infection risk):

• All cat bites (twofold higher infection risk than dog bites, frequently infected with Pasteurella multocida) 6, 7
• Puncture wounds 5, 7
• Hand wounds 5, 7
• Wounds requiring closure 7
• Immunocompromised patients 7
• Delayed presentation (>8-12 hours) 3

Antibiotic choice:

• Amoxicillin-clavulanate is the first-line prophylactic antibiotic for animal bites, providing broad-spectrum coverage against Pasteurella, anaerobes, and other common pathogens 7

Step 5: Mandatory Follow-Up

• Schedule follow-up within 24-48 hours after initiating therapy to assess for infection 6
• Report animal bites to local health department (legally required in most states) 7

Common Pitfalls to Avoid

• Never delay rabies prophylaxis waiting for animal testing results if the animal is high-risk or unavailable 1, 2
• Never administer HRIG after day 7 of the vaccine series 1, 2
• Never exceed the recommended HRIG dose (20 IU/kg) as excess suppresses vaccine response 3
• Do not withhold prophylaxis based on time elapsed since exposure unless clinical rabies is present 2
• Do not suture high-risk wounds (puncture wounds, hand bites, cat bites) as this increases infection risk 3
• Prophylaxis can be discontinued only if laboratory testing (direct fluorescent antibody test) confirms the animal was not rabid 1, 2