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Prevention and Treatment of Dog Bites R Prevention and Treatment of Dog Bites R. JOHN PRESUTTI, D.O., Mayo Clinic Jacksonville, Jacksonville, Florida Almost one half of all dog bites involve an animal owned by the victim’s family or neighbors. A large percentage of dog bite victims are children. Although some breeds O A patient informa- of dogs have been identified as being more aggressive than other breeds, any dog tion handout on the prevention and treat- may attack when threatened. All dog bites carry a risk of infection, but immediate ment of dog bites, copious irrigation can significantly decrease that risk. Assessment for the risk of written by the author tetanus and rabies virus infection, and subsequent selection of prophylactic antibi- of this article, is pro- otics, are essential in the management of dog bites. The dog bite injury should be doc- vided on page 1573. umented with photographs and diagrams when appropriate. Family physicians should educate parents and children on ways to prevent dog bites. (Am Fam Physician 2001; 63:1567-72,1573-4.) ach year approximately 4 million ing from a dog bite most often involve a sleep- Americans are bitten by dogs, and ing baby.1,2 about 800,000 of these persons Several dog breeds have been identified for (44 percent of whom are younger their role in fatal dog bite attacks, including than 14 years) present for medical pit bull breeds, malamutes, chows, Rottweil- Etreatment.1-3 More than one dozen fatalities ers, huskies, German shepherds and wolf related to dog bites occur each year in this hybrids.1,2,8 From 1979 to 1988, pit bull country; most of these victims are children.1,2 breeds accounted for more than 41 percent of Although most dog bite attacks are not pro- dog bite–related fatalities, three times as voked,3 there are several measures that adults many as German shepherds.2 and children can take to decrease the possibil- ity of being bitten. Family physicians can edu- Management of Dog Bites cate parents and children on ways to prevent INITIAL WOUND MANAGEMENT dog bites, but, when dog bites do occur, the After confirming that the victim is med- physician must be knowledgeable about how ically stable, physicians should begin a pri- to treat the bites effectively. mary assessment by taking a history. Several As of 1994, an estimated 34 million Ameri- medical conditions place a patient at high risk can households owned at least one dog, of wound and rabies virus infection from a accounting for a canine population in the dog bite (Table 1).7 Information that can help United States in excess of 55 million.1,2,4 Most determine the patient’s risk of infection dogs never bite a human; however, under cer- tain circumstances, any dog is capable of inflicting harm. The most common victims of TABLE 1 dog bites are children, especially in incidents Medical Conditions Associated with a that prove fatal.2,5-7 Almost one half of all High Risk of Infection After a Dog Bite reported cases of dog bites involve an animal owned by the victim’s family or the victim’s Chronic disease Previous mastectomy neighbors.3 Most victims are involved in nor- Chronic edema of Prosthetic valve or joint the extremity mal, nonprovoking activities before the dog Splenectomy Diabetes mellitus 2 Systemic lupus attacks. For example, neonatal deaths result- Immunosuppression erythematosus Liver dysfunction More than one dozen fatalities related to dog bites occur Adapted with permission from Lewis KT, Stiles M. Management of cat and dog bites. Am Fam Physi- each year in this country; most of these victims are children. cian 1995;52:482. APRIL 15, 2001 / VOLUME 63, NUMBER 8 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1567 radiographs may be obtained, especially with 5 Treatment with prophylactic antibiotics for three to seven puncture wounds near a joint or bone. The role of wound closure remains contro- days is appropriate for dog bite wounds, unless the risk of versial. Puncture wounds, wounds that appear infection is low or the wound is superficial. clinically infected and wounds more than 24 hours old may have a better outcome with delayed primary closure or healing by sec- includes the time of the injury, whether the ondary intention.5,6 Some physicians close animal was provoked, and the general health, wounds that are less than eight hours old and immunization status and current location of wounds located on the face.5 The success of the animal.7 In some locations, notification of closing facial wounds can probably be attrib- animal control or local law enforcement may uted to the enhanced blood supply to the face be necessary. Also, the patient’s tetanus and the lack of dependent edema.5 Plastic immunization status, current medications surgery, general surgery or maxillofacial and allergies must be noted in the record.7 surgery may be necessary for deep wounds or During the physical examination, the mea- those requiring significant debridement and surement and classification of the wound closure. Cultures are usually not helpful unless (laceration, puncture, crushing or avulsion), the wound appears infected or is unresponsive and the range of motion of the affected and to appropriate antibiotic therapy. When a cul- adjacent areas should be documented. Nerve, ture is necessary, aerobic and anaerobic cul- vascular and motor function, including perti- tures should be obtained and observed for a nent negative findings, should be recorded. minimum of seven to 10 days to allow for Diagrams and photographs are useful, espe- slow-growing pathogens.7 Orthopedic consul- cially in cases with irregular wounds or signs tation should be considered for wounds that of infection,9 and in cases that may involve directly involve joints or other bony structures. litigation, such as a wound inflicted by an unleashed dog.7 ANTIBIOTIC TREATMENT Timely and copious irrigation with normal Only 15 to 20 percent of dog bite wounds saline or Ringer’s lactate solution may reduce become infected. Crush injuries, puncture the rate of infection markedly. Injection of the wounds and hand wounds are more likely to tissue with irrigant solution should be become infected than scratches or tears.9 Most avoided, because this can spread the infec- infected dog bite wounds yield polymicrobial tion.5,7 Necrotic or devitalized tissues should organisms.8 Pasteurella multocida and Staph- be removed, but care must be taken not to ylococcus aureus are the most common aerobic debride so much tissue as to cause problems organisms, occurring in 20 to 30 percent of with wound closure and appearance.9 Baseline infected dog bite wounds.4,5 Other possible aerobic pathogens include Streptococcus species, Corynebacterium species, Eikenella corrodens and Capnocytophaga canimorsus The Author (formerly known as DF-2).5,7,8 Anaerobic R. JOHN PRESUTTI, D.O., is a consultant and associate program director in the Depart- organisms, including Bacteroides fragilis, Fuso- ment of Family Medicine at Mayo Clinic Jacksonville, Jacksonville, Fla. Dr. Presutti is also bacterium species and Veillonella parvula, have an assistant professor of Family Medicine at Mayo Medical School, Rochester, Minn. Dr. also been implicated in infected dog bites. One Presutti received his osteopathic medical degree from Nova Southeastern University, 8 Fort Lauderdale, Fla., and completed a residency in family medicine at Mayo Clinic Jack- review article identified 28 species of aerobic sonville. He is a diplomate in family medicine and osteopathic family medicine. organisms and 12 species of anaerobic organ- Address correspondence to R. John Presutti, D.O., Mayo Clinic Jacksonville, 4500 San isms isolated from dog bite wounds. Pablo Rd., Jacksonville, FL 32224. Reprints are not available from the author. Treatment with prophylactic antibiotics for 1568 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 63, NUMBER 8 / APRIL 15, 2001 Dog Bites three to seven days is appropriate for dog bite mal on the loose, it is important to document wounds, unless the risk of infection is low or the conditions surrounding the attack. As a the wound is superficial.4,5,7 If frank cellulitis is result of widespread vaccination of dogs evident, a 10- to 14-day course of treatment is against rabies in the United States, the most more appropriate.9 Amoxicillin-clavulanate common source of the rabies virus is now potassium (Augmentin) is the antibiotic of wild animals, specifically raccoons, skunks choice for a dog bite. For patients who are aller- and bats.7 Nonetheless, there are still reported gic to penicillin, doxycycline (Vibramycin) is an cases of rabies virus associated with a dog acceptable alternative, except for children bite.13 Patients with a bite from a nonpro- younger than eight years and pregnant women. voked dog should be considered at higher risk Erythromycin can also be used, but the risk of for rabies infection than patients with a bite treatment failure is greater because of antimi- from a provoked dog. If the dog owner is reli- crobial resistance.7,10 Other acceptable combi- able and can confirm that the animal’s vacci- nations include clindamycin (Cleocin) and a nation against rabies virus is current, the dog fluoroquinolone in adults or clindamycin and may be observed at the owner’s home. Obser- trimethoprim-sulfamethoxazole (Bactrim, vation by a veterinarian is appropriate when Septra) in children.11 When compliance is a concern, daily intramuscular injections of cef- triaxone (Rocephin) are appropriate.7 TABLE 2 Occasionally, outpatient treatment of infec- Summary of ACIP Recommendations for Tetanus Prophylaxis tion fails and the patient needs to be hospital- in Routine Wound Management ized and treated intravenously with antibiotics. Reasons for hospitalization include systemic Clean, minor wounds All other wounds* signs of infection; fever or chills; severe or History of adsorbed rapidly spreading cellulitis or advancement of tetanus toxoid (doses) Td† TIG Td† TIG cellulitis past one joint; and involvement of a bone, joint, tendon or nerve.5 Unknown or less than three Yes No Yes Yes Consultation with a maxillofacial or plastic Three or more‡ No§ No No|| No surgeon may be required if the patient has a facial or other highly visible wound.
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