What is the appropriate management for a patient presenting with a dog bite, considering tetanus vaccination status, risk of infection, and potential for rabies transmission?

Dog Bite Management

Immediate Wound Care

All dog bite wounds must be immediately and thoroughly washed with soap and water for at least 15 minutes, as this single intervention reduces rabies transmission risk more effectively than any vaccine or immunoglobulin. 1

• Follow initial washing with copious irrigation using sterile normal saline under pressure 2
• Consider adding povidone-iodine solution to the irrigation to further reduce infection risk 2
• Explore the wound for tendon or bone involvement, periosteal penetration, and foreign bodies 2
• Perform meticulous debridement of devitalized tissue and wound edges 3

Wound Closure Decision Algorithm

Facial wounds should receive primary closure after thorough irrigation and debridement for optimal cosmetic outcomes. 2

• Non-facial wounds, particularly hand wounds, should NOT be closed primarily but may be approximated rather than fully closed to reduce infection risk. 2
• Heavily contaminated wounds should be left open regardless of location 4
• Wounds presenting >8 hours after injury carry higher infection risk and generally should not be closed primarily 2

Antibiotic Prophylaxis

Amoxicillin-clavulanate is the first-line antibiotic for dog bite wounds, providing coverage against Pasteurella multocida (present in 50% of dog bites), staphylococci, streptococci, and anaerobes. 5, 2

• Prophylactic antibiotics reduce infection incidence with a relative risk of 0.56 (95% CI: 0.38-0.82), requiring treatment of 14 patients to prevent one infection 6
• Mandatory antibiotic prophylaxis for: immunocompromised patients, asplenic patients, those with advanced liver disease, hand injuries, crushed tissue, and presentation >8 hours after injury 2
• Duration: 3-5 days for prophylaxis 2
• AVOID first-generation cephalosporins (cephalexin), penicillinase-resistant penicillins (dicloxacillin), macrolides (erythromycin), and clindamycin alone due to poor activity against Pasteurella multocida. 5, 2

Alternative oral regimens if amoxicillin-clavulanate is contraindicated:

• Doxycycline 5
• Fluoroquinolones (moxifloxacin, levofloxacin) PLUS metronidazole or clindamycin 5

For severe infections requiring IV therapy:

• Ampicillin-sulbactam or other β-lactam/β-lactamase combinations 5

Tetanus Prophylaxis

Administer tetanus prophylaxis to patients without vaccination within the past 10 years. 2

Rabies Risk Assessment and Post-Exposure Prophylaxis (PEP)

For Healthy Domestic Dogs:

Confine and observe the dog for 10 days without starting rabies prophylaxis if the dog is healthy, domestic, and observable. 1, 2

For Stray, Unwanted, or Unobservable Dogs:

The dog should be euthanized immediately with head submitted for rabies examination, and rabies PEP should be initiated immediately. 2

Rabies PEP Regimen for Previously Unvaccinated Persons:

Administer rabies immunoglobulin (RIG) at 20 IU/kg on day 0, infiltrating the full dose around and into the wound(s) if anatomically feasible, with any remaining volume given IM at a site distant from vaccine administration. 1

• RIG must be given within 7 days of starting vaccine; beyond day 7, it is contraindicated. 1
• NEVER administer RIG in the same syringe or anatomical site as vaccine. 1

Administer rabies vaccine on days 0,3,7, and 14 in the deltoid muscle (or anterolateral thigh in children), NEVER in the gluteal area. 1, 2

• The 4-dose schedule has replaced the older 5-dose schedule (which included day 28) with no documented failures 1

For Previously Vaccinated Persons:

Individuals with documented prior complete rabies vaccination should receive vaccine ONLY on days 0 and 3, WITHOUT RIG. 1

• RIG is contraindicated in previously vaccinated persons as it may suppress the anamnestic antibody response 1

Critical Timing Consideration:

Initiate PEP regardless of time elapsed since exposure, as incubation periods >1 year have been documented. 1

Follow-Up Care

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

Monitor for:

• Cellulitis, abscess formation 2
• Septic arthritis, osteomyelitis, tendonitis 2
• Rarely bacteremia or sepsis 2

Common Pitfalls to Avoid

• Do NOT close non-facial wounds primarily, especially hand wounds 2
• Do NOT use first-generation cephalosporins or penicillinase-resistant penicillins alone due to poor Pasteurella coverage 5, 2
• Do NOT administer rabies vaccine in the gluteal area as this results in lower neutralizing antibody titers 5
• Do NOT give RIG and vaccine in the same anatomical site 1
• Do NOT give RIG to previously vaccinated persons 1