What is the appropriate treatment and management for an adult or child with no significant medical history who has been bitten by a dog?

Dog Bite Treatment and Patient Education

For any dog bite, immediately irrigate the wound copiously with sterile normal saline, administer amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days prophylactically (or 7-10 days if infection is present), update tetanus vaccination if needed, and arrange follow-up within 48-72 hours. 1, 2, 3

Immediate Wound Management

Irrigation is the single most critical intervention to reduce both infection and rabies transmission risk. 3

• Use a 20-mL or larger syringe to deliver high-pressure irrigation with sterile normal saline, mechanically removing bacteria and debris from the wound 3
• Carefully debride any devitalized tissue, particularly for facial wounds where cosmetic outcomes matter 3
• Do NOT primarily close most dog bite wounds—leave them open to drain or loosely approximate them at most 4, 3
• Exception: Facial wounds should be copiously irrigated, cautiously debrided, treated with preemptive antibiotics, and may be primarily closed for optimal cosmetic results 4, 2
• Hand wounds and puncture wounds should never be closed due to higher infection rates 4

Antibiotic Therapy

Start amoxicillin-clavulanate immediately as it provides comprehensive coverage against the polymicrobial flora of dog bites. 1, 2, 3

Prophylactic Dosing (Uninfected Wounds)

• Amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days for patients with: 2, 3
  • Hand injuries
  • Moderate-to-severe injuries
  • Wounds that may have penetrated periosteum or joint capsule
  • Immunocompromised status, asplenia, or advanced liver disease
  • Edema of the affected area

Treatment Dosing (Established Infection)

• Amoxicillin-clavulanate 875/125 mg twice daily for 7-10 days for uncomplicated soft tissue infection 1, 3
• 4 weeks of antibiotics for septic arthritis 1, 2
• 6 weeks of antibiotics for osteomyelitis 1, 2

Alternative Regimens (β-lactam Allergy)

• Fluoroquinolone (ciprofloxacin or levofloxacin) PLUS metronidazole 4
• Moxifloxacin as a single agent 4
• Doxycycline 100 mg twice daily (excellent activity against Pasteurella multocida and anaerobes) 4, 2

Rationale for Amoxicillin-Clavulanate

Dog bite wounds contain an average of 5 bacterial species, with 60% having mixed aerobic-anaerobic flora. 1 The most common pathogens include:

• Pasteurella species (isolated from 50% of dog bites, causing rapidly developing cellulitis within 12-24 hours) 1
• Streptococci and Staphylococcus aureus 4
• Eikenella corrodens (resistant to first-generation cephalosporins, macrolides, clindamycin, and aminoglycosides) 4
• Multiple anaerobes including Fusobacterium, Prevotella, and Porphyromonas species 4

Tetanus Prophylaxis

Administer tetanus toxoid if the patient has not received vaccination within 10 years. 4, 1, 3

• Tdap is preferred over Td if the patient has not previously received Tdap 4, 1, 3
• For dirty wounds, give a booster if >5 years has elapsed since the last dose 4
• For clean wounds, give a booster if >10 years has elapsed 4
• Patients who have not completed the primary vaccine series should do so 4

Rabies Assessment and Management

If the dog is healthy and available, confine and observe it for 10 days WITHOUT administering rabies vaccine during the observation period. 1, 2, 3

• A healthy domestic dog that remains alive and healthy for 10 days after biting would not have been shedding rabies virus at the time of the bite 2
• Only begin post-exposure prophylaxis if the dog develops signs of rabies during observation (behavioral changes, paralysis, excessive salivation, aggression, neurological signs) 2
• If the dog is stray, unwanted, or cannot be observed, consult local health officials immediately regarding rabies risk 1, 2
• If signs of rabies develop, euthanize the animal immediately and submit the head for laboratory testing while simultaneously initiating PEP 2, 3

Complete Rabies PEP Regimen (If Indicated)

For previously unvaccinated individuals: 2

• Human rabies immune globulin (HRIG) 20 IU/kg on day 0 (infiltrate around/into wound, remainder IM at site distant from vaccine)
• 4-dose vaccine series on days 0,3,7, and 14

For previously vaccinated individuals: 2

• Only 2 doses of vaccine on days 0 and 3
• Do NOT give HRIG (it will suppress the anamnestic antibody response)

Mandatory Follow-Up

Schedule follow-up within 48-72 hours to assess for signs of infection and evaluate wound healing. 1, 2, 3

Warning Signs Requiring Immediate Re-evaluation or Hospitalization

• Fever or systemic symptoms 1
• Rapidly spreading erythema or lymphangitis 1
• Abscess formation 1
• Signs of septic arthritis 1
• Failure to improve within 48 hours of appropriate antibiotics 1
• Presence of serous or purulent drainage (indicates established infection requiring treatment-dose antibiotics) 1

Patient Education

Infection Prevention

• Watch for signs of infection: increasing redness, warmth, swelling, purulent drainage, fever, or red streaks extending from the wound 1
• Infections typically present 8-12 hours or more after injury, occurring in approximately 16% of dog bites 1
• Hand wounds carry higher infection risk and require closer monitoring 4, 2

Wound Care Instructions

• Keep the wound clean and dry 5
• Change dressings as directed
• Do not submerge the wound in water until cleared by your provider
• Complete the full course of antibiotics even if the wound appears to be healing 1, 3

When to Seek Immediate Care

Return immediately if you develop: 1

• Fever or chills
• Increasing pain, redness, or swelling
• Pus or foul-smelling drainage
• Red streaks extending from the wound
• Numbness or inability to move the affected area
• Any systemic symptoms

Rabies Observation Period

• If the dog is being observed, report any changes in the dog's behavior or health to your provider immediately 2, 3
• Do not handle or approach the dog during the observation period 2

Special Considerations

High-Risk Wounds Requiring Aggressive Management

• Hand wounds: Higher infection rates and risk of functional complications 2
• Deep wounds near joints or bones: Evaluate for potential penetration of periosteum or joint capsule 2, 3
• Immunocompromised patients: Require more aggressive follow-up and prophylaxis due to higher infection risk 2, 3

Potential Complications

Infectious complications: 2

• Cellulitis (most common)
• Abscess formation
• Septic arthritis
• Osteomyelitis
• Bacteremia (rare)

Non-infectious complications: 2

• Nerve or tendon injury
• Compartment syndrome
• Post-traumatic arthritis
• Scarring