What is the recommended treatment for a dog bite, considering wound care, infection prevention, rabies exposure, and tetanus status?

Dog Bite Management

Immediate Wound Care

All dog bite wounds must be immediately and thoroughly washed with soap and water for at least 15 minutes, as this single intervention reduces infection risk and potential rabies transmission more effectively than any other measure. 1

• After soap and water cleansing, irrigate copiously with sterile normal saline or dilute povidone-iodine solution using a 20-mL or larger syringe to remove debris and reduce bacterial load. 2, 1, 3
• Examine the wound carefully for tendon or bone involvement, joint penetration, nerve damage, and assess neurovascular function (pulses, sensation) and range of motion of adjacent joints. 1, 4
• Remove any foreign bodies and devitalized tissue during wound exploration. 4

Wound Closure Decisions

• Avoid primary closure for most dog bite wounds, particularly puncture wounds and hand injuries, due to high infection risk. 2
• Facial wounds are an exception and may be closed primarily after meticulous irrigation and prophylactic antibiotics to optimize cosmetic outcomes. 1
• Non-infected wounds seen early (<8 hours) may be approximated with Steri-Strips rather than sutures if closure is desired. 5

Rabies Post-Exposure Prophylaxis

For healthy domestic dogs in the United States, confine and observe the animal for 10 days rather than initiating immediate rabies prophylaxis. 1

Decision Algorithm for Rabies Treatment

• If the dog remains healthy for the full 10-day observation period, no rabies prophylaxis is needed, as the dog was not shedding rabies virus at the time of the bite. 1
• Initiate immediate rabies post-exposure prophylaxis if: 1
  • The dog is stray, unwanted, or cannot be confined for observation
  • The dog dies or develops illness before completing the 10-day observation period
  • The dog shows signs suggestive of rabies during observation
  • The dog is confirmed rabid by laboratory testing

Rabies Prophylaxis Regimen for Previously Unvaccinated Persons

• Administer Human Rabies Immune Globulin (HRIG) at 20 IU/kg body weight once on day 0: infiltrate up to half the dose around and into the wound if anatomically feasible, with the remainder given intramuscularly in the gluteal area at a site distant from vaccine administration. 2, 1
• Give rabies vaccine (HDCV or PCECV) in a 4-dose series on days 0,3,7, and 14 (the updated schedule for immunocompetent patients). 6, 1
• HRIG can be administered up to day 7 after the first vaccine dose if not given initially; beyond day 7, HRIG is not indicated as vaccine-induced antibody response is presumed to have occurred. 2, 6

Critical Pitfalls to Avoid

• Never administer more than the recommended 20 IU/kg dose of HRIG, as excess may partially suppress active antibody production. 6, 1
• Do not inject rabies vaccine in the gluteal area; use the deltoid in adults and anterolateral thigh in children, as gluteal injection results in lower neutralizing antibody titers. 6

Previously Vaccinated Persons

• Individuals who have previously received complete rabies vaccination (pre-exposure or post-exposure) should receive only a 2-dose vaccine booster on days 0 and 3, without HRIG. 2, 6

Antibiotic Management

Amoxicillin-clavulanate is the first-line antibiotic for both prophylaxis and treatment of dog bite wounds, providing broad coverage for the polymicrobial nature of these infections (Pasteurella, Staphylococcus, Streptococcus, anaerobes). 1, 3, 7, 4

Indications for Antibiotic Prophylaxis

• Consider antibiotic prophylaxis for all dog bites, particularly for: 1, 4
  • Hand wounds
  • Wounds over tendons or bones
  • Puncture wounds
  • Immunocompromised patients
  • Wounds requiring closure

Alternative Antibiotic Regimens

• For penicillin-allergic patients, use doxycycline, or a fluoroquinolone (ciprofloxacin, levofloxacin, moxifloxacin) plus metronidazole or clindamycin. 1, 7
• For severe infections requiring intravenous therapy, use ampicillin-sulbactam or piperacillin-tazobactam as first-line agents. 5

Infectious Complications to Monitor

• Watch for septic arthritis, osteomyelitis, subcutaneous abscess, tendonitis, and bacteremia, particularly from Pasteurella species and Capnocytophaga canimorsus (which can cause fatal sepsis in asplenic or hepatically compromised patients). 1

Tetanus Prophylaxis

Assess tetanus immunization status and administer tetanus toxoid (0.5 mL intramuscularly) if vaccination status is outdated, unknown, or incomplete. 2, 5, 1

Follow-Up and Monitoring

• Elevate injured extremities if swollen to reduce edema. 5
• Arrange follow-up within 24 hours for all outpatients to assess for signs of infection. 5
• Consider hospitalization if infection progresses despite appropriate antimicrobial therapy. 5