From the Guidelines
For a fish hook puncture wound treated in the emergency department, I recommend empiric antibiotic therapy with amoxicillin-clavulanate 875/125 mg orally twice daily for 5-7 days. This recommendation is based on the guidelines for the diagnosis and management of skin and soft tissue infections, which suggest that amoxicillin-clavulanate is a suitable option for treating infections following animal or human bites 1. Although the guidelines do not specifically address fish hook puncture wounds, the principles of treating skin and soft tissue infections can be applied to this type of injury.
The choice of amoxicillin-clavulanate is due to its broad-spectrum activity against various bacteria, including streptococci, staphylococci, and anaerobes, which can be introduced into the wound through the fish hook injury. Alternative options, such as trimethoprim-sulfamethoxazole (TMP-SMX) or doxycycline, may also be considered, but amoxicillin-clavulanate is generally recommended as the first-line treatment 1.
It is essential to note that the wound should be thoroughly cleaned, and tetanus prophylaxis should be administered if the patient's immunization status is not up to date. Patients should be instructed to keep the wound clean and dry, watch for signs of infection, and seek follow-up care if these symptoms develop or if the wound doesn't improve within 48 hours. Deep or complicated wounds may require longer courses of antibiotics or intravenous therapy.
In terms of specific antibiotic regimens, the guidelines suggest that amoxicillin-clavulanate 875/125 mg bid is a suitable option for treating skin and soft tissue infections 1. Other options, such as cephalexin 500 mg four times daily with metronidazole 500 mg three times daily, may be considered for patients with penicillin allergy. However, amoxicillin-clavulanate remains the recommended first-line treatment due to its broad-spectrum activity and efficacy in treating skin and soft tissue infections 1.
From the Research
Antibiotic Prescriptions for Fish Hook Puncture Wounds
- The choice of antibiotic for a fish hook puncture wound that was removed in the ED is not universally agreed upon, with different studies suggesting various options 2, 3, 4, 5, 6.
- A case report published in 2024 suggested the use of levofloxacin for a catfish spine puncture wound 2.
- A prospective study from 1991 found that routine systemic antibiotic prophylaxis is not necessary for uncomplicated soft tissue injury due to fishhooks not involving cartilage or tendons 3.
- A case report from 2014 recommended the use of prophylactic antibiotics suitable for treatment of Aeromonas species, such as those found in freshwater environments, to prevent complications 4.
- A retrospective analysis published in 2025 found that prophylactic antibiotic use did not change patient outcome, regardless of fishhook location or presence of an immunocompromising condition, with cephalexin being the most commonly prescribed antibiotic 5.
- A prospective observational study from 2018 suggested that amoxicillin and clavulanic acid is an adequate first-line antibiotic for fish spike injuries, but that flucloxacillin may be more appropriate given that most bacteria were from patients' own skin flora 6.
Considerations for Antibiotic Choice
- The type of fishhook and the location of the wound may influence the choice of antibiotic 3, 5.
- The presence of immunocompromising conditions, such as diabetes, may also affect the decision to prescribe antibiotics 5.
- The risk of infection with marine-specific pathogens, such as Aeromonas hydrophila, should be considered when choosing an antibiotic 4, 6.