What is the recommended acute management for a dog bite, including wound irrigation, tetanus and rabies prophylaxis, antibiotic therapy, analgesia, and follow‑up?

Acute Management of Dog Bite Wounds

Immediately wash the wound thoroughly with soap and water for 15 minutes, then irrigate with povidone-iodine solution, administer amoxicillin-clavulanate prophylaxis, update tetanus if needed, and confine healthy domestic dogs for 10-day observation rather than initiating rabies prophylaxis unless the dog is unavailable, unvaccinated, or shows signs of illness. 1

Immediate Wound Management

Wound cleansing is the single most effective intervention for preventing both rabies and bacterial infection. 1

• Wash all bite wounds immediately and thoroughly with soap and water for approximately 15 minutes to markedly reduce infection risk and potential rabies transmission 2, 1
• After soap and water cleansing, irrigate the wound with povidone-iodine solution or similar virucidal agent using a 20-mL or larger syringe to further reduce viral and bacterial load 2, 3
• Carefully examine wounds for tendon or bone involvement, joint penetration, nerve damage, or foreign bodies, and assess neurovascular function including pulses, sensation, and range of motion 1, 4
• Remove any devitalized tissue and foreign bodies during wound exploration 4

Wound Closure Considerations

• Consider primary closure for facial wounds if seen early and properly cleaned, balancing cosmetic factors against infection risk 1
• Avoid suturing when possible, particularly for puncture wounds, hand wounds, or heavily contaminated wounds, as closure increases infection risk 2, 5
• Wounds on the face may be closed for cosmetic reasons if there is low risk of infection 4

Antibiotic Prophylaxis

Amoxicillin-clavulanate is the first-line prophylactic antibiotic for all dog bite wounds. 1, 3

• Administer amoxicillin-clavulanate prophylaxis for all dog bites, particularly for hand wounds, puncture wounds, wounds over tendons or bones, and in immunocompromised patients 1, 4
• For penicillin-allergic patients, use doxycycline, a fluoroquinolone plus an agent active against anaerobes, or clindamycin plus a fluoroquinolone 1
• Antibiotic prophylaxis targets Pasteurella multocida (isolated in 20-30% of dog bites), Staphylococci, anaerobes, and Capnocytophaga canimorsus, which can cause fatal sepsis especially in asplenic or hepatically compromised patients 1, 6

Tetanus Prophylaxis

• Assess tetanus immunization status and administer tetanus toxoid to patients with unknown or incomplete tetanus immunization 2, 1
• Update tetanus vaccination as indicated based on standard guidelines for contaminated wounds 3, 6

Rabies Post-Exposure Prophylaxis Decision Algorithm

The 10-day observation period is the cornerstone of rabies risk assessment for healthy domestic dogs in the United States. 1, 7

When to Observe Rather Than Treat

• Confine and observe healthy domestic dogs for 10 days to determine if they are shedding rabies virus at the time of the bite 1, 7
• If the dog remains healthy for the full 10 days, no rabies prophylaxis is needed, as dogs do not shed rabies virus in saliva more than 10 days before showing clinical signs 1, 7
• A currently vaccinated dog is unlikely to become infected with rabies, though rare cases have been reported 1

When to Initiate Immediate Rabies Prophylaxis

Initiate rabies post-exposure prophylaxis immediately without waiting for observation if: 1, 7

• The dog is stray or unwanted and cannot be confined for observation
• The dog's vaccination status is unknown or not up-to-date
• The dog is unavailable for observation
• The dog dies or develops illness before completing the 10-day observation period
• The dog shows any signs suggestive of rabies during observation
• The attack was unprovoked (unprovoked attacks are more likely to indicate rabies than provoked attacks) 1

Rabies Prophylaxis Protocol for Previously Unvaccinated Persons

• Administer Human Rabies Immune Globulin (HRIG) 20 IU/kg body weight given once on day 0 2, 1
• Infiltrate the full calculated HRIG dose into and around the wound(s) if anatomically feasible; inject any remaining volume intramuscularly in the gluteal area 2, 8
• Administer rabies vaccine series on days 0,3,7, and 14 (4-dose schedule for immunocompetent patients) 8, 3
• 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, 8

Rabies Prophylaxis for Previously Vaccinated Persons

• Previously vaccinated persons receive only 2 doses of rabies vaccine on days 0 and 3, without HRIG 8, 7

Critical Timing Considerations

• Begin rabies post-exposure prophylaxis immediately after exposure (within 24 hours ideally), though even delayed treatment is indicated as rabies incubation periods exceeding 1 year have been documented 8, 7
• There is no absolute cutoff for starting rabies treatment; administer prophylaxis regardless of the length of delay as long as clinical rabies symptoms have not appeared 7

Analgesia

• Provide appropriate pain control based on wound severity using standard analgesic protocols (acetaminophen, NSAIDs, or opioids for severe injuries) 4

Follow-Up and Monitoring

Monitor closely for infectious complications including: 1

• Septic arthritis, osteomyelitis, subcutaneous abscess, tendonitis, and bacteremia
• Signs of infection typically develop within 24-48 hours for Pasteurella species
• Capnocytophaga canimorsus sepsis, particularly in asplenic or hepatically compromised patients

Schedule follow-up within 24-48 hours to reassess the wound for signs of infection 4

Critical Pitfalls to Avoid

• Never delay wound cleansing, as it is the first and most important intervention 1
• Never initiate unnecessary rabies post-exposure prophylaxis for healthy domestic dogs that can be observed for 10 days 1
• Never exceed the recommended 20 IU/kg HRIG dose, as excess HRIG can suppress active antibody production 8, 1
• Never inject rabies vaccine in the gluteal area; use deltoid in adults and anterolateral thigh in children, as gluteal injection results in lower neutralizing antibody titers 8
• Never suture hand wounds or heavily contaminated wounds due to high infection risk 5