How should I manage a dog bite in a patient in their 60s?

Management of Dog Bite in a Patient in Their 60s

For a dog bite in a patient in their 60s, immediately perform thorough wound irrigation with copious sterile normal saline, assess for high-risk features (hand/face location, deep puncture, immunocompromise), prescribe amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days if presenting within 24 hours with high-risk features, update tetanus if needed, confine and observe the dog for 10 days if possible, and ensure 48-72 hour follow-up. 1, 2, 3

Immediate Wound Management

Wound cleansing is your most critical intervention to prevent both infection and rabies transmission. 3

• Thoroughly irrigate the wound with copious sterile normal saline using a 20-mL or larger syringe, ideally with a 20-gauge catheter attached for adequate pressure. 3, 4
• Consider adding povidone-iodine solution to the irrigation to reduce infection risk. 3
• Carefully explore the wound for tendon or bone involvement, periosteal penetration, and foreign bodies—this is especially critical in hand wounds. 1, 3
• Remove superficial debris and debride any clearly devitalized tissue. 3

Risk Stratification for Antibiotic Prophylaxis

The decision to prescribe antibiotics depends on timing and risk factors. 2

High-Risk Features Requiring Antibiotics (if presenting within 24 hours):

Wound location criteria: 1, 2

• Hand, foot, face, or genital wounds
• Wounds near joints or that may have penetrated periosteum or joint capsule

Patient risk factors: 1, 2

• Immunocompromised status
• Diabetes mellitus
• Advanced liver disease (especially important given age)
• Asplenia
• Prosthetic joints or heart valves
• Pre-existing or resultant edema of the affected area

Critical Timing Consideration:

• If presenting ≥24 hours after the bite WITHOUT signs of infection, do NOT prescribe antibiotics—prophylactic antibiotics are only beneficial when given early (within 24 hours) for fresh wounds at high risk. 2
• If presenting ≥24 hours WITH signs of infection (erythema, warmth, purulence, swelling), treat as established infection rather than prophylaxis. 2

Antibiotic Selection

Amoxicillin-clavulanate 875/125 mg twice daily is the first-line antibiotic because it provides comprehensive coverage against the polymicrobial flora in dog bites, including Pasteurella multocida (present in 50% of dog bites), Staphylococcus aureus, Streptococcus species, and anaerobes. 1, 2, 3

Alternative Oral Options (if penicillin allergy):

• Doxycycline (excellent activity against Pasteurella multocida) 1, 2
• Moxifloxacin as monotherapy 2
• Clindamycin plus a fluoroquinolone 2

Duration:

• 3-5 days for prophylaxis in high-risk wounds 1, 2
• 7-10 days for uncomplicated established infections 2
• 3-4 weeks for septic arthritis 1
• 4-6 weeks for osteomyelitis 1

Critical Pitfall to Avoid:

Never use first-generation cephalosporins, macrolides, or penicillinase-resistant penicillins alone—they have poor activity against Pasteurella multocida. 2, 3

Wound Closure Decision

Primary closure depends on wound location: 1, 3

• Facial wounds: May receive primary closure after thorough irrigation and debridement for optimal cosmetic outcomes. 1, 3
• Non-facial wounds: Generally should NOT be closed primarily but may be approximated rather than fully closed to reduce infection risk. 1, 3
• Hand wounds: Should NOT be closed primarily due to high infection risk and potential for serious complications. 1, 3

Tetanus Prophylaxis

• Administer tetanus toxoid if the patient has not been vaccinated within the past 10 years. 1, 3
• Tdap is preferred over Td if the patient has not previously received Tdap. 1

Rabies Risk Assessment and Management

The approach depends on whether the dog can be observed: 5, 1, 3

If the dog is healthy, domestic, and can be confined:

• Confine and observe the dog for 10 days WITHOUT administering rabies vaccine to the dog during observation. 5, 1
• Do NOT start rabies post-exposure prophylaxis (PEP) in the patient immediately. 1, 3
• Monitor the dog daily for any signs of illness. 5
• Only initiate rabies PEP if the dog develops signs suggestive of rabies during the 10-day observation period. 1
• If signs develop, euthanize the dog and submit the head for rabies examination. 5, 1

If the dog is stray, unwanted, or cannot be observed:

• The dog should be euthanized immediately and the head submitted for rabies examination. 5, 1
• Initiate rabies PEP immediately while awaiting results. 1, 3
• Rabies PEP consists of one dose of rabies immunoglobulin at presentation plus rabies vaccine on days 0,3,7, and 14 for previously unvaccinated persons. 1, 3, 4

Consult local health officials to determine specific rabies risk in your area and whether PEP is indicated. 1, 3

Mandatory Follow-Up

All patients must be seen within 48-72 hours to assess for signs of infection and evaluate wound healing progress. 1, 3

Signs of infection to monitor:

• Erythema, warmth, swelling, purulence 1
• Fever or systemic symptoms 1
• Lymphangitis or lymphadenopathy 1

Serious complications requiring urgent evaluation:

• Cellulitis, abscess formation 1
• Septic arthritis, osteomyelitis 1, 2
• Tendonitis 3
• Nerve or tendon injury, compartment syndrome 1

Special Considerations for Patients in Their 60s

• Elderly patients may have decreased renal function—amoxicillin-clavulanate is substantially excreted by the kidney, so monitor renal function and adjust dosing if creatinine clearance is <30 mL/min. 6
• Older patients are more likely to have comorbidities (diabetes, liver disease, immunosuppression) that increase infection risk and warrant more aggressive antibiotic prophylaxis. 1, 2
• Consider that elderly patients may be on anticoagulation or have fragile skin, increasing bleeding and wound complications. 6

Key Pitfalls to Avoid

• Do NOT prescribe antibiotics "just in case" if presenting >24 hours without infection—this violates guidelines and promotes resistance. 2
• Do NOT close hand wounds primarily—they have the highest infection risk and serious functional complications. 1, 3, 7
• Do NOT use inadequate antibiotics (first-generation cephalosporins, macrolides alone)—they lack coverage for Pasteurella. 2, 3
• Do NOT forget rabies assessment—even domestic animals are often unvaccinated. 4
• Do NOT skip the 48-72 hour follow-up—infections often develop within this timeframe. 1, 3