What is the recommended management for a rabbit bite or scratch?

Management of Rabbit Bites and Scratches

For rabbit bites or scratches, immediately cleanse the wound thoroughly with soap and water for 15 minutes, assess rabies risk based on local epidemiology and animal exposure history, and initiate prophylactic antibiotics with amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days if the wound is deep, involves high-risk sites (hands, face, joints), or the patient is immunocompromised.

Immediate Wound Management

• Irrigate all rabbit bite wounds immediately and thoroughly with soap and water for approximately 15 minutes to reduce bacterial load and potential viral transmission 1
• Follow soap-and-water cleansing with povidone-iodine solution irrigation to further reduce microbial contamination 1, 2
• Examine wounds carefully for tendon involvement, bone penetration, or joint space violation, as these require more aggressive management 1
• Avoid primary wound closure, especially for puncture wounds or hand injuries, as closure increases infection risk 1
• Remove superficial debris and debride any necrotic tissue 2
• Elevate the injured extremity to accelerate healing 3

Rabies Risk Assessment and Prophylaxis

Rabbits and lagomorphs are almost never found to be infected with rabies and have not been known to cause rabies among humans in the United States 4. However, rare cases have been documented:

• Seven pet rabbits and one guinea pig were confirmed with raccoon-variant rabies in New York State, requiring postexposure treatment for exposed humans 5
• Consult your local or state health department before initiating rabies prophylaxis for rabbit bites, as the decision must be individualized based on local rabies epidemiology 4

When to Consider Rabies Prophylaxis:

• Wild or feral rabbits in areas with high rabies prevalence should be treated similarly to wild carnivores 4
• Rabbits with wounds of unknown origin or known contact with wild animals (especially raccoons, skunks, foxes, or bats) 5
• If the rabbit cannot be confined for observation or dies before completing observation 1
• Unprovoked attacks are more concerning than provoked attacks 1

Rabies Post-Exposure Prophylaxis Protocol (if indicated):

• For previously unvaccinated individuals: Human Rabies Immune Globulin (HRIG) 20 IU/kg body weight on day 0, infiltrated into and around the wound when anatomically feasible 1
• Rabies vaccine series: 5 doses on days 0,3,7,14, and 28 1
• HRIG may be given up to day 7 after the first vaccine dose if not administered initially; after day 7, HRIG is contraindicated as it may suppress active antibody production 1

Antibiotic Prophylaxis

The microbiology of rabbit bite wounds reflects the rabbit's oral flora and includes polymicrobial aerobic and anaerobic bacteria 6:

First-Line Antibiotic Therapy:

• Amoxicillin-clavulanate 875/125 mg orally twice daily for 3-5 days is the recommended first-line prophylactic antibiotic 1, 3, 2
• This provides optimal coverage against Pasteurella species, staphylococci, streptococci, and anaerobes that comprise mammalian bite wound flora 3

Alternative Regimens for Penicillin-Allergic Patients:

• Doxycycline 100 mg twice daily (excellent activity against Pasteurella multocida) 3, 2
• Clindamycin 300 mg three times daily plus a fluoroquinolone for severe penicillin allergy 2

Antibiotics to Avoid:

• Do not use first-generation cephalosporins (e.g., cephalexin) due to poor activity against Pasteurella species 3
• Avoid penicillinase-resistant penicillins alone (e.g., dicloxacillin) 3
• Avoid clindamycin monotherapy as it lacks coverage for Pasteurella 3

High-Risk Situations Requiring Prophylaxis:

• Deep puncture wounds (rabbit teeth can penetrate deeply) 3
• Hand, foot, face, or genital wounds 3
• Wounds near joints or over tendons/bones 1
• Immunocompromised patients (diabetes, liver disease, asplenia, immunosuppressive therapy) 3, 2
• Advanced age (increased risk of complications) 2
• Presentation within 24 hours of injury 3

Tetanus Prophylaxis

• Assess tetanus immunization status and administer tetanus toxoid (or Tdap) if vaccination is unknown, incomplete, or last dose was >10 years ago for clean wounds or >5 years ago for contaminated wounds 1, 3

Follow-Up and Monitoring

• Re-evaluate within 24-48 hours either by phone or office visit to assess for signs of infection 3, 2
• Monitor for infectious complications including cellulitis, abscess formation, septic arthritis, osteomyelitis, or tendonitis 1
• Consider hospitalization if systemic signs develop (fever, rapidly progressing erythema, deep tissue involvement) or for immunocompromised patients with established infection 3

Critical Pitfalls to Avoid

• Never delay wound cleansing—this is the single most important intervention 1
• Do not suture rabbit bite wounds, especially puncture wounds or hand injuries, as this dramatically increases infection risk 1
• Do not rely on topical antibiotics alone without systemic coverage for deep or high-risk wounds 3
• Avoid high-pressure irrigation as it may drive bacteria deeper into tissues 3, 2
• Do not exceed the recommended HRIG dose if rabies prophylaxis is indicated, as excess can suppress active antibody production 1
• Do not dismiss the need for rabies evaluation based solely on the assumption that rabbits don't carry rabies—consult local health authorities 4, 5