How should I manage a human bite wound in the emergency department, including irrigation, debridement, tetanus prophylaxis, antibiotic choice (amoxicillin‑clavulanate or alternatives for penicillin allergy), analgesia, follow‑up, and special considerations for hand bites or exposure to hepatitis or HIV?

Human Bite Wound Management in the Emergency Department

Immediate Wound Care

All human bite wounds must be evaluated in a medical facility as soon as possible and irrigated thoroughly with copious amounts of running tap water or sterile saline until all visible debris is removed. 1, 2

Irrigation Technique

• Use a 20-mL or larger syringe to generate adequate pressure for effective irrigation 2
• Running tap water is as effective as sterile saline and superior to antiseptic solutions like povidone-iodine 1, 3
• Avoid high-pressure irrigation as it may drive bacteria deeper into tissue layers 1
• Continue irrigation until no foreign matter remains visible in the wound 1

Debridement

• Remove all necrotic and devitalized tissue through surgical debridement, as this is critical for preventing bacterial proliferation and spread 1, 4
• Devitalized tissue accelerates peripheral bacterial dissemination and must be excised 4

Wound Closure Decisions

Do not close human bite wounds except for facial lacerations. 2

• Infected wounds and wounds presenting >8 hours after injury should never be closed 2
• For non-infected wounds seen early (<8 hours), consider approximation with Steri-Strips rather than sutures 2
• Facial wounds are the exception and may be closed primarily after meticulous irrigation and prophylactic antibiotics 2

Antibiotic Therapy

Amoxicillin-clavulanate (875/125 mg twice daily) is the first-line oral antibiotic for human bite wounds. 2

Indications for Antibiotics

• Fresh, deep wounds 1
• Hand bites (strongest evidence for prophylaxis benefit) 1
• Wounds near joints, feet, face, or genitals 1
• Immunocompromised patients or those with implants (artificial heart valves) 1
• Wounds with crush injury or devitalized tissue 2
• Do not give antibiotics if presenting ≥24 hours after bite without signs of infection 1

Duration

• Prophylactic treatment: 3-5 days 1
• Complicated infections (osteomyelitis): 4-6 weeks 2
• Septic arthritis/synovitis: 3-4 weeks 2

Alternative Regimens for Penicillin Allergy

Oral alternatives: 2

• Doxycycline (monotherapy)
• Penicillin VK plus dicloxacillin
• Fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin) plus metronidazole or clindamycin

Intravenous therapy (for severe infections): 2

• First-line: Ampicillin-sulbactam or piperacillin-tazobactam
• Alternatives: Cefoxitin, ertapenem, imipenem, or meropenem

Microbiology Rationale

• Human bite wounds harbor polymicrobial flora including Streptococcus (50%), S. aureus (40%), and Eikenella corrodens (30%) 1
• Anaerobes (Fusobacterium, Prevotella, Bacteroides, Porphyromonas) are common 1

Tetanus Prophylaxis

Administer tetanus toxoid (0.5 mL intramuscularly) if vaccination status is outdated or unknown. 2, 5

Bloodborne Pathogen Exposure

Human bites can transmit HBV, HCV, and HIV; post-exposure prophylaxis should be considered in every case. 1

• Obtain baseline serology testing for the victim to document pre-exposure status 5
• Attempt to determine viral status of the biter when possible 5
• Initiate appropriate post-exposure prophylaxis based on risk assessment and CDC guidelines 1

Rabies Consideration

• Rabies transmission from human bites is extraordinarily rare in the United States 2
• Consider rabies prophylaxis only in exceptional circumstances where the biting person has suspected rabies exposure or compatible clinical signs 2

Special Considerations for Hand Bites

Clenched-fist injuries require immediate expert hand surgery evaluation. 2

• These injuries have high risk of penetration into synovium, joint capsule, or bone 2
• Complications include septic arthritis and osteomyelitis 2
• Hand bites are the only bite location with strong evidence supporting antibiotic prophylaxis 1

Analgesia

• Provide appropriate pain control based on wound severity and patient factors 2
• Elevate the injured extremity to reduce swelling and accelerate healing 2

Follow-Up

All outpatients require follow-up within 24 hours by phone or office visit. 2

• Monitor for signs of infection: redness, swelling, foul-smelling drainage, increased pain, or fever 1
• Consider hospitalization if infection progresses despite appropriate antimicrobial therapy 2

Critical Pitfalls to Avoid

• Never delay evaluation: Early intervention is essential to prevent serious complications 1
• Never use antiseptic solutions for irrigation: Water or saline is superior 1, 3
• Never close infected wounds or those presenting late: This traps bacteria and increases infection risk 2
• Never omit hand surgery consultation for clenched-fist injuries: These require specialized evaluation 2
• Never forget bloodborne pathogen assessment: HBV, HCV, and HIV transmission is a real risk 1