What are the proper steps for cleaning and treating a dog bite wound in a patient with a compromised immune system or at high risk of infection, such as diabetes?

Dog Bite Wound Washing and Management

Immediately and thoroughly wash all dog bite wounds with soap and water, followed by irrigation with sterile saline or tap water, and consider adding a virucidal agent such as povidone-iodine solution—this wound cleansing is the single most critical intervention for preventing infection and rabies transmission. 1

Immediate Wound Cleansing Protocol

Primary Irrigation Technique

• Use copious irrigation with sterile normal saline or running tap water to remove debris, foreign matter, and bacterial contamination from the wound 1, 2
• Apply irrigation using a 20-mL or larger syringe to generate adequate pressure for effective cleansing without forcing bacteria deeper into tissues 1, 2
• Avoid high-pressure irrigation that may spread bacteria into deeper tissue layers 1

Antiseptic Agents

• Add povidone-iodine solution to the irrigation as a virucidal agent, which is particularly important for rabies prevention 1
• Tap water irrigation is reasonable and produces similar infection rates compared to sterile saline, making it acceptable when sterile solutions are unavailable 1
• Povidone-iodine in addition to irrigation does not demonstrate significant benefit over irrigation alone for preventing bacterial infection, but remains recommended for its virucidal properties against rabies 1

Debridement Considerations

• Perform cautious debridement of devitalized tissue only, preserving as much viable tissue as possible, especially for facial wounds where cosmetic outcomes matter 2
• Remove obvious debris and foreign matter during the cleansing process 1

Special Considerations for High-Risk Patients

Immunocompromised and Diabetic Patients

• These patients require immediate medical facility evaluation due to substantially increased infection risk 1
• Broad-spectrum antibiotics effective against aerobic and anaerobic organisms are mandatory for patients with compromised immune status, severe comorbidities, or systemic signs of infection 1
• Amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days is the first-line prophylactic antibiotic, covering Pasteurella multocida, Staphylococcus aureus, Streptococcus species, and anaerobes 2, 3

Alternative Antibiotics for Penicillin Allergy

• Doxycycline 100 mg twice daily has excellent activity against Pasteurella multocida 2
• Avoid first-generation cephalosporins, macrolides, or clindamycin alone as they have poor activity against Pasteurella multocida, which is present in 20-25% of dog bite infections 2, 4

Additional Essential Interventions

Tetanus Prophylaxis

• Administer tetanus prophylaxis if vaccination is not current within the past 5 years for contaminated wounds like dog bites 2
• Tdap is preferred over Td if not previously given 2

Rabies Assessment

• Consult local health officials immediately to determine if rabies post-exposure prophylaxis is indicated 2
• If the dog is stray, unwanted, or cannot be observed, consider euthanasia and rabies testing 1
• For previously unvaccinated persons exposed to suspected rabid animals, administer both rabies immune globulin (RIG) and vaccine 1
• RIG dose is 20 IU/kg body weight, with as much as anatomically feasible infiltrated around and into the wound, and remaining volume given intramuscularly at a site distant from vaccine administration 1

Wound Closure Decisions

• Do not routinely close dog bite wounds, as this increases infection risk 1
• Facial wounds are the explicit exception—primary closure after thorough cleansing is recommended due to rich vascular supply and cosmetic importance 2
• If discharge or infection is already present, do not close the wound until infection is controlled 2

Critical Pitfalls to Avoid

• Never delay wound cleansing—animal studies demonstrate that thorough wound cleansing alone markedly reduces rabies likelihood 1
• Do not use inadequate irrigation volume or pressure, as this fails to remove bacterial contamination 1, 2
• Never rely on topical antibiotics alone for dog bite wounds—they cannot address the polymicrobial flora and are explicitly inadequate 2
• Do not close infected wounds or wounds with purulent discharge 2
• Avoid suturing hand wounds even after cleansing, as these carry particularly high infection risk 5
• Do not forget to evaluate for rabies risk in every dog bite case, regardless of how minor the wound appears 1, 2

Follow-Up Monitoring

• Monitor closely for signs of infection including increasing pain, redness, swelling, purulent discharge, or fever 1, 2
• Elevate the injured area to reduce swelling and accelerate healing 2
• Extend antibiotic therapy to 2-4 weeks if complications such as osteomyelitis, septic arthritis, or perichondritis develop 2
• Arrange follow-up within 24 hours for high-risk wounds, especially facial injuries 2