Cleanse Wound:
- Gently cleanse wound with at least 250mL of normal saline with a splashguard shield.
- Do not use hibiclens or povidone-iodine solution.
- Do not irrigate puncture wounds.
Discharge home with follow up in 48 hours.
Is Tetanus Prophylaxis Needed?
Patient’s Immunization Status | Vaccine Needed? | Tetanus Immune Globulin Needed? |
|---|---|---|
Received fewer than 3 tetanus vaccines or Unknown | Yes | Yes |
Received 3 or more vaccines, <5 years since the most recent | No | No |
Received 3 or more vaccines, ≥5 years since the most recent | Yes | No |
Tetanus vaccine required:
- Tdap if patient is <7 years old
- DTaP if patient is ≥ 7 years old
Severe bite wound or patient history of MRSA?
Add vancomycin until cultures return.
Does the patient require tetanus vaccine prophylaxis?
Previously received rabies immunization series or documented rabies antibody titers?
- Sustained animal bite wound
- Hemodynamic instability
- Signs of systemic infection
Does the patient require rabies prophylaxis?
Does the patient require tetanus immunoglobulin prophylaxis?
Does the patient require antibiotic prophylaxis?
Administer tetanus immune globulin.
X-ray.
Obtain History, including:
- Type of animal, domestic or wild
- Location of bite
- Timing of bite
- Patient’s immunization status
- Assess patient’s risk for infection (e.g., immunocompromised or asplenic)
- Patient’s allergies
Examine the patient, including:
- Vital signs
- Location of bite
- Characteristics
- Extension
- Severity
- Signs of infection
- Neurovascular exam
Culture wound.
Is Antibiotic Prophylaxis Needed?
- Does the patient meet any of the following criteria?
- Immunocompromised
- Asplenic
- Have advanced liver disease
- Have pre-existing or new edema of the affected area
- Suffered moderate to severe puncture wounds
- Injury to bone, tendon, or joint capsule
- Wounds to face, hand, or genitals
Has it been >8 hours since bite Or are there signs of edema or infection?
Infection is the most common risk associated with animal bites. Infections from animal bites are polymicrobial containing aerobic and anaerobic bacteria from the mouth of the animal and the skin of the victim.
Most frequently isolated bacteria:
- Pasteurellaspp
- Staphylococcusspp
- Streptococci
- Anaerobes
- Capnocytophagaspp
- Moraxellaspp
- Neisseriaspp
- Corynebacterium spp
Systemic infections can occur as well, including:
- Rabies
- Tetanus
- Bartonella (cat-scratch disease)
- Tularemia
- Brucellosis
- Leptospirosis
Careful evaluation of the infectious risks is necessary to determine when prophylaxis is required to prevent serious and life-threatening infections.
- Immediately initiate 4-dose rabies prophylaxis regimen.
- Immediately administer human rabies immune globulin (HRIG).
- Infiltrate wound site with HRIG.
3-5 day course of:
Oral:
- Augmentin-clavulanate
- For penicillin-allergic patients: Extended-spectum oral cepahlosporin or trimethoprim-sulfamethoxazole
- PLUS Clindamycin
Intravenous:
- Ampicillin- sulbactam
- For penicillin-allergic patient: Extended-spectrum cephalosporin or trimethoprim-sulfamethoxazole
- PLUS Clindamycin
Wound Closure:
- Wounds on the face and neck should undergo primary closure after careful irrigation and debridement.
Do not close:
- Wounds on the hands
- Wounds >8-12 hours
- Wounds with early signs of infection
Primary closure of other wounds can be considered on an individual basis.
Immediately administer rabies vaccine today (day 0) and in three days (day 3).
Is Rabies Prophylaxis Needed?
Animal | Risk | Vaccination Needed? | Immunoglobulin Needed? |
|---|---|---|---|
Dog, cat, or ferret | Animal is healthy and can be observed for 10 days | No | No |
Suspected of being rapid | Yes | Yes | |
Uncertainty regarding animal’s status | Contact local public health authorities | Contact local public health authorities | |
Bats, skunks, raccoons, woodchucks, foxes, and other carnivores | Considered high risk unless the animal is proven to be negative by lab results | Yes | Yes |
Livestock, rodents, and rabbits | Often low risk for rabies, but local public health officials should be consulted to discuss local patterns of disease | Contact local public health authorities | Contact local public health authorities |
