How should I medically manage a dog bite wound, including irrigation, debridement, prophylactic antibiotics, tetanus update, rabies prophylaxis, wound closure, analgesia, and follow‑up?

Medical Management of Dog Bite Wounds

Irrigate the wound immediately with copious amounts of running tap water or sterile saline, administer amoxicillin-clavulanate for prophylaxis (especially for hand wounds, puncture wounds, or wounds presenting >8 hours after injury), update tetanus status, assess rabies risk with local health officials, and leave most wounds open to heal by secondary intention—only facial wounds may be closed primarily after meticulous care. 1, 2

Immediate Wound Irrigation and Debridement

• Irrigate extensively with large volumes of running tap water or sterile saline until no visible debris remains—tap water is as effective as sterile saline and superior to antiseptic solutions like povidone-iodine. 1, 2

• Remove superficial debris during irrigation, but avoid aggressive debridement that enlarges the wound or causes additional tissue damage. 1, 2

• If deeper debridement is necessary (presence of devitalized tissue), perform it cautiously to preserve viable tissue and facilitate skin closure. 1

• Do not use iodine-based or antibiotic-containing irrigation solutions—they provide no advantage over water or saline. 1, 2

Prophylactic Antibiotic Therapy

Amoxicillin-clavulanate is the first-line antibiotic for both prophylaxis and treatment of dog bite wounds, as it covers the polymicrobial flora including Pasteurella multocida (present in 50% of dog bites), staphylococci, streptococci, and anaerobes. 1, 2

Indications for Prophylactic Antibiotics (3-5 days):

• Hand wounds (highest infection risk) 1, 2
• Puncture wounds 2
• Wounds presenting >8 hours after injury 1, 2
• Immunocompromised or asplenic patients 1
• Advanced liver disease 1
• Wounds with crush injury or devitalized tissue 2
• Wounds near bone or joint (risk of periosteal penetration) 1
• Moderate to severe injuries, especially to hand or face 1

Alternative Antibiotic Regimens for Penicillin-Allergic Patients:

• Doxycycline (monotherapy acceptable) 1, 2
• Penicillin VK plus dicloxacillin 1
• Fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin) plus metronidazole or clindamycin for anaerobic coverage 1, 2

Antibiotics to AVOID:

Do not use first-generation cephalosporins (cephalexin), penicillinase-resistant penicillins alone (dicloxacillin monotherapy), macrolides (erythromycin), or clindamycin monotherapy—all have poor activity against P. multocida. 1, 2

Wound Closure Decisions

Most dog bite wounds should NOT be closed primarily—leave them open to heal by secondary intention or delayed primary closure. 1, 2

Specific Closure Guidelines:

• Never close infected wounds or wounds presenting >8 hours after injury (high infection risk). 1, 2

• Facial wounds are the exception: may be closed primarily by a plastic surgeon after meticulous irrigation, copious debridement, and administration of prophylactic antibiotics. 1, 2

• For clean wounds presenting <8 hours after injury, consider approximation with Steri-Strips rather than sutures, followed by delayed primary or secondary closure. 1

Tetanus Prophylaxis

Administer tetanus toxoid (0.5 mL intramuscularly) if vaccination status is outdated or unknown. 1

• Give booster if >10 years since last dose for clean wounds. 2
• Give booster if >5 years since last dose for contaminated wounds. 2
• Tdap is preferred over Td if the patient has not previously received Tdap. 1

Rabies Risk Assessment and Prophylaxis

Consult local health officials immediately to determine if rabies prophylaxis is indicated based on the animal species, geographic prevalence, circumstances of attack, and vaccination status of the dog. 1, 2

Rabies Prophylaxis Protocol (for previously unvaccinated persons):

• Administer rabies immune globulin (HRIG) on day 0 at the wound site and surrounding tissue. 2
• Administer rabies vaccine (HDCV or PCECV) on days 0,3,7,14, and 28 at a different anatomic site. 2
• Never use the gluteal area for vaccine administration due to lower antibody titers. 2
• Begin vaccination immediately without waiting for animal observation results. 2

High-Risk Scenarios for Rabies:

• Bites from feral or wild animals 1
• Geographic areas with high rabies prevalence 1
• Unprovoked attacks 2
• Unknown vaccination status of domestic dog 2

Wound Care and Elevation

• Cover the wound with a clean occlusive dressing after irrigation and debridement to promote healing and reduce infection. 1, 2

• Elevate the injured extremity (especially if swollen) using a sling for outpatients or tubular stockinet attached to an IV pole for inpatients—elevation accelerates healing. 1, 2

Analgesia

Provide appropriate analgesia for pain control, as pain may cause immunocompromise and impair wound healing. 3

Follow-Up Protocol

Arrange follow-up within 24 hours by phone or office visit to assess for signs of infection. 1, 2

Warning Signs Requiring Immediate Re-evaluation:

• Progressive redness, swelling, or warmth 2
• Purulent or foul-smelling drainage 2
• Increasing pain (especially pain disproportionate to injury near bone or joint, suggesting periosteal penetration) 1
• Fever or systemic symptoms 2

If infection progresses despite appropriate antimicrobial and ancillary therapy, hospitalize the patient for intravenous antibiotics and possible surgical intervention. 1

Intravenous Antibiotic Options for Severe Infections

For patients requiring hospitalization or with severe infections:

• Ampicillin-sulbactam 1
• Piperacillin-tazobactam 1
• Second-generation cephalosporins (cefoxitin) 1
• Carbapenems (ertapenem, imipenem, meropenem) 1

A single initial dose of parenteral antimicrobial may be administered before transitioning to oral therapy. 1

Special Considerations for High-Risk Wounds

Hand Wounds:

Hand wounds are the highest-risk location for infection and complications (septic arthritis, osteomyelitis, tendonitis) and always warrant prophylactic antibiotics. 1, 2

Complications Requiring Prolonged Therapy:

• Osteomyelitis: 4-6 weeks of antibiotics 1
• Septic arthritis/synovitis: 3-4 weeks of antibiotics 1
• Tendonitis, subcutaneous abscess, bacteremia: individualized duration based on clinical response 1

Critical Pitfalls to Avoid

• Do not close wounds >8 hours old or any infected wounds (except facial wounds with proper precautions). 1, 2

• Do not use antiseptic solutions for irrigation—they offer no benefit over water or saline. 1, 2

• Do not prescribe antibiotics with poor Pasteurella coverage (cephalexin, macrolides, clindamycin alone, dicloxacillin alone). 1, 2

• Do not delay rabies prophylaxis while waiting for animal observation results. 2

• Do not perform aggressive debridement that causes additional tissue damage or impairs closure. 1, 2