How should a dog bite be managed, including wound care, antibiotic prophylaxis, tetanus immunization update, and rabies post‑exposure prophylaxis?

Dog Bite Management

All dog bite wounds should be immediately and thoroughly washed with soap and water for 15 minutes, followed by povidone-iodine irrigation, with amoxicillin-clavulanate prophylaxis for high-risk wounds (hand injuries, puncture wounds, immunocompromised patients), tetanus prophylaxis as indicated, and rabies post-exposure prophylaxis only if the dog cannot be observed for 10 days or shows signs of illness. 1

Immediate Wound Care

• Wash all bite wounds immediately with soap and water for approximately 15 minutes to markedly reduce infection risk and potential rabies transmission 1
• After soap-and-water cleansing, irrigate the wound with povidone-iodine solution using a ≥20 mL syringe to further lower viral and bacterial load 1
• Examine wounds carefully for tendon or bone involvement, joint penetration, or pain disproportionate to the injury near bones or joints 1
• Remove any foreign bodies and devitalized tissue during wound exploration 2
• Assess neurovascular function (pulses, sensation) and range of movement of adjacent joints 2

Wound Closure Considerations

• Avoid suturing whenever possible—especially for puncture wounds, hand injuries, or heavily contaminated wounds—because primary closure increases infection risk 1
• Consider wound closure for facial wounds if seen early and properly cleaned, balancing cosmetic factors against infection risk 1
• Primary closure may be performed if there is low risk of infection 2

Antibiotic Prophylaxis

Amoxicillin-clavulanate 875/125 mg twice daily is the first-line prophylactic antibiotic for dog bite wounds. 3

Indications for Prophylaxis (3-5 days)

Preemptive antibiotic therapy is recommended for patients who meet any of the following criteria 3:

• Immunocompromised status
• Asplenia
• Advanced liver disease
• Preexisting or resultant edema of the affected area
• Moderate to severe injuries, especially to the hand or face
• Injuries that may have penetrated the periosteum or joint capsule

Evidence Context

A meta-analysis found that prophylactic antibiotics reduce infection risk in dog bite wounds (relative risk 0.56), with a cumulative infection incidence of 16% in untreated controls 4. However, the benefit appears marginal for low-risk wounds presenting within 12-24 hours, particularly those without puncture wounds, not involving the face/hand/foot, and in immunocompetent patients 3.

Alternative Regimens for Penicillin Allergy

• Doxycycline 100 mg twice daily (excellent activity against Pasteurella multocida, though some streptococci are resistant) 3
• Fluoroquinolone plus metronidazole 3
• Clindamycin plus fluoroquinolone 3

Tetanus Prophylaxis

• Assess tetanus immunization status for all dog bite patients 1
• Administer tetanus toxoid (or tetanus-diphtheria-pertussis vaccine) to patients with unknown or incomplete tetanus immunization 1

Rabies Post-Exposure Prophylaxis

Risk Assessment Algorithm

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

• If the dog remains healthy for the full 10 days, no rabies prophylaxis is needed because dogs do not shed rabies virus in saliva more than 10 days before showing clinical signs 1
• The dog must be confined and observed prospectively, not retrospectively 5

Indications to Initiate Immediate Prophylaxis

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

• The dog is stray or unwanted
• The dog 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 attack was unprovoked (unprovoked attacks are more likely to indicate rabies) 1

Prophylaxis Regimen for Previously Unvaccinated Persons

Human Rabies Immune Globulin (HRIG) and vaccine series:

• HRIG 20 IU/kg body weight given once on day 0 1
• Infiltrate the full calculated HRIG dose into and around the wound(s) whenever anatomically feasible; inject any remaining volume intramuscularly in the gluteal region 1
• HRIG may be given up to day 7 after the first vaccine dose if not administered initially; after day 7, HRIG is not indicated because vaccine-induced antibodies are presumed present 1
• Rabies vaccine series: 5 doses on days 0,3,7,14, and 28 (or 4 doses on days 0,3,7, and 14 per some protocols) 3, 1
• For adults, administer vaccine intramuscularly in the deltoid area; for children, the anterolateral thigh is also acceptable 3
• Never use the gluteal area for vaccine injections, as this results in lower neutralizing antibody titers 3

Prophylaxis for Previously Vaccinated Persons

• Persons who have previously received complete vaccination regimens should receive only vaccine (no HRIG) 3
• Administer 2 doses of vaccine on days 0 and 3 5

Potential Complications to Monitor

• Infectious complications include septic arthritis, osteomyelitis, subcutaneous abscess, tendonitis, and bacteremia 1
• Common organisms include Pasteurella species, Staphylococci, and anaerobes 1
• Capnocytophaga canimorsus can cause fatal sepsis, especially in patients with asplenia or underlying hepatic disease 1

Critical Pitfalls to Avoid

• Never delay wound cleansing—it is the first and most important intervention 1
• Do not initiate unnecessary post-exposure prophylaxis for healthy domestic dogs that can be observed for 10 days 1
• Do not exceed the recommended HRIG dose, as excess HRIG can suppress active antibody production 1
• Do not suture high-risk wounds (puncture wounds, hand injuries, heavily contaminated wounds) 1