What is the management approach for a patient presenting with a dog bite, considering potential infection risk and need for tetanus toxoid booster, antibiotic prophylaxis, and rabies post-exposure prophylaxis (PEP)?

Dog Bite Management

Immediate Wound Care

All dog bite wounds require immediate copious irrigation with sterile normal saline or dilute povidone-iodine solution using a 20-mL or larger syringe, as this markedly decreases bacterial infection risk and is especially critical for rabies prevention. 1, 2

• Perform gentle but thorough wound cleansing—studies demonstrate that proper irrigation alone significantly reduces rabies transmission risk even without other prophylaxis 3
• Explore wounds carefully for nerve or tendon lacerations, bone involvement, and foreign bodies 3, 1
• Perform cautious debridement of devitalized tissue only, avoiding enlargement of the wound that could impair closure 3, 1
• Avoid iodine- or antibiotic-containing irrigation solutions; sterile normal saline is sufficient 3

Wound Closure Decision Algorithm

Primary closure depends on anatomic location and timing:

• Facial/head wounds: Close primarily after meticulous cleaning and debridement due to rich vascular supply and cosmetic importance 3, 1, 4
• Hand wounds: Generally avoid closure as these are higher risk for serious complications including osteomyelitis and septic arthritis 3
• Other body locations: Avoid suturing when possible; use Steri-Strips for approximation with delayed primary or secondary closure 3
• Infected wounds: Never close wounds showing signs of infection 3, 4

Antibiotic Prophylaxis

Administer amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days as preemptive therapy for all dog bite wounds, particularly facial lacerations and high-risk wounds. 1, 4

• Amoxicillin-clavulanate provides essential coverage against Pasteurella multocida, Staphylococcus aureus, Streptococcus species, and anaerobes commonly found in dog bites 1, 4
• For penicillin-allergic patients, use doxycycline 100 mg twice daily due to excellent activity against P. multocida 1
• Meta-analysis shows prophylactic antibiotics reduce infection risk with relative risk of 0.56, requiring treatment of 14 patients to prevent one infection 5
• Critical pitfall: Avoid first-generation cephalosporins, macrolides, or clindamycin alone—these provide inadequate coverage against common dog bite pathogens 1, 4

Tetanus Prophylaxis

Administer tetanus toxoid 0.5 mL intramuscularly if vaccination status is outdated or unknown. 3, 1

• Update tetanus prophylaxis if not current within past 5 years for contaminated wounds 1, 4
• Use Tdap if patient has not previously received it 4

Rabies Post-Exposure Prophylaxis

Consult local health department immediately to determine rabies risk and need for prophylaxis. 3

When Rabies PEP is Indicated:

• Previously unvaccinated persons: Administer both human rabies immune globulin (HRIG) and vaccine 3, 1
• HRIG dosing: 20 IU/kg body weight, with full dose infiltrated around and into wound when anatomically feasible; remaining volume injected IM at site distant from vaccine 3, 1
• Vaccine schedule: Five 1-mL doses on days 0,3,7,14, and 28 3
• Previously vaccinated persons: Vaccine only (no HRIG) 3
• HRIG can be administered up to day 7 if not given initially; beyond day 7 it is not indicated 3
• Never administer HRIG in same syringe or anatomic site as first vaccine dose 3

Rabies Risk Assessment:

• Consider for all feral and wild animal bites 3
• Healthy domestic dogs can be confined and observed for 10 days; if animal remains healthy, rabies prophylaxis is not needed 3
• Stray or unwanted animals should be euthanized and tested immediately 3
• Unprovoked attacks are more likely to indicate rabid animal 3

High-Risk Wound Complications

Monitor for pain disproportionate to injury near bone or joint, suggesting periosteal penetration, osteomyelitis, or septic arthritis. 3

• Hand wounds carry higher risk for serious complications requiring prolonged therapy 3
• Osteomyelitis requires 4-6 weeks of antibiotics 3, 1
• Septic arthritis requires 3-4 weeks of antibiotics 3, 1

Follow-Up Care

Evaluate patients within 24 hours by phone or office visit. 3, 1

• Elevate injured area using passive methods (sling for outpatients, tubular stockinet with IV pole for inpatients) 3, 1
• Monitor for infection signs: increasing pain, redness, swelling, or purulent discharge 1, 4
• Consider hospitalization if infection progresses despite appropriate therapy 3
• Single initial dose of parenteral antimicrobial may be given before starting oral therapy 3

Critical Pitfalls to Avoid

• Inadequate irrigation: This is the single most important preventive measure and significantly increases infection risk when omitted 1, 4
• Wrong antibiotic selection: First-generation cephalosporins, macrolides, or clindamycin alone have poor activity against P. multocida 1, 4
• Closing infected wounds: Only close clinically uninfected wounds after thorough preparation 3, 4
• Excessive HRIG dosing: Do not exceed 20 IU/kg as this can suppress active antibody production 3
• Delaying rabies consultation: Contact local health department immediately for all dog bites to assess rabies risk 3, 1