Treatment of Squirrel Bites
Immediately wash the wound thoroughly with soap and water for 15 minutes, administer tetanus prophylaxis if needed, and initiate amoxicillin-clavulanate for infection prophylaxis, while rabies prophylaxis is generally not required for squirrel bites in the United States. 1, 2
Immediate Wound Management
Irrigate the wound copiously with soap and water for at least 15 minutes immediately after the bite – this single intervention reduces infection risk more effectively than any other measure and markedly decreases rabies transmission in animal studies. 3, 1, 4
Follow irrigation with a virucidal agent such as povidone-iodine solution if available, taking care not to damage skin or tissues. 3, 1
Avoid primary closure of the wound unless it is a facial wound requiring cosmetic consideration – infected wounds should never be closed, and non-infected wounds may be approximated with Steri-Strips rather than sutures. 2, 4
Facial wounds are an exception and may be closed primarily after meticulous irrigation and prophylactic antibiotics due to cosmetic concerns. 2, 4
Tetanus Prophylaxis
Administer tetanus toxoid 0.5 mL intramuscularly if vaccination status is outdated or unknown. 1, 2, 4
For dirty wounds, a booster is needed if more than 5 years have elapsed since the last dose; for clean wounds, a booster is needed if more than 10 years have elapsed. 2
Rabies Risk Assessment
Rabies prophylaxis is generally NOT required for squirrel bites in the United States, as small rodents including squirrels are not considered significant rabies vectors and are rarely infected with rabies. 3, 2, 4
Consultation with local health departments is necessary for regional risk assessment in exceptional circumstances where rabies exposure is suspected. 2
If rabies prophylaxis is deemed necessary after consultation, previously unvaccinated persons should receive human rabies immune globulin (HRIG) at exactly 20 IU/kg body weight as a single dose on day 0, with the full dose infiltrated around and into the wound if anatomically feasible. 1, 4
Administer rabies vaccine as a 4-dose series on days 0,3,7, and 14 in conjunction with HRIG. 1, 4
Never administer vaccine in the gluteal area, as this results in lower neutralizing antibody titers. 3, 1
Antibiotic Management
Initiate amoxicillin-clavulanate as first-line oral antibiotic therapy for prophylaxis or treatment of infected squirrel bite wounds, providing broad coverage for the polymicrobial nature of these infections including typical wound pathogens and anaerobes. 2, 4
For penicillin allergy, oral alternatives include doxycycline, fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin) plus metronidazole or clindamycin. 4, 5
Intravenous therapy with ampicillin-sulbactam or piperacillin-tazobactam is indicated for severe infections or hospitalized patients. 2, 4
Standard wound infections should be treated for 7-10 days. 2
Special Consideration: Tularemia
Consider tularemia (caused by Francisella tularensis) in the differential diagnosis if the patient develops headache, increasing pain, lymphadenitis, fever, and impaired wound healing after a squirrel bite, as squirrel-transmitted tularemia has been documented in Europe and can be life-threatening without treatment. 6, 7
Tularemia can be identified by real-time PCR assay of wound swabs or by antibody detection via ELISA if the incident dates back longer than 2 weeks. 6
If tularemia is confirmed, treat with ciprofloxacin or streptomycin (1-2 g daily in divided doses for 7-14 days until the patient is afebrile for 5-7 days). 8, 6, 7
Follow-Up and Monitoring
Elevate the injured extremity if swollen to reduce swelling and accelerate healing. 2, 4
Follow up within 24 hours by phone or office visit for all outpatients to assess for signs of infection, lymphadenitis, or systemic symptoms. 2, 4
Consider hospitalization if infection progresses despite appropriate antimicrobial therapy, deep tissue involvement is suspected, or the patient is immunocompromised. 2
Common Pitfalls
Do not delay wound irrigation while waiting for medical evaluation – immediate washing is critical. 3, 1
Do not assume rabies risk is zero without consulting local health authorities, though it is exceedingly rare for squirrels. 3, 2
Do not overlook tularemia in patients with persistent lymphadenopathy and systemic symptoms despite standard antibiotic therapy. 6, 7
Hand wounds or wounds near joints require expert evaluation for potential penetration into synovium or bone and may necessitate hospitalization and intravenous antibiotics. 2