What is the appropriate acute management of a dog bite wound, including irrigation, debridement, closure decisions, tetanus immunization, rabies post‑exposure prophylaxis (human rabies immune globulin and vaccine), and antibiotic therapy?

Acute Management of Dog Bite Wounds

Immediate Wound Care

Irrigate the wound immediately and copiously with sterile normal saline or clean water under moderate pressure—this single intervention markedly reduces infection risk and is the most critical step in preventing rabies transmission. 1, 2, 3

• Perform abundant irrigation before any debridement to lower bacterial contamination 2
• Use sterile normal saline or clean water; iodine-based solutions are not required for routine irrigation 2
• After irrigation, debride only superficial debris and devitalized tissue without enlarging the wound 2, 3
• Examine for deep structure injury: pain disproportionate to the visible wound suggests possible periosteal penetration, nerve, or tendon damage requiring imaging 2
• Document neurovascular function (pulses, sensation) and range of motion of adjacent joints 4

Wound Closure Decision

Close facial wounds primarily after meticulous irrigation and debridement, ideally within 8 hours; for all other anatomic locations, avoid primary closure and use delayed closure with adhesive strips (Steri-Strips) or allow healing by secondary intention. 2, 3

Specific closure guidelines:

• Facial wounds: Primary closure is appropriate and should be performed, preferably by a plastic surgeon, after copious irrigation, careful debridement, and prophylactic antibiotics 2, 3
• Hand wounds: Never close primarily—these have the highest infection risk if sutured 3
• Puncture wounds: High-risk for deep infection; do not close 2
• Infected wounds at presentation: Absolute contraindication to closure 2
• High-risk patients: Do not suture wounds in immunocompromised, asplenic, advanced liver disease, or patients with pre-existing edema 2

Antibiotic Prophylaxis

Prescribe amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days for all dog bites, as this covers both aerobic and anaerobic bacteria including Pasteurella multocida. 2, 3, 4

Indications for prophylactic antibiotics (3-5 days):

• Immunocompromised patients 3
• Asplenic patients 3
• Advanced liver disease 3
• Pre-existing or resulting edema of the affected area 3
• Moderate to severe lesions, especially on the hand or face 3
• All wounds given the low cost and high benefit of prophylaxis 4

Tetanus Immunization

Administer 0.5 mL intramuscular tetanus toxoid if the patient has not been vaccinated in the last 10 years for clean wounds, or in the last 5 years for contaminated wounds. 2, 3

• Prefer Tdap over Td if the patient has never received Tdap 2, 3
• Give tetanus toxoid when immunization status is unknown or outdated 2

Rabies Post-Exposure Prophylaxis

For healthy domestic dogs that can be confined: observe the animal for 10 days without initiating rabies prophylaxis; a fully vaccinated dog (≥2 doses) is unlikely to be rabid. 1, 2

Initiate rabies PEP immediately (within 24 hours) for:

• Bites from wild, feral, or stray animals that cannot be quarantined 2
• Situations where the dog's rabies status cannot be determined 2
• Regions with high rabies prevalence 2
• Any animal that develops signs of rabies during the 10-day observation period 1

Rabies PEP regimen for previously unvaccinated persons:

• Human rabies immune globulin (HRIG): Administer once on day 0 at a site separate from the vaccine; can be given up to day 7 if not given initially 1
• Rabies vaccine: 5-dose intramuscular series on days 0,3,7,14, and 28 1, 2
• Site of administration: Anterolateral thigh or deltoid in children; never use the gluteal region as it yields lower antibody titers 2
• Timing: Initiate regardless of delay since exposure, provided the patient shows no clinical signs of rabies 1

Important caveats:

• Consult local health department for risk assessment before initiating PEP 2, 3
• An unprovoked attack is more likely to indicate rabies than a provoked attack 1
• Dogs along the US-Mexico border and in areas with enzootic wildlife rabies pose higher risk 1

Follow-Up and Monitoring

Arrange outpatient follow-up within 24 hours (telephone or in-person) to reassess wound status and compliance with prophylaxis. 2

Monitor for complications:

• Disproportionate pain near bone or joint structures warrants imaging for periosteal penetration 2
• Hospitalize if infection progresses despite appropriate antimicrobial therapy 2
• Infectious complications requiring prolonged therapy include septic arthritis (3-4 weeks), osteomyelitis (4-6 weeks), subcutaneous abscesses, and tendinitis 2
• Elevate the injured body part if swollen to accelerate healing 2