Dog Bite Treatment

1. Initial Assessment

Before any wound care, gather three key pieces of history:

Circumstances of the attack: timing (bites >6 hours old carry higher infection risk), provoked vs. unprovoked (affects rabies decision), anatomical location
The animal: known owner, vaccination status, current whereabouts, breed (pit bulls, German shepherds, Rottweilers exert higher bite pressures of 300-450 psi and cause deeper "hole and tear" injuries)
The patient: immunosuppression, diabetes, asplenia, current medications, tetanus status

- Rosen's Emergency Medicine, p. 799

2. Wound Care (Most Important Step)

Thorough wound care is more important than antibiotics.

Analgesia first - adequate pain control is required before proper examination
Wash with soap and water - use gentle scrubbing with a fine-pore sponge
Virucidal agent (e.g., povidone-iodine solution) on the surrounding skin - avoid applying inside wound tissue as it is toxic to exposed tissue
High-pressure irrigation with saline or sterile water - this is the single most effective method to reduce bacterial counts
Explore in a bloodless field - inflate a BP cuff above systolic for up to 20 min to examine for tendon injury, joint capsule violation, or retained tooth fragments
Extend puncture wounds over joints and tendons to allow adequate visualization
Neurovascular assessment for all extremity bites

- Rosen's Emergency Medicine, p. 800; Roberts and Hedges' Clinical Procedures in Emergency Medicine

3. Wound Closure

Primary closure of dog bites is generally safe and recommended, unlike other animal bites - but with important exceptions:

Wound Type	Recommendation
Face/scalp, <6 hours old	Suture (low infection risk due to rich blood supply)
Most other dog bite wounds	Safe to suture primarily
Hand and foot wounds	Rarely suture - highest infection risk
Puncture wounds	Do NOT suture
Wounds >12 hours old	Do NOT suture
Already infected wounds	Do NOT suture

For wounds too high-risk to close: loosely approximate edges with adhesive strips, or plan delayed primary closure at 48-72 hours if no infection develops.

- Rosen's Emergency Medicine, p. 800

4. Prophylactic Antibiotics

Antibiotics are given within 3 hours of the bite to achieve a prophylactic effect, continued for 5 days.

When to give prophylaxis:

All hand and foot wounds
Deep puncture wounds
Crush injuries or damage to deep structures
Delayed presentation (>6 hours)
Wounds closed primarily
Immunocompromised patients (diabetes, asplenia, liver disease, HIV, immunosuppressive therapy)

Drug of choice: Amoxicillin-clavulanate (Augmentin) - covers Pasteurella spp., streptococci, staphylococci, and anaerobes

Avoid as monotherapy: Erythromycin, clindamycin, penicillinase-resistant penicillins (dicloxacillin), and first-generation cephalosporins (cephalexin) - these have documented treatment failures against Pasteurella

Penicillin-allergic patients: Ciprofloxacin or moxifloxacin (fluoroquinolone), OR clindamycin + trimethoprim-sulfamethoxazole

- Rosen's Emergency Medicine, p. 800; Andrews' Diseases of the Skin

5. Microbiology of Dog Bite Infections

Infections are polymicrobial (average of 5 isolates per wound culture):

Predominant organism: Pasteurella species (~50% of cases)
Other aerobes: Streptococci, staphylococci, Neisseria spp., Corynebacterium spp., Moraxella spp.
Anaerobes (especially in abscesses): Fusobacterium, Bacteroides, Porphyromonas, Prevotella, Propionibacterium

Infection rates overall: 1-30%, with hand bites at the highest risk. Cellulitis is most common; tenosynovitis and septic joints occur with hand bites.

Special pathogen - Capnocytophaga canimorsus:

Gram-negative rod in normal dog/cat oral flora
Causes rare but life-threatening sepsis
High-risk: asplenic patients, alcoholics, those with chronic respiratory or liver disease
Presents with fever, nausea, vomiting within 1-3 days; characteristic necrotizing eschar at bite site; can progress to DIC and extensive dry gangrene
Treatment: intensive IV antibiotics; susceptible to fluoroquinolones, macrolides, carbapenems, clindamycin, 3rd-generation cephalosporins
Resistant to TMP-SMX and aminoglycosides

- Rosen's Emergency Medicine, p. 799; Andrews' Diseases of the Skin

6. Tetanus Prophylaxis

Consider tetanus prophylaxis for all bite wounds based on the patient's immunization history and wound characteristics (update if >5 years since last booster for dirty wounds, >10 years for clean wounds).

7. Rabies Prophylaxis

Assess rabies risk based on:

Whether the bite was provoked or unprovoked (unprovoked = higher risk)
Geographic region (local endemicity)
Animal vaccination status and owner
If the animal can be observed for 10 days (domestic dogs in many areas): prophylaxis can be withheld pending observation; initiate immediately if the animal develops signs of illness

Wound care is the first step in rabies prevention - rabies virus is very sensitive to soap, sunlight, and drying.

Rabies post-exposure prophylaxis (PEP) in unvaccinated patients = wound care + rabies immune globulin (RIG, infiltrated around wound) + rabies vaccine (4-dose series: days 0, 3, 7, 14).

- Harrison's Principles of Internal Medicine 22E (2025), p. 1187; Rosen's Emergency Medicine

8. Indications for Hospital Admission

Established infection with systemic signs (fever, lymphangitis, lymphadenopathy)
Tenosynovitis, septic arthritis, or osteomyelitis
Suspected C. canimorsus sepsis
Immunocompromised patient with severe wound
Failure of outpatient antibiotics
Wounds requiring operative debridement or repair

Patients managed as outpatients should be reevaluated in 24-48 hours.

- Rosen's Emergency Medicine, p. 800

Recent evidence note: A 2025 systematic review on pediatric dog bite surgical management (PMID: 39462695) is available if you want more detail on the surgical approach in children specifically.

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