What is the appropriate management of a dog bite wound, including wound care, antibiotic prophylaxis, tetanus immunization, and rabies prophylaxis?

Dog Bite Management

For dog bite wounds, immediately irrigate with soap and water, administer amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days for high-risk wounds, update tetanus if >10 years, and consult local health officials for rabies risk assessment—if the dog is healthy and available, observe for 10 days without starting rabies prophylaxis. 1, 2

Immediate Wound Care

• Thoroughly wash the wound with soap and water for 15 minutes immediately—this is the single most effective measure for preventing rabies infection and markedly reduces transmission risk. 1
• Irrigate with sterile normal saline using a 20-mL or larger syringe; avoid high-pressure irrigation as it may drive bacteria into deeper tissue layers. 3, 4
• Remove superficial debris and foreign bodies; deeper debridement should be performed cautiously to avoid enlarging the wound. 3
• Examine and document neurovascular function (pulses, sensation) and range of motion of adjacent joints. 5

Antibiotic Prophylaxis

Administer preemptive antibiotics for 3-5 days in the following high-risk situations: 3, 1

• Deep wounds or wounds that may have penetrated periosteum or joint capsule
• Hand, foot, face, or genital wounds
• Wounds near joints
• Immunocompromised patients, asplenic patients, or those with advanced liver disease
• Edema of the affected area
• Moderate to severe injuries
• Presentation within 24 hours of injury

First-line antibiotic: Amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days, providing coverage against Pasteurella multocida, Staphylococcus, Streptococcus, and anaerobes. 1, 5

Alternative oral options: 1

• Doxycycline (excellent activity against Pasteurella multocida)
• Fluoroquinolones with additional anaerobic coverage (e.g., moxifloxacin)

IV options for severe infections or inability to take oral medications: 1

• Ampicillin-sulbactam
• Piperacillin-tazobactam
• Second-generation cephalosporins
• Carbapenems

Do not administer antibiotics if the patient presents ≥24 hours after the bite with no clinical signs of infection. 3

Wound Closure Decisions

Facial wounds: Primary closure is recommended after copious irrigation, cautious debridement, and initiation of prophylactic antibiotics for optimal cosmetic results. 3, 1

Non-facial wounds: Generally should not be closed primarily; approximation of wound margins with Steri-Strips followed by delayed primary or secondary closure is preferred. 3, 1

Infected wounds should never be closed. 3

Tetanus Prophylaxis

Administer tetanus toxoid 0.5 mL intramuscularly if: 3, 6

• Last tetanus vaccination was >10 years ago for clean, minor wounds
• Last tetanus vaccination was >5 years ago for all other wounds (contaminated, puncture, traumatic)
• Vaccination status is unknown

Tdap is preferred over Td if the patient has not previously received Tdap. 1

Rabies Prophylaxis

Critical decision algorithm: 1, 2

If the dog is healthy and available for observation:

• Do NOT initiate rabies vaccination immediately
• Confine and observe the dog for 10 days
• Begin post-exposure prophylaxis (PEP) only if the dog develops signs of rabies during observation (behavioral changes, paralysis, excessive salivation, aggression, neurological signs)
• A healthy dog that remains alive and healthy for 10 days would not have been shedding rabies virus at the time of the bite

If the dog is unavailable, stray, or shows signs of illness:

• Initiate rabies PEP immediately
• Consult local health officials for regional rabies epidemiology

Complete PEP regimen (if indicated): 1, 2

For previously unvaccinated individuals:

• Human rabies immune globulin (HRIG) 20 IU/kg on day 0: infiltrate full dose around and into the wound if anatomically feasible, with remaining volume injected IM at a site distant from vaccine
• Human diploid cell rabies vaccine (HDCV) on days 0,3,7, and 14
• Never administer HRIG in the same syringe or at the same anatomical site as the vaccine

For previously vaccinated individuals:

• Vaccine only on days 0 and 3
• Do NOT give HRIG as it will suppress the anamnestic antibody response

Rabies PEP can be administered through day 7 after the first vaccine dose; beyond day 7, HRIG is not indicated. 2

Follow-up

All patients must be seen within 48-72 hours to assess for signs of infection and evaluate wound healing progress. 1

If infection progresses despite appropriate antimicrobial therapy, hospitalization should be considered. 1

Special Considerations

Hand wounds require aggressive management due to higher risk of infection, septic arthritis, osteomyelitis, and functional complications. 3, 1

For established infections: 1

• Septic arthritis: 4 weeks of antibiotic therapy
• Osteomyelitis: 6 weeks of antibiotic therapy

Immunocompromised patients require more aggressive follow-up due to higher infection risk. 1

Critical Pitfalls to Avoid

• Do not withhold rabies PEP while waiting for the 10-day observation period if the dog is unavailable or shows any signs of illness. 1
• Do not use high-pressure irrigation, as it may spread bacteria into deeper tissue layers. 3
• Do not close infected wounds or high-risk non-facial wounds primarily. 3
• Do not administer HRIG and vaccine at the same site or after day 7 of vaccine initiation. 1, 2
• Do not give HRIG to previously vaccinated individuals, as it suppresses the immune response. 1