What is the recommended treatment for a healthy individual with no known allergies or immunocompromised conditions after a dog bite?

Dog Bite Management in Healthy Individuals

For a healthy individual with a dog bite, immediately irrigate the wound copiously with sterile saline, administer tetanus prophylaxis if not vaccinated within 10 years, confine and observe the dog for 10 days if available, and consider prophylactic amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days for high-risk wounds (hand injuries, puncture wounds, moderate-to-severe injuries, or wounds penetrating periosteum/joint capsule). 1, 2

Immediate Wound Management

• Perform copious irrigation with sterile normal saline using a 20-mL or larger syringe to mechanically remove bacteria and debris, as this single intervention markedly reduces rabies risk and bacterial infection 3, 4
• Debride any devitalized tissue carefully, particularly for facial wounds where cosmetic outcomes matter 1, 2
• Explore the wound for tendon or bone involvement and foreign bodies 4
• Leave most wounds open to drain or loosely approximate them at most—primary closure should be reserved for facial wounds only (after irrigation, debridement, and prophylactic antibiotics) to optimize cosmetic results 1, 2

Antibiotic Prophylaxis Decision

The Infectious Diseases Society of America provides clear criteria for when prophylactic antibiotics are warranted versus when they can be withheld:

• Administer prophylactic amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days if the patient has: 2

  • Hand injuries (higher infection risk and functional complications)
  • Puncture wounds
  • Moderate-to-severe injuries
  • Wounds that may have penetrated periosteum or joint capsule
  • Edema of the affected area

• For healthy patients with low-risk wounds (superficial lacerations not involving hands), prophylactic antibiotics may be withheld, though meta-analysis shows antibiotics reduce infection rates from 16% to approximately 9% (number needed to treat = 14) 5

• Amoxicillin-clavulanate is first-line because dog bite wounds contain an average of 5 bacterial species, with 60% having mixed aerobic-anaerobic flora, and 50% containing Pasteurella species 1

Tetanus Prophylaxis

• Administer tetanus toxoid if the patient has not received vaccination within 10 years 1
• Tdap is preferred over Td if the patient has not previously received Tdap 1, 2

Rabies Assessment

This is a critical component that must not be overlooked:

• If the dog is healthy and available for observation, confine it and observe daily for 10 days without administering rabies vaccine during the observation period 1, 2
• Do not initiate rabies post-exposure prophylaxis during the observation period if the dog remains healthy 2
• If the dog develops signs suggestive of rabies during observation, humanely euthanize it and submit the head under refrigeration for laboratory examination 3
• If the dog is stray, unwanted, or cannot be observed, consult local health officials immediately regarding rabies post-exposure prophylaxis, which consists of rabies immunoglobulin at presentation plus vaccine on days 0,3,7, and 14 3, 4
• Exposures to dogs in rabies-endemic areas outside the United States carry high risk and may warrant immediate prophylaxis initiation 3

Mandatory Follow-Up

• Schedule follow-up within 48-72 hours to assess for signs of infection and evaluate wound healing 1, 2
• Established infections typically present 8-12 hours or more after injury with serous or purulent drainage, erythema, warmth, and swelling 1

Warning Signs Requiring Immediate Re-evaluation or Hospitalization

Watch for these complications that indicate treatment failure or severe infection:

• Fever or systemic symptoms 1
• Rapidly spreading erythema or lymphangitis 1
• Abscess formation 1
• Signs of septic arthritis (joint pain, swelling, decreased range of motion) 1
• Failure to improve within 48 hours of appropriate antibiotics 1

Treatment of Established Infection

If infection develops despite prophylaxis or in patients presenting late:

• Switch from prophylactic dosing to treatment dosing: amoxicillin-clavulanate 875/125 mg twice daily for 7-10 days for uncomplicated soft tissue infection 1
• For septic arthritis: 4 weeks of antibiotics 1, 2
• For osteomyelitis: 6 weeks of antibiotics 1, 2

Common Pitfalls to Avoid

• Do not primarily close non-facial wounds—this traps bacteria and increases infection risk 1, 2
• Do not neglect hand wounds—these require special attention due to higher infection risk and potential for functional complications 2
• Do not administer rabies vaccine during the 10-day observation period if the dog is healthy and available—this wastes resources and is unnecessary 1, 2
• Do not assume domestic dogs are vaccinated against rabies—even domestic animals are often unvaccinated 4