UpToDate Rabies

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Animal bites (dogs, cats, and other animals): Evaluation

and management
Authors: Larry M Baddour, MD, FIDSA, FAHA, Marvin Harper, MD
Section Editor: Allan B Wolfson, MD
Deputy Editors: Keri K Hall, MD, MS, Michael Ganetsky, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2023. | This topic last updated: Jun 24, 2022.
INTRODUCTION
The evaluation and management of animal bite wounds will be discussed here.
Issues related to zoonoses from dogs and cats are found elsewhere. (See "Zoonoses: Dogs" and
"Zoonoses: Cats" and "Capnocytophaga" and "Pasteurella infections" and "Microbiology,
epidemiology, clinical manifestations, and diagnosis of cat scratch disease".)
Issues related to the evaluation and management of human bite wounds are discussed
separately. (See "Human bites: Evaluation and management".)
EPIDEMIOLOGY
Animal bites are common worldwide and may be associated with significant morbidity. In North
America, two to five million animal bites occur annually, which account for about 1 percent of
emergency department visits and 10,000 inpatient admissions annually [1-3].
Dog bites account for approximately 90 percent of animal bites (rate of 103 to 118 per 100,000
population) [4]. Most dog bite victims are children, with the highest number in boys between
five and nine years of age [5-9]. Fatalities are rare but disproportionately affect children
younger than 10 years of age [10,11]. In resource-poor regions of the world, stray dog bites are
an important cause of rabies transmission. (See "Clinical manifestations and diagnosis of
rabies", section on 'Animal reservoirs'.)
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Cat bites account for approximately 10 percent of animal bite wounds and occur most often in
adult women [7]. Infections are more common after cat bites than dog bites [12,13]. For
example, in one retrospective series including more than 2500 dog bites and almost 1000 cat
bites, infection rates were 7 and 49 percent, respectively [12,13].
Factors that increase the risk of infection following an animal bite include [4,14]:
● Underlying immunosuppression (including diabetes)

● Bite involving the hand or foot
● Bite in an extremity with underlying venous and/or lymphatic compromise
● Bite near or in a prosthetic joint or vascular graft
● Crush injury or puncture wound
● Cat bite (given propensity for association with deep puncture wounds)
● Delayed presentation (≥12 hours after a bite on the extremities and ≥24 hours after a bite
on the face)
MICROBIOLOGY
Relevant pathogens in the setting of animal bite wounds include the oral flora of the biting
animal and human skin flora (such as staphylococci and streptococci) [15,16].
Important oral animal flora include:
● Pasteurella spp – Pasteurella species are isolated from 50 percent of dog bite wounds and
75 percent of cat bite wounds ( picture 1) [15]. Pasteurella multocida are fastidious
organisms and are often misidentified. The incubation period for P. multocida infection is
one to three days. (See "Pasteurella infections".)
● Capnocytophaga spp – Capnocytophaga canimorsus can cause bacteremia and fatal sepsis
after animal bites, especially in patients with asplenia, alcoholism, or underlying hepatic
disease [17]. The incubation period for C. canimorsus infection is one to three days. (See
"Capnocytophaga".)
● Bartonella henselae – B. henselae may be transmitted via the bite of an infected cat; other
forms of transmission include cat scratches, flea exposure, and contact with cat saliva via
broken skin or mucosal surfaces. The incubation period for B. henselae infection is 7 to 14
days. (See "Microbiology, epidemiology, clinical manifestations, and diagnosis of cat
scratch disease".)
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● Anaerobes – Anaerobes isolated from dog and cat bite wounds include Bacteroides
species, fusobacteria, Porphyromonas species, Prevotella species, cutibacteria (formerly
propionibacteria), and peptostreptococci [18].
The average bite wound culture yields five types of bacterial isolates [15]. Mixed aerobic and
anaerobic bacteria are observed in 60 percent of cases; skin flora are isolated in about 40
percent of cases [15].
Specimens obtained at the time of debridement of infected wounds should be sent for aerobic
and anaerobic bacterial cultures to identify the causative pathogen(s), prior to initiation of
antibiotics. The laboratory requisition should note that an animal bite wound is the culture
source, given the fastidious nature of P. multocida. (See 'Debridement' below.)
CLINICAL EVALUATION
Patients may seek care for evaluation of bite injury (in absence of infection) or established bite
infection.
History and physical examination — The typical location and nature of bite injury differs
depending upon the nature of the animal inflicting the bite.
● Dog bites – In young children, dog bites usually involve the head and neck [8,19]. In older
children, adolescents and adults, dog bites usually involve the extremities, particularly the
dominant hand [4,7].
Dog bites may be associated with a range of injuries, from minor wounds (eg, scratches,
abrasions) to major wounds (eg, open lacerations, deep puncture wounds, tissue
avulsions, and crush injuries) ( picture 2) [7,20]. In particular, the jaws of large dogs,
such as pit bull terriers, German shepherds, and Rottweilers can exert a strong force that
may inflict serious injury and damage underlying structures [21,22].
In children, a dog bite to the head may penetrate the skull, resulting in depressed skull
fracture, local infection, and/or brain abscess [23,24].
● Cat bites – Cat bites usually occur on the extremities [7]. Cat bite wounds tend to
penetrate deeply with higher risk of deep infection (abscess, septic arthritis, osteomyelitis,
tenosynovitis, bacteremia, or necrotizing soft tissue infection) than dog bites [7,25,26].
The physical examination should first ensure that the patient is hemodynamically stable and
should assess for injuries to adjacent structures, especially for bites with deep puncture
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wounds on the head, neck, trunk, or close to joints. Bite wounds should be evaluated carefully
for foreign material, and a neurovascular assessment should be performed in areas distal to
the wound.
The likelihood of wound infection should be determined based upon physical findings. The
median time to signs and symptoms of infection following a dog bite is approximately 24 hours;
the median time to signs and symptoms of infection following a cat bite is typically shorter (ie,
approximately 12 hours) and infections apparent within hours of a cat bite have been described
[15].
Bite wound infection may be superficial (eg, cellulitis, with or without abscess) or deep (abscess,
septic arthritis, osteomyelitis, tenosynovitis, or necrotizing soft tissue infection):
● Clinical manifestations of cellulitis include fever, tenderness, erythema, swelling, and

warmth; purulent drainage and/or lymphangitis may be present ( picture 3). An
associated superficial abscess may present as a tender, erythematous, fluctuant nodule.
● In addition to the above manifestations, clues for deep infection include persistent or
progressive pain several days following the initial injury, pain with passive movement, pain
out of proportion to exam findings, crepitus, joint swelling, systemic illness (fever,
hemodynamic instability), and persistent signs of infection despite initial wound care and
antibiotic administration.
The level of suspicion for deep infection should be increased for patients with
immunosuppression (including diabetes) or neuropathy; these patients often present later
in their course with increased risk of serious infection and limited pain on clinical exam.
Clinical manifestations of wound infection and associated complications are described further
separately. (See "Cellulitis and skin abscess: Epidemiology, microbiology, clinical manifestations,
and diagnosis" and "Septic arthritis in adults" and "Nonvertebral osteomyelitis in adults: Clinical
manifestations and diagnosis" and "Infectious tenosynovitis" and "Necrotizing soft tissue
infections".)
Laboratory testing — Laboratory testing should be reserved for patients with infected bite
wounds. In these patients, laboratory findings are nonspecific. Leukocytosis and elevated
serum inflammatory markers may or may not be observed in patients with bite-associated
infection.
Cultures from infected bite wounds should be obtained to establish the microbiology of the
infection and to guide antibiotic therapy. Wound cultures are not indicated in clinically
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uninfected bite wounds because results do not correlate with subsequent infection [14,27].
Bacteremia may occur in the setting of superficial or deep infection. Blood cultures should be
obtained in patients with fever or other signs of systemic infection and patients who are
immunosuppressed [14,28]. In other patients, the yield of blood cultures is typically low and the
risk of false positives likely outweighs the benefit.
Imaging — Imaging is not necessary for most clinically uninfected, superficial bites. Deep bite
wounds, including those near joints warrant radiographs (anterior-posterior and lateral) to
evaluate for evidence of foreign bodies (such as embedded teeth), fracture, or joint disruption.
In children <3 years with a dog bite to the scalp associated with a wound of uncertain depth,
computed tomography (CT) of the head may be useful to evaluate for penetrating injury of the
skull [24,29]. Radiographic findings may include skull fracture, puncture through the outer plate
of the skull, and free air in the cranial vault.
In patients with clinical manifestations suspicious for superficial infection, plain radiographs as
described above can help determine the depth of the wound and potential for infection of
adjacent deep soft tissues, joints, or bone. In addition, bedside ultrasound can identify the
presence of an abscess and facilitate drainage. (See "Techniques for skin abscess drainage",
section on 'Bedside ultrasonography'.)
If there is concern for deeper infection (eg, pyomyositis or osteomyelitis), magnetic resonance
imaging (MRI) is the optimal technique. CT may be used if MRI is not immediately available.
Plain radiographs are warranted if other forms of imaging are not available ( picture 4).
Ultrasound may be useful for identifying deep abscess formation but does not facilitate
evaluation of bony structures. (See "Nonvertebral osteomyelitis in adults: Clinical
manifestations and diagnosis", section on 'Radiography' and "Primary pyomyositis", section on
'Radiographic imaging'.)
MANAGEMENT
Patients may seek care for evaluation of bite injury (in absence of infection) or established bite
infection.
Life-threatening wounds — Deep wounds to vital structures should be treated as major

penetrating trauma as discussed separately. (See "Approach to the initially stable child with
blunt or penetrating injury", section on 'Penetrating trauma' and "Penetrating neck injuries:
Initial evaluation and management" and "Severe lower extremity injury in the adult patient".)
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Uninfected bite — For patients with an animal bite injury in the absence of clinical evidence for
infection (on physical examination or imaging), components of management include wound
care, foreign body removal (if present), and assessment of need for antibiotic prophylaxis,
tetanus prophylaxis, and rabies prophylaxis [14,30].
Wound care
Preparation — Appropriate wound management is the most important factor for

preventing infection in patients with animal bites [7].
Components of bite wound care include (see "Basic principles of wound management"):
● Control bleeding (direct pressure should be applied to actively bleeding wounds).
● Clean wound with soap and water, povidone iodine, or other antiseptic solution.
● Provide local anesthesia, followed by irrigation with sterile saline and removal of grossly
visible debris. Clinically uninfected bite wounds should not be cultured; results are not
predictive of subsequent infection [4,14]. (See "Subcutaneous infiltration of local
anesthetics" and "Clinical use of topical anesthetics in children" and "Minor wound
evaluation and preparation for closure".)
● Carefully re-examine the clean wound and determine whether wound closure is
appropriate. (See 'History and physical examination' above and 'Closure' below.)
● Puncture wounds should not be closed; management of these wounds is discussed

separately. (See "Infectious complications of puncture wounds", section on
'Management'.)
Closure — The decision to close a dog or cat bite laceration must weigh the benefit of
enhanced cosmesis with the increased risk of infection associated with animal bites. Indications
for surgical consultation are discussed below. (See 'Surgical consultation' below.)
We suggest that bite wounds be left open to heal by secondary intention (rather than closed
primarily) in the following circumstances [14,31-34]:
● Crush injuries
● Puncture wounds
● Cat bite wounds (facial wounds are an exception; see below)
● Wounds involving the hands and feet ( picture 3)
● Wounds ≥12 hours old (≥24 hours old on the face)
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● Wounds in immunocompromised hosts (including diabetes)

● Wounds in patients with venous stasis
Wounds left open to heal by secondary intention should be debrided, irrigated copiously,
dressed, and evaluated daily for signs of infection.
Primary closure is a reasonable alternative for simple lacerations due to dog bites on the face,
trunk, arms, or legs. In addition, primary closure may be performed for lacerations caused by
cat bites on the face, given the cosmetic importance of this region.
Lacerations closed primarily should be clinically uninfected and ideally <24 hours old (facial
lacerations) or <12 hours old (sites other than the face) [35]. Meticulous debridement and
copious irrigation should be performed prior to closure. Subcutaneous sutures should be
avoided or used sparingly because foreign material in a contaminated wound increases the risk
of infection [14]. Bite wounds should not be closed with tissue adhesive ("glue").
Antibiotic prophylaxis is suggested for all patients who undergo primary closure of a dog or cat
bite. In addition, these patients warrant a wound check at 24 to 48 hours to assess for signs of
infection. (See 'Antibiotic prophylaxis' below.)
Alternatively, the patient may be started on prophylactic antibiotics and return for delayed
primary closure if no signs of infection are present after two to three days.
The Infectious Diseases Society of American (IDSA) recommends against primary closure of dog
or cat bites, other than for facial lacerations; the face is an exception because it is cosmetically
important and has a lower rate of infection relative to other areas, perhaps due to better blood
supply [1].
In general, most experts favor forgoing primary closure of lacerations from cat bites in regions
other than the face, in agreement with the IDSA. However, some experts favor pursuing
primary closure of lacerations due to dog bites on the trunk, arms, or legs (though not on the
hands or feet) [36,37]. The approach depends on individual circumstances including the nature
of the wound, whether irrigation and debridement can reasonably clean the wound, and the
immune status of the host.
Primary closure of simple lacerations after a dog bite is associated with an infection rate of 5 to
8 percent (with or without administration of prophylactic antibiotics); lacerations less than eight
hours old or located on the face have a lower risk of infection [35-38]. In one small trial of dog
bites, laceration closure was not associated with increased rate of infection when compared
with healing by secondary intention [36]. In one series of 80 children with facial dog bite
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wounds managed with primary wound closure and prophylactic antibiotic treatment, no cases
of infection were observed [39].
Surgical consultation — Surgical consultation is warranted in the following circumstances

[33]:
● Complex facial lacerations (see "Assessment and management of facial lacerations")

● Deep wounds that penetrate bone, tendons, joints, or other major structures
● Wounds associated with neurovascular compromise
Antibiotic prophylaxis — In some circumstances, antibiotic prophylaxis is warranted for

patients who present for evaluation of bite injury in the absence of signs or symptoms of
infection.
Indications — We suggest antibiotic prophylaxis for patients with clinically uninfected

wounds and any one of the following features that further raise the risk of infection [1,40-43]:
● Lacerations undergoing primary closure and wounds requiring surgical repair

● Wounds on the hand(s), face, or genital area
● Wounds in close proximity to a bone or joint (including prosthetic joints)
● Wounds in areas of underlying venous and/or lymphatic compromise (including vascular
grafts)
● Wounds in immunocompromised hosts (including diabetes)
● Deep puncture wounds or laceration (especially due to cat bites)
● Wounds with associated crush injury
In the absence of the above factors, we do not favor use of antibiotic prophylaxis; however,
some favor administration of antibiotic prophylaxis for animal bites that are older than eight
hours [44]; the approach should be tailored to individual circumstances.
The above indications for antibiotic prophylaxis are supported by a prospective observational
study including more than 400 patients with dog bites, and infection developed in 5 percent of
cases; wounds at greatest risk of infection included puncture wounds and wounds closed
during treatment [41]. Use of antibiotic prophylaxis is also based upon indirect evidence for a
higher risk of wound infection in certain regions of the body such as the hands, feet, or genital
area and in patients with poor circulation and immunocompromise.
In the absence of the above factors, the benefit of antibiotic prophylaxis appears to be
marginal. In a meta-analysis including eight randomized trials of patients with dog bite wounds,
the cumulative incidence of infection was 16 percent; the relative risk of infection in patients
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treated with antibiotics compared with controls was 0.6 (95% CI 0.4-0.8) [42]. A subsequent
Cochrane review concluded that prophylactic antibiotics did not appear to reduce the rate of
infection after bites by cats or dogs but did reduce the rate of infection following hand bites
(odds ratio 0.1, 95% CI 0.0-0.9) [43].
Regimen — Antibiotic prophylaxis should include empiric coverage of the expected oral
animal flora; appropriate agents are outlined in the table ( table 1). These regimens also
include reasonable coverage of methicillin-susceptible Staphylococcus aureus and streptococci.
Patients who warrant antimicrobial prophylaxis should receive the first dose as soon as possible
after the injury. (See 'Microbiology' above.)
Because of its spectrum of coverage, the preferred antibiotic agent for prevention of infection
due to animal bite wounds is amoxicillin-clavulanate ( table 1) [1].
Alternative prophylaxis regimens for patients unable to take amoxicillin-clavulanate should

include an agent with activity against P. multocida and an agent with anaerobic activity;
regimens and dosing are summarized in the table ( table 1) [1,14,42,45,46].
Agents lacking in vitro activity against P. multocida should be avoided; these include first-
generation cephalosporins (such as cephalexin), penicillinase-resistant penicillins (such as
dicloxacillin), and macrolides (such as erythromycin) [47].
The duration of prophylactic oral antibiotics is three to five days with close follow-up [1]. Signs
of infection on follow-up examination should prompt further evaluation (with radiographic
imaging and/or surgical consultation, if needed), an extension of the antibiotic course, and/or a
switch to intravenous therapy.
Infected bite — For patients with an animal bite and clinical evidence for infection (on physical
examination and/or imaging), components of management include surgical consultation for
selected patients as described below, debridement of infected tissue, foreign body removal (if
present), obtaining wound cultures (and blood cultures in patients with immunocompromise or
signs of systemic infection), administration of antibiotic therapy, and providing tetanus and
rabies prophylaxis as needed [14,30].
Surgical consultation — Surgical consultation for bite-associated infection is warranted in the

following circumstances [33]:
● Deep infection (abscess, septic arthritis, osteomyelitis, tenosynovitis, pyomyositis, or

necrotizing soft tissue infection)
● Infection involving the hands or face
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● Infection associated with neurovascular compromise

● Infection with associated foreign body requiring removal
● Infection in immunocompromised hosts (including diabetes) or patients with venous stasis
● Rapidly progressive infection
● Presence of crepitus
● Persistent signs and symptoms of infection despite appropriate antibiotic therapy
Debridement — Debridement of infected tissue is an important component of management

for an infected bite. If previously repaired, suture material should be removed. Associated
abscess(es) should be drained. (See "Techniques for skin abscess drainage".)
Specimens should be obtained at the time of debridement and prior to the initiation of
antibiotics. They should be sent for aerobic and anaerobic bacterial cultures to identify the
causative pathogen(s). The laboratory requisition should note that an animal bite wound is the
culture source.
In general, infected bite wounds should be left open following debridement, with
approximation of wound edges to facilitate closure by secondary intention. Primary closure is
appropriate for facial wounds, large lacerations, and disfiguring wounds.
Antibiotic therapy — Antibiotic therapy should be administered to patients with suspected or

known bite-associated infection, following collection of blood cultures and wound cultures.
Spectrum of therapy — Antibiotic therapy should include empiric coverage of the

expected oral animal flora; appropriate agents are outlined in the tables ( table 1 and
table 2). These regimens include reasonable coverage of methicillin-susceptible S. aureus and
streptococci. (See 'Microbiology' above and 'Antibiotic prophylaxis' above.)
For patients with risk factors for colonization with methicillin-resistant S. aureus (MRSA)
( table 3), empiric antibiotic coverage for MRSA may be important. In addition, pets can
become colonized with MRSA and transmit it via bites and scratches [48,49]. Issues related to
risk factors and treatment of MRSA are discussed further separately. (See "Methicillin-resistant
Staphylococcus aureus (MRSA) in adults: Treatment of skin and soft tissue infections" and
"Methicillin-resistant Staphylococcus aureus (MRSA) in adults: Epidemiology".)
Route and duration of therapy — The route of antibiotic therapy should be based on
individual clinical circumstances, such as severity of clinical presentation and patient
comorbidities.
Treatment with parenteral antibiotics ( table 2) is warranted in the following circumstances:
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● Systemic signs of toxicity (eg, fever >100.5°F/38°C, hypotension, or sustained tachycardia)

● Deep infection (septic arthritis, osteomyelitis, tenosynovitis, bacteremia, or necrotizing
soft tissue infection)
● Rapid progression of erythema
● Progression of clinical findings after 48 hours of oral antibiotic therapy
● Inability to tolerate oral therapy
● Proximity of the lesion to an indwelling device (eg, prosthetic joint or vascular graft)
The presence of an immunocompromising condition should lower the threshold for parenteral
therapy.
If parenteral antimicrobial therapy is initiated, then a switch to oral treatment is reasonable

once a clinical response to treatment is achieved.
Patients with superficial abscess (in the absence of bacteremia) who undergo drainage may be
managed with initial parenteral antibiotic therapy until infection is resolving, followed by oral
therapy to complete a course of 5 to 14 days [1]. Antibiotic therapy should be continued at least
one to two days after signs and symptoms have resolved; this is typically less than seven days,
but longer treatment may be needed if there is slow resolution of skin and soft tissue findings.
Patients with superficial wound infection (in the absence of abscess) and without signs of
systemic infection may be managed with wound debridement and oral antibiotic therapy
( table 1) to complete a course of 5 to 14 days with close outpatient follow-up; as mentioned
above, a longer course of treatment is used in patients who have a slow response to treatment.
Antibiotic therapy should be tailored to culture and susceptibility data when available. Issues
related to management of infection due to Pasteurella spp, Capnocytophaga spp, and B. henselae
infection are discussed separately. (See "Pasteurella infections" and "Capnocytophaga" and
"Treatment of cat scratch disease".)
In the setting of bacteremia, the approach to antibiotic therapy depends on the nature of the
pathogen identified (see related topics).
Patients with complicated infections (such as tenosynovitis, septic arthritis, or osteomyelitis)

require prolonged therapy tailored to individual circumstances [1]. (See "Infectious
tenosynovitis" and "Septic arthritis in adults" and "Nonvertebral osteomyelitis in adults:
Treatment".)
In patients with infection not requiring debridement or drainage, decisions regarding likely
pathogens should be made based on the clinical history and patient risk factors. (See
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'Microbiology' above.)
PREVENTING TETANUS AND RABIES
Tetanus immunization status should be determined in all patients with bite wounds and
prophylaxis provided as needed. Animal bites are considered a tetanus-prone wound. Issues
related to tetanus prophylaxis are summarized in the table ( table 4) and discussed
separately. (See "Tetanus-diphtheria toxoid vaccination in adults" and "Diphtheria, tetanus, and
pertussis immunization in children 6 weeks through 6 years of age" and "Diphtheria, tetanus,
and pertussis immunization in children 7 through 18 years of age".):
Bites, scratches, abrasions, or contact with animal saliva via mucous membranes or a break in
the skin all can transmit rabies. For bites by potentially rabid animals, early and vigorous
cleansing with soap and water and use of an antiseptic with activity against rabies virus (such as
povidone iodine or 2% benzalkonium chloride) are important methods to decrease the risk of
transmission in addition to timely administration of rabies immune globulin and vaccine [50-
52]. (See 'Preparation' above.)
Issues related to rabies prophylaxis are summarized in the table and algorithm ( table 5 and
algorithm 1) and discussed further separately. (See "Indications for post-exposure rabies
prophylaxis" and "Rabies immune globulin and vaccine".)
UNUSUAL ANIMAL BITES
In general, the bites of small animals (such as squirrels, rodents, rabbits, and guinea pigs)
should be treated in the same fashion as cat bites [53]. Antibiotic prophylaxis and empiric
antibiotic therapy for infected bite wounds typically involves broad spectrum coverage of gram-
positive, gram-negative, and anaerobic bacteria, similar to the spectrum for dog or cat bites.
In some instances, unique bite wound pathogens are identified (eg, Aeromonas species in
alligator bites, Salmonella species in iguana bites, or Vibrio species in shark bites) [54-58].
Antimicrobial therapy should be guided by wound cultures results in consultation with an
infectious disease specialist.
The United States Centers for Disease Control and Prevention provides guidance regarding
the risk for rabies and the need for postexposure prophylaxis based on type of animal
exposure.
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COMPLICATIONS
Complications of animal bites include infection and trauma to deep structures. Fatal injuries
associated with animal bites are rare; they usually occur in young children with injuries
involving the head and neck or direct penetration of vital organs [10,59].
Children who have suffered dog bites may also develop symptoms of post-traumatic stress
disorder [60]. (See "Posttraumatic stress disorder in children and adolescents: Epidemiology,
pathogenesis, clinical manifestations, course, assessment, and diagnosis".)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Skin and soft tissue
infections" and "Society guideline links: Rabies" and "Society guideline links: Dog and cat bites".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print
or email these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Beyond the Basics topics (see "Patient education: Animal and human bites (Beyond the
Basics)" and "Patient education: Rabies (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
● Frequency and complications

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• Dog bites – These account for approximately 90 percent of animal bites and occur
most often in children. They are associated with minor or major wounds and/or soft
tissue infection. In children, dog bites usually involve the head and neck; in adolescents
and adults, they usually involve the extremities. (See 'Epidemiology' above and 'History
and physical examination' above.)
• Cat bites – These account for approximately 10 percent of animal bite wounds and
happen most often in adult women. Cat bites usually occur on the extremities and have
a much higher rate of infection (up to 50 percent) than dog bites. Because cat bites
tend to penetrate deeply, deep infection is more common from cat bites (abscess,
septic arthritis, osteomyelitis, tenosynovitis, bacteremia, or necrotizing soft tissue
infection). (See 'Epidemiology' above and 'History and physical examination' above.)
● Physical examination of wound – Ensure that the patient is hemodynamically stable and
assess for injuries to adjacent structures, especially for bites with deep puncture wounds
on the head, neck, or trunk, or close to joints. Bite wounds should be evaluated carefully
for foreign material, and a neurovascular assessment should be performed in areas distal
to the wound. (See 'History and physical examination' above.)
● Diagnosis of infection – The likelihood of wound infection is based upon physical

findings. Bite wound infection may be superficial (eg, cellulitis, with or without abscess) or
deep (abscess, septic arthritis, osteomyelitis, tenosynovitis, or necrotizing soft tissue
infection). (See 'History and physical examination' above.)
• Superficial infection – Clinical manifestations of superficial infection include fever,

erythema, swelling, and warmth, purulent drainage, and/or lymphangitis. An
associated superficial abscess may present as a tender, erythematous, fluctuant
nodule.
• Deep infection – In addition to the above manifestations, clues for deep infection
include persistent or progressive pain several days following the initial injury, pain with
passive movement, pain out of proportion to exam findings, crepitus, joint swelling,
systemic illness (fever, hemodynamic instability), and persistent signs of infection
despite initial wound care and antibiotic administration. The level of suspicion for deep
infection should be increased in patients with immunodeficiency (including diabetes
mellitus) or neuropathy.
● Role of imaging – Imaging is not necessary for most clinically uninfected, superficial bites.
Deep bite wounds, including those near joints warrant radiographs (anterior-posterior and
lateral) to evaluate for evidence of foreign bodies (such as embedded teeth), fracture, or
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joint disruption. Selected patients with deep bite wounds or findings of deep infection
may warrant advanced imaging such as computed tomography or magnetic resonance
imaging. (See 'Imaging' above.)
● Management of uninfected bites – For patients with an animal bite injury in the absence
of clinical evidence for infection (on physical examination or imaging), essential
components of management include local wound care, foreign body removal (if present),
and administration of antibiotic prophylaxis, tetanus prophylaxis, and rabies prophylaxis,
as needed. (See 'Uninfected bite' above.)
• Wound management – We suggest that bite wounds be left open to heal by

secondary intention (rather than closed primarily) in the following circumstances
(Grade 2C) (see 'Closure' above):
- Crush injuries
- Puncture wounds
- Cat bite wounds (facial wounds are an exception)
- Wounds involving the hands and feet
- Wounds ≥12 hours old (≥24 hours old on the face)
- Wounds in immunocompromised hosts (including diabetes)
- Wounds in patients with venous stasis
Primary closure is a reasonable alternative for simple lacerations due to dog bites on
the face, trunk, arms, or legs. In addition, primary closure may be performed for
lacerations caused by cat bites on the face, given the cosmetic importance of this
region. Lacerations closed primarily should be clinically uninfected and ideally <24
hours old (facial lacerations) or <12 hours old (sites other than the face).
• Indications for surgical consultation – These include complex facial lacerations, deep
wounds, and neurovascular compromise. (See 'Surgical consultation' above.)
• Indications for prophylactic antibiotics – We suggest administering antibiotic

prophylaxis for patients with uninfected bite wounds in the following circumstances
( table 1) (Grade 2C):
- Wounds closed primarily and wounds requiring surgical repair

- Wounds on the hand(s), face, or genital area
- Wounds in close proximity to a bone or joint (including prosthetic joints)
- Wounds in areas of underlying venous and/or lymphatic compromise (including
vascular grafts)
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- Wounds in immunocompromised hosts (including diabetes)

- Deep puncture wounds or laceration (especially due to cat bites)
- Wounds with associated crush injury
Amoxicillin-clavulanate is the preferred agent for prophylaxis; dosing and alternative

regimens are summarized in the table ( table 1). (See 'Antibiotic prophylaxis' above.)
• Rabies and tetanus prophylaxis – Issues related to tetanus and rabies prophylaxis are
summarized above and in the tables ( table 4 and table 5). (See 'Preventing
tetanus and rabies' above.)
● Management of infected bites
• Wound debridement – Debridement of infected tissue and abscess fluid (ie, source
control) is a cornerstone of management. Surgical consultation is indicated in selected
cases. In general, infected bite wounds are left open after debridement, except for
facial wounds, large lacerations, and disfiguring wounds. Wound specimens should be
obtained for culture. (See 'Debridement' above and 'Surgical consultation' above.)
• Antibiotic selection – Antibiotic regimens should cover the oral flora of the biting
animal (such as Pasteurella spp, Capnocytophaga spp, and anaerobes) as well as human
skin flora (such as staphylococci and streptococci). (See 'Microbiology' above and
'Spectrum of therapy' above.)
- Oral antibiotics – Oral antibiotics are often adequate, and amoxicillin-clavulanate

is the preferred agent; dosing and alternative regimens are summarized in the
table ( table 1). (See 'Antibiotic therapy' above.)
- Indications for parenteral antibiotics – Treatment with parenteral antibiotics is

warranted in certain circumstances, such as deep or rapidly progressive infection
or systemic toxicity. Ampicillin-sulbactam is a favored agent; other agents and
dosages are listed in the table ( table 2). (See 'Antibiotic therapy' above and
'Route and duration of therapy' above.)
- Duration of therapy – Superficial infections typically require 5 to 14 days of

antimicrobial therapy. Deeper or complication infections often require longer
durations, based on the underlying infectious process. (See 'Route and duration of
therapy' above.)
• Rabies and tetanus prophylaxis – Issues related to tetanus and rabies prophylaxis are
summarized above and in the tables ( table 4 and table 5). (See 'Preventing
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tetanus and rabies' above.)
Use of UpToDate is subject to the Terms of Use.
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management of skin and soft tissue infections: 2014 update by the infectious diseases
society of America. Clin Infect Dis 2014; 59:147.
2. Lyu C, Jewell MP, Piron J, et al. Burden of Bites by Dogs and Other Animals in Los Angeles
County, California, 2009-2011. Public Health Rep 2016; 131:800.
3. Centers for Disease Control and Prevention (CDC). Nonfatal dog bite-related injuries
treated in hospital emergency departments--United States, 2001. MMWR Morb Mortal Wkly
Rep 2003; 52:605.
4. Ellis R, Ellis C. Dog and cat bites. Am Fam Physician 2014; 90:239.
5. MacBean CE, Taylor DM, Ashby K. Animal and human bite injuries in Victoria, 1998-2004.
Med J Aust 2007; 186:38.
6. Hon KL, Fu CC, Chor CM, et al. Issues associated with dog bite injuries in children and
adolescents assessed at the emergency department. Pediatr Emerg Care 2007; 23:445.
7. Aziz H, Rhee P, Pandit V, et al. The current concepts in management of animal (dog, cat,
snake, scorpion) and human bite wounds. J Trauma Acute Care Surg 2015; 78:641.
8. Schalamon J, Ainoedhofer H, Singer G, et al. Analysis of dog bites in children who are
younger than 17 years. Pediatrics 2006; 117:e374.
9. Garvey EM, Twitchell DK, Ragar R, et al. Morbidity of pediatric dog bites: a case series at a
level one pediatric trauma center. J Pediatr Surg 2015; 50:343.
10. De Munnynck K, Van de Voorde W. Forensic approach of fatal dog attacks: a case report
and literature review. Int J Legal Med 2002; 116:295.
11. Forrester JA, Weiser TG, Forrester JD. An Update on Fatalities Due to Venomous and
Nonvenomous Animals in the United States (2008-2015). Wilderness Environ Med 2018;
29:36.
12. Jaindl M, Grünauer J, Platzer P, et al. The management of bite wounds in children--a
retrospective analysis at a level I trauma centre. Injury 2012; 43:2117.
13. Jaindl M, Oberleitner G, Endler G, et al. Management of bite wounds in children and adults-
an analysis of over 5000 cases at a level I trauma centre. Wien Klin Wochenschr 2016;
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14. Fleisher GR. The management of bite wounds. N Engl J Med 1999; 340:138.
15. Talan DA, Citron DM, Abrahamian FM, et al. Bacteriologic analysis of infected dog and cat
bites. Emergency Medicine Animal Bite Infection Study Group. N Engl J Med 1999; 340:85.
16. Goldstein EJ, Citron DM, Wield B, et al. Bacteriology of human and animal bite wounds. J
Clin Microbiol 1978; 8:667.
17. Butler T. Capnocytophaga canimorsus: an emerging cause of sepsis, meningitis, and post-
splenectomy infection after dog bites. Eur J Clin Microbiol Infect Dis 2015; 34:1271.
18. Goldstein EJ. New horizons in the bacteriology, antimicrobial susceptibility and therapy of
animal bite wounds. J Med Microbiol 1998; 47:95.
19. Patronek GJ, Slavinski SA. Animal bites. J Am Vet Med Assoc 2009; 234:336.
20. Daniels DM, Ritzi RB, O'Neil J, Scherer LR. Analysis of nonfatal dog bites in children. J
Trauma 2009; 66:S17.
21. Sacks JJ, Sinclair L, Gilchrist J, et al. Breeds of dogs involved in fatal human attacks in the
United States between 1979 and 1998. J Am Vet Med Assoc 2000; 217:836.
22. Kaye AE, Belz JM, Kirschner RE. Pediatric dog bite injuries: a 5-year review of the experience
at the Children's Hospital of Philadelphia. Plast Reconstr Surg 2009; 124:551.
23. Sutton LN, Alpert G. Brain abscess following cranial dog bite. Clin Pediatr (Phila) 1984;
23:580.
24. Iannelli A, Lupi G. Penetrating brain injuries from a dog bite in an infant. Pediatr Neurosurg
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25. Goldstein EJ. Bite wounds and infection. Clin Infect Dis 1992; 14:633.
26. Chodakewitz J, Bia FJ. Septic arthritis and osteomyelitis from a cat bite. Yale J Biol Med 1988;
61:513.
27. Callaham M. Prophylactic antibiotics in common dog bite wounds: a controlled study. Ann
Emerg Med 1980; 9:410.
28. Oehler RL, Velez AP, Mizrachi M, et al. Bite-related and septic syndromes caused by cats and
dogs. Lancet Infect Dis 2009; 9:439.
29. Steen T, Ravin K, Timmons S, Kershenovich A. Intracranial Injuries from Dog Bites in
Children. Pediatr Neurosurg 2015; 50:187.
30. Abrahamian FM. Dog Bites: Bacteriology, Management, and Prevention. Curr Infect Dis Rep
2000; 2:446.
31. Brook I. Human and animal bite infections. J Fam Pract 1989; 28:713.
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32. Goldstein EJ. Management of human and animal bite wounds. J Am Acad Dermatol 1989;
21:1275.
33. Kannikeswaran N, Kamat D. Mammalian bites. Clin Pediatr (Phila) 2009; 48:145.
34. Bhaumik S, Kirubakaran R, Chaudhuri S. Primary closure versus delayed or no closure for
traumatic wounds due to mammalian bite. Cochrane Database Syst Rev 2019;
12:CD011822.
35. Paschos NK, Makris EA, Gantsos A, Georgoulis AD. Primary closure versus non-closure of
dog bite wounds. a randomised controlled trial. Injury 2014; 45:237.
36. Maimaris C, Quinton DN. Dog-bite lacerations: a controlled trial of primary wound closure.
Arch Emerg Med 1988; 5:156.
37. Chen E, Hornig S, Shepherd SM, Hollander JE. Primary closure of mammalian bites. Acad
Emerg Med 2000; 7:157.
38. Rui-feng C, Li-song H, Ji-bo Z, Li-qiu W. Emergency treatment on facial laceration of dog bite
wounds with immediate primary closure: a prospective randomized trial study. BMC Emerg
Med 2013; 13 Suppl 1:S2.
39. Wu PS, Beres A, Tashjian DB, Moriarty KP. Primary repair of facial dog bite injuries in
children. Pediatr Emerg Care 2011; 27:801.
40. Morgan M, Palmer J. Dog bites. BMJ 2007; 334:413.

41. Tabaka ME, Quinn JV, Kohn MA, Polevoi SK. Predictors of infection from dog bite wounds:
which patients may benefit from prophylactic antibiotics? Emerg Med J 2015; 32:860.
42. Cummings P. Antibiotics to prevent infection in patients with dog bite wounds: a meta-
analysis of randomized trials. Ann Emerg Med 1994; 23:535.
43. Medeiros I, Saconato H. Antibiotic prophylaxis for mammalian bites. Cochrane Database
Syst Rev 2001; :CD001738.
44. Dendle C, Looke D. Management of mammalian bites. Aust Fam Physician 2009; 38:868.
45. Brakenbury PH, Muwanga C. A comparative double blind study of amoxycillin/clavulanate
vs placebo in the prevention of infection after animal bites. Arch Emerg Med 1989; 6:251.
46. Callaham M. Prophylactic antibiotics in dog bite wounds: nipping at the heels of progress.
Ann Emerg Med 1994; 23:577.
47. Goldstein EJ, Citron DM, Richwald GA. Lack of in vitro efficacy of oral forms of certain
cephalosporins, erythromycin, and oxacillin against Pasteurella multocida. Antimicrob
Agents Chemother 1988; 32:213.
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48. Baptiste KE, Williams K, Willams NJ, et al. Methicillin-resistant staphylococci in companion
animals. Emerg Infect Dis 2005; 11:1942.
49. Sing A, Tuschak C, Hörmansdorfer S. Methicillin-resistant Staphylococcus aureus in a family
and its pet cat. N Engl J Med 2008; 358:1200.
50. Rabies. Local treatment of wounds. World Health Organization. http://www.who.int/rabies/
vaccines/treatment_wound/en/ (Accessed on October 01, 2018).
51. PEREZ GALLARDO F, ZARZUELO E, KAPLAN MM. Local treatment of wounds to prevent
rabies. Bull World Health Organ 1957; 17:963.
52. KAPLAN MM, COHEN D, KOPROWSKI H, et al. Studies on the local treatment of wounds for
the prevention of rabies. Bull World Health Organ 1962; 26:765.
53. Snyder CC. Animal bite wounds. Hand Clin 1989; 5:571.
54. Flandry F, Lisecki EJ, Domingue GJ, et al. Initial antibiotic therapy for alligator bites:
characterization of the oral flora of Alligator mississippiensis. South Med J 1989; 82:262.
55. Kelsey J, Ehrlich M, Henderson SO. Exotic reptile bites. Am J Emerg Med 1997; 15:536.
56. Pavia AT, Bryan JA, Maher KL, et al. Vibrio carchariae infection after a shark bite. Ann Intern
Med 1989; 111:85.
57. Abrahamian FM, Goldstein EJ. Microbiology of animal bite wound infections. Clin Microbiol
Rev 2011; 24:231.
58. Dendle C, Looke D. Review article: Animal bites: an update for management with a focus on
infections. Emerg Med Australas 2008; 20:458.
59. Brogan TV, Bratton SL, Dowd MD, Hegenbarth MA. Severe dog bites in children. Pediatrics
1995; 96:947.
60. Peters V, Sottiaux M, Appelboom J, Kahn A. Posttraumatic stress disorder after dog bites in
children. J Pediatr 2004; 144:121.
Topic 7671 Version 38.0
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GRAPHICS
Pasteurella multocida: Gram stain
Gram stain of purulent drainage from a wound on the finger

following a cat bite (x1000) shows inflammatory cells and small,
gram-negative rods and coccobacilli. Pasteurella multocida grew from
this specimen.
Courtesy of Harriet Provine.
Graphic 70953 Version 5.0
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Uninfected dog bite
This child was bitten multiple times by a dog in the back (Panel A)
and thigh (Panel B).
Reproduced with permission from: Ludwig S (Ed). Bites and stings. In: Atlas of
Pediatric Emergency Medicine, Fleisher GR, Ludwig S, Baskin M (Eds), Lippincott
Williams & Wilkins, Philadelphia 2004. Copyright © 2004 Lippincott Williams &
Wilkins. www.lww.com.
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An infected dog bite
Note the sutured hand wounds, including the puncture wound at

the base of the thumb.
Reproduced with permission from: Ludwig S. Bites and stings. In: Atlas of Pediatric
Emergency Medicine, Fleisher GR, Ludwig S, Baskin M (Eds), Lippincott Williams &
Wilkins, Philadelphia 2004. Copyright © 2004 Lippincott Williams & Wilkins.
www.lww.com.
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Dog bite with fracture
This child sustained a dog bite to the foot, which was sutured at
another institution. On follow-up, he had both cellulitis (Panel A) and
a phalangeal fracture (Panel B), possibly complicated by
osteomyelitis.
Reproduced with permission from: Ludwig S. Bites and stings. In: Atlas of Pediatric
Emergency Medicine, Fleisher GR, Ludwig S, Baskin M (Eds), Lippincott Williams &
Wilkins, Philadelphia 2004. Copyright © 2004 Lippincott Williams & Wilkins.
www.lww.com.
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Dog and cat bites: Oral antibiotic regimens for prophylaxis and empiric
treatment*
Children and infants >28

Antibiotic Adults
days old [1]
Agent of choice
Amoxicillin-clavulanate 875/125 mg twice daily 7:1 formulation: 22.5 mg/kg

(amoxicillin component) twice
daily (maximum 875 mg
amoxicillin and 125 mg
clavulanate per dose)
OR
4:1 formulation: 10 mg/kg

(amoxicillin component) 3 times
daily (maximum 500 mg
amoxicillin and 125 mg
clavulanate per dose)
OR
14:1 formulation: Not ideal for

this use unless clinician
increases the amoxicillin
component dose to 45 mg/kg
twice daily ¶
Alternate regimens include Δ :
One of the following agents with activity against Pasteurella multocida ◊ :
Doxycycline § 100 mg twice daily 1 to 2 mg/kg twice daily

(maximum 100 mg per dose) ¥
TMP-SMX § 1 double-strength tablet twice 4 to 6 mg/kg (trimethoprim

daily component) twice daily
(maximum 160 mg
trimethoprim per dose)
Penicillin V 500 mg 4 times daily 12.5 mg/kg 4 times daily

(maximum 500 mg per dose)
Cefuroxime 500 mg twice daily 10 to 15 mg/kg twice daily

Ciprofloxacin 500 to 750 mg twice daily Use with caution in children <18
years of age ǂ :
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10 to 15 mg/kg twice daily

Levofloxacin 750 mg daily Use with caution in children <18

years of age ǂ :
≥6 months old and <50 kg: 8 to

10 mg/kg twice daily
≥50 kg: 750 mg once daily
PLUS
One of the following agents with anaerobic activity:
Metronidazole 500 mg 3 times daily 10 mg/kg 3 times daily

Clindamycin § 300 to 450 mg 3 times daily 10 mg/kg 3 times daily

OR
Monotherapy with a fluoroquinolone:
Moxifloxacin † 400 mg daily Not recommended; insufficient

experience
The doses recommended above are intended for patients with normal renal function; the doses of
some of these agents must be adjusted in patients with renal insufficiency. Additional coverage for
certain gram-positive pathogens may also be warranted (eg, if the patient has risk factors for
colonization with community-acquired MRSA). Refer to the UpToDate topics on soft tissue infections
due to animal bites and MRSA treatment for recommendations.
TMP-SMX: trimethoprim-sulfamethoxazole; MRSA: methicillin-resistant Staphylococcus aureus.
* The duration of antibiotic prophylaxis is 3 to 5 days; the duration of antibiotic therapy for
established infection is 5 to 14 days.
¶ The use of increased doses of amoxicillin-clavulanate may be considered in pediatric patients with
infected bite wounds.
∆ The preferred regimen for children allergic to penicillin is TMP-SMX OR extended-spectrum

cephalosporin PLUS clindamycin. Alternative regimens for adults allergic to penicillin or beta-
lactams include doxycycline, OR TMP-SMX, OR a fluoroquinolone (ciprofloxacin or levofloxacin) PLUS
metronidazole, OR moxifloxacin (may be used as monotherapy).
◊ The following agents have poor activity against P. multocida and should be avoided: cephalexin,
dicloxacillin, and erythromycin.
§ Doxycycline, TMP-SMX, and clindamycin may also be active against MRSA. If clindamycin is used
for MRSA, confirm susceptibility.
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¥ Teeth staining can occur with repeated course of doxycycline among young children (<8 years); use
with caution.
‡ Use of fluoroquinolones in children should be limited to the treatment of infections for which no
safe and effective alternative exists or in situations where oral therapy is a reasonable alternative to
intravenous therapy with a different class of antibiotics. [1]
† Moxifloxacin has good anaerobic activity and can be used as monotherapy. [2]
Data from:
1. American Academy of Pediatrics. Red Book: 2021-2024 Report of the Committee on Infectious Diseases, 32nd ed,
Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH (Eds), American Academy of Pediatrics, Itasca, IL 2021.
2. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft
tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis 2014; 59:147.
3/30/23, 2:02 AM 7671
Dog and cat bites: Intravenous antibiotic regimens for empiric treatment
Children and infants >28

Antibiotic Adults
days old [1]
Preferred regimens include:
Monotherapy with a beta-lactam/beta-lactamase inhibitor, such as one of the following:
Ampicillin-sulbactam 3 g every 6 hours 50 mg/kg (based on ampicillin

component; maximum 2 g per
dose) every 6 hours
Piperacillin-tazobactam 3.375 g every 6 to 8 hours 100 mg/kg (based on

piperacillin component;
maximum 3 g per dose) every 8
hours
OR
A third-generation cephalosporin, such as:
Ceftriaxone 1 g every 12 hours or 2 g every 50 to 75 mg/kg every 24 hours

24 hours or 50 mg/kg every 12 hours
(maximum 1 g per dose)
PLUS
Metronidazole 500 mg every 8 hours 10 mg/kg every 8 hours

Clindamycin* 600 mg every 6 to 8 hours 10 to 13 mg/kg every 8 hours

Alternative regimens include:
A fluoroquinolone, such as one of the following:
Ciprofloxacin 400 mg every 12 hours Use with caution in children <18

years of age ¶ : 10 to 15 mg/kg
twice daily (maximum 400 mg
per dose)
Levofloxacin 750 mg daily Use with caution in children <18

years of age ¶ :
≥6 months old and <50 kg: 8 to

10 mg/kg every 12 hours
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>50 kg: 500 mg every 24 hours

(maximum 750 mg per day)
PLUS
Metronidazole 500 mg every 8 hours 10 mg/kg every 8 hours

Clindamycin* 600 mg every 6 to 8 hours 10 to 13 mg/kg every 8 hours

OR
Monotherapy with a carbapenem Δ , such as one of the following:
Imipenem-cilastatin 500 mg every 6 hours 15 to 25 mg/kg every 6 hours

Meropenem 1 g every 8 hours 20 mg/kg every 8 hours

(maximum 1 g per dose)
Ertapenem 1 g daily Children <13 years old: 15

mg/kg every 12 hours
Children ≥13 years old: 1 g

daily
OR
Monotherapy with a fluoroquinolone:
Moxifloxacin ◊ 400 mg daily Not recommended; insufficient

experience
The doses recommended above are intended for patients with normal renal function; the doses of
some of these agents must be adjusted in patients with renal insufficiency. When a range of doses is
given, the higher dose is used for more severe infections. Additional coverage for certain gram-
positive pathogens may also be warranted (eg, if the patient has risk factors for colonization with
community-acquired MRSA). Refer to the UpToDate topics on soft tissue infections due to dog and
cat bites and MRSA treatment for recommendations.
MRSA: methicillin-resistant Staphylococcus aureus.
* Clindamycin may also be active against MRSA; if it is used for MRSA, confirm susceptibility.
¶ Use of fluoroquinolones in children should be limited to the treatment of infections for which no
safe and effective alternative exists or in situations where oral therapy is a reasonable alternative to
intravenous therapy with a different class of antibiotics. [1]
Δ Carbapenems should not be used routinely in patients with a history of hypersensitivity to beta-
lactams; skin testing and graded challenge may be useful for assessment of immediate-type
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hypersensitivity reactions. For guidance, refer to the UpToDate topic on carbapenem use in
penicillin-allergic patients.
◊ Moxifloxacin has good anaerobic activity and can be used as a monotherapy. [2]
Data from:
1. American Academy of Pediatrics. Red Book: 2021-2024 Report of the Committee on Infectious Diseases, 32nd ed,
Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH (Eds), American Academy of Pediatrics, Itasca, IL 2021.
2. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft
tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis 2014; 59:147.
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Risk factors for methicillin-resistant Staphylococcus aureus (MRSA) infection

in adults
Health care exposures during the prior 12 months:
Recent hospitalization
Residence in a long-term care facility
Recent surgery
Hemodialysis
Patient-specific risk factors:
Known MRSA colonization or past infection with MRSA
Recent close contact with a person colonized or infected with MRSA
HIV infection
Injection drug use
Homelessness
Men who have sex with men
Antibiotic use within prior 6 months
Environmental exposures associated with outbreaks of MRSA skin abscesses*:
Incarceration or working as prison guard
Military service
Attending schools or living in communities with high colonization rates
Living in crowded conditions
Attending or working in childcare centers
Playing contact sports or sharing sporting equipment
Sharing needles, razors, or other sharp objects
MRSA: methicillin-resistant Staphylococcus aureus.
* These exposures are generally not associated with other types of MRSA infections, including
cellulitis without abscess.
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Wound management and tetanus prophylaxis
Previous Clean and minor wound All other wounds ¶

doses of
Tetanus toxoid- Human tetanus Tetanus toxoid- Human tetanus
tetanus
containing immune containing immune
toxoid* vaccine Δ globulin vaccine Δ globulin ◊
<3 doses or Yes § No Yes § Yes

unknown
≥3 doses Only if last dose No Only if last dose No

given ≥10 years given ≥5 years
ago ago ¥
Appropriate tetanus prophylaxis should be administered as soon as possible following a wound but
should be given even to patients who present late for medical attention. This is because the
incubation period is quite variable; most cases occur within 8 days, but the incubation period can be
as short as 3 days or as long as 21 days. For patients who have been vaccinated against tetanus
previously but who are not up to date, there is likely to be little benefit in administering human
tetanus immune globulin more than 1 week or so after the injury. However, for patients thought to
be completely unvaccinated, human tetanus immune globulin should be given up to 21 days
following the injury; Td or Tdap should be given concurrently to such patients.
DT: diphtheria-tetanus toxoids adsorbed; DTP/DTwP: diphtheria-tetanus whole-cell pertussis; DTaP:

diphtheria-tetanus-acellular pertussis; Td: tetanus-diphtheria toxoids absorbed; Tdap: booster
tetanus toxoid-reduced diphtheria toxoid-acellular pertussis; TT: tetanus toxoid.
* Tetanus toxoid may have been administered as DT, DTP/DTwP (no longer available in the United
States), DTaP, Td, Tdap, or TT (no longer available in the United States).
¶ Such as, but not limited to, wounds contaminated with dirt, feces, soil, or saliva; puncture wounds;
avulsions; or wounds resulting from missiles, crushing, burns, or frostbite.
Δ The preferred vaccine preparation depends upon the age and vaccination history of the patient:
<7 years: DTaP.
Underimmunized children ≥7 and <11 years who have not received Tdap previously: Tdap.
Children who receive Tdap at age 7 through 9 years should receive another dose of Tdap at
age 11 through 12 years.
≥11 years: A single dose of Tdap is preferred to Td for all individuals in this age group who
have not previously received Tdap; otherwise, Td or Tdap can be administered without
preference. Pregnant women should receive Tdap during each pregnancy.
◊ 250 units intramuscularly at a different site than tetanus toxoid; intravenous immune globulin
should be administered if human tetanus immune globulin is not available. Persons with HIV
infection or severe immunodeficiency who have contaminated wounds should also receive human
tetanus immune globulin, regardless of their history of tetanus immunization.
§ The vaccine series should be continued through completion as necessary.
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¥ Booster doses given more frequently than every 5 years are not needed and can increase adverse
effects.
References:
1. Liang JL, Tiwari T, Moro P, et al. Prevention of Pertussis, Tetanus, and Diphtheria with Vaccines in the United States:
Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2018; 67:1.
2. Havers FP, Moro PL, Hunter P, et al. Use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccines:
Updated recommendations of the Advisory Committee on Immunization Practices - United States, 2019. MMWR Morb
Mortal Wkly Rep 2020; 69:77.
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Rabies post-exposure prophylaxis (United States guidelines)* [1,2]
Vaccination
Biologic Schedule
category
Not RIG ¶ Total dose of HRIG Δ is 20 international units/kg body weight,

previously administered on day 0 ◊ . As much of the full dose as feasible should
vaccinated be infiltrated around the wound(s) and any remaining should be
given IM at a different location than the vaccine § .
Vaccine HDCV or PCECV: one dose (1 mL) IM ¥ on days 0 ◊ , 3, 7, and 14 ‡ .
Previously RIG Not indicated

vaccinated †
Vaccine HDCV or PCECV: one dose (1 mL) IM ¥ on days 0 ◊ and 3
RIG: rabies immune globulin; IM: intramuscularly; HDCV: human diploid cell vaccine; PCECV: purified
chick embryo cell vaccine; PVRV: purified Vero cell rabies vaccine.
* Post-exposure prophylaxis should be administered as soon after exposure as possible.
¶ RIG should always be given in a different syringe from the vaccine.
Δ RIG is derived from pooled plasma samples of hyperimmunized human donors (human RIG, or
HRIG) or from horses (equine RIG, or ERIG). Both preparations are considered equally potent and
effective, but only HRIG is recommended for use in the United States. Outside the United States, if
ERIG is used, the dose is 40 international units/kg body weight.
◊ Day 0 is the day the first dose of vaccine (and RIG, if indicated) is administered.
§ The preferred location for IM administration of remaining RIG is the deltoid muscle contralateral to
the vaccine dose. If there is no obvious wound (eg, suspected bat exposure), the entire volume of
RIG should be administered IM, preferably into the anterolateral thigh or the deltoid muscle
contralateral to the vaccine dose. Injection into the gluteus muscle should be avoided as it carries
the risk for sciatic nerve damage.
¥ In adults (ie, age ≥19 years), the deltoid muscle of the arm is the only acceptable IM site of vaccine
administration. In children 3 to 18 years old, the deltoid muscle of the arm is preferred, although the
anterolateral aspect of the thigh is an acceptable alternative. In children ≤2 years old, the
anterolateral aspect of the thigh is preferred; however, in children aged 12 months to 2 years, the
deltoid muscle of the arm is an acceptable alternative if the deltoid muscle mass is adequate.
Vaccine should never be administered in the gluteal area because this may result in lower antibody
titers.
‡ For persons with immunosuppression, rabies post-exposure prophylaxis should be administered

using five doses of vaccine on days 0, 3, 7, 14, and 28. Such patients should have antibody titers
checked 7 to 14 days after the final dose to assess their response.
† To qualify as "previously vaccinated," an individual must meet one of the following criteria: prior
completion of a 3-dose pre-exposure series or a post-exposure series of ≥4 doses, completion of at
least two doses of a pre-exposure prophylaxis series within the 3 years prior to exposure, or prior
partial completion of a pre- or post-exposure series with a subsequent titer that showed ≥0.5
3/30/23, 2:02 AM 7671
international units/mL. All prior vaccine doses must have been given after the advent of modern
vaccines (PCECV, HDCV, or PVRV), which became available in the United States in the early 1980s. All
patients who were immunosuppressed at the time of their prior vaccinations must have had a titer
check that showed ≥0.5 international units/mL. All individuals who do not meet these criteria should
be treated as if they have never been vaccinated.
References:
1. Rupprecht CE, Briggs D, Brown CM, et al. Use of a reduced (4-dose) vaccine schedule for postexposure prophylaxis to
prevent human rabies: recommendations of the advisory committee on immunization practices. MMWR Recomm Rep
2010; 59:1.
2. Rao AK, Briggs D, Moore S, et al. Use of a modified preexposure prophylaxis vaccination schedule to prevent human
rabies: Recommendations of the Advisory Committee on Immunization Practices – United States, 2022. MMWR Morb
Mortal Wkly Rep 2022; 71:619.
3/30/23, 2:02 AM 7671
Rabies postexposure prophylaxis algorithm
PEP: postexposure prophylaxis.
* PEP should be initiated immediately in patients with severe bites to the head, neck, or trunk after an unpro
attack from a high-risk animal. PEP can be discontinued if testing proves the animal was not rabid.
¶ In areas without an endemic, terrestrial strain of rabies (eg, dog, raccoon, skunk, fox, mongoose), contact
public health authorities for risk assessment.
Courtesy of Alfred DeMaria Jr, MD and the Massachusetts Department of Public Health.
3/30/23, 2:02 AM 7671
Contributor Disclosures
Larry M Baddour, MD, FIDSA, FAHA Consultant/Advisory Boards: Boston Scientific [Cardiovascular device
infection]; Roivant Sciences [Phage therapy for Staphylococcus aureus bacteremia and endocarditis]. All of
the relevant financial relationships listed have been mitigated. Marvin Harper, MD No relevant financial
relationship(s) with ineligible companies to disclose. Allan B Wolfson, MD No relevant financial
relationship(s) with ineligible companies to disclose. Keri K Hall, MD, MS No relevant financial
relationship(s) with ineligible companies to disclose. Michael Ganetsky, MD No relevant financial
relationship(s) with ineligible companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy

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Animal bites (dogs, cats, and other animals): Evaluation

● Underlying immunosuppression (including diabetes)

Important oral animal flora include:

● Clinical manifestations of cellulitis include fever, tenderness, erythema, swelling, and

Life-threatening wounds — Deep wounds to vital structures should be treated as major

Preparation — Appropriate wound management is the most important factor for

● Control bleeding (direct pressure should be applied to actively bleeding wounds).

● Puncture wounds should not be closed; management of these wounds is discussed

● Wounds in immunocompromised hosts (including diabetes)

Surgical consultation — Surgical consultation is warranted in the following circumstances

● Complex facial lacerations (see "Assessment and management of facial lacerations")

Antibiotic prophylaxis — In some circumstances, antibiotic prophylaxis is warranted for

Indications — We suggest antibiotic prophylaxis for patients with clinically uninfected

● Lacerations undergoing primary closure and wounds requiring surgical repair

Alternative prophylaxis regimens for patients unable to take amoxicillin-clavulanate should

Surgical consultation — Surgical consultation for bite-associated infection is warranted in the

● Deep infection (abscess, septic arthritis, osteomyelitis, tenosynovitis, pyomyositis, or

● Infection associated with neurovascular compromise

Debridement — Debridement of infected tissue is an important component of management

Antibiotic therapy — Antibiotic therapy should be administered to patients with suspected or

Spectrum of therapy — Antibiotic therapy should include empiric coverage of the

Treatment with parenteral antibiotics ( table 2) is warranted in the following circumstances:

● Systemic signs of toxicity (eg, fever >100.5°F/38°C, hypotension, or sustained tachycardia)

If parenteral antimicrobial therapy is initiated, then a switch to oral treatment is reasonable

Patients with complicated infections (such as tenosynovitis, septic arthritis, or osteomyelitis)

PREVENTING TETANUS AND RABIES

UNUSUAL ANIMAL BITES

SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

SUMMARY AND RECOMMENDATIONS

● Frequency and complications

● Diagnosis of infection – The likelihood of wound infection is based upon physical

• Superficial infection – Clinical manifestations of superficial infection include fever,

• Wound management – We suggest that bite wounds be left open to heal by

• Indications for prophylactic antibiotics – We suggest administering antibiotic

- Wounds closed primarily and wounds requiring surgical repair

- Wounds in immunocompromised hosts (including diabetes)

Amoxicillin-clavulanate is the preferred agent for prophylaxis; dosing and alternative

● Management of infected bites

- Oral antibiotics – Oral antibiotics are often adequate, and amoxicillin-clavulanate

- Indications for parenteral antibiotics – Treatment with parenteral antibiotics is

- Duration of therapy – Superficial infections typically require 5 to 14 days of

tetanus and rabies' above.)

Use of UpToDate is subject to the Terms of Use.

40. Morgan M, Palmer J. Dog bites. BMJ 2007; 334:413.

Pasteurella multocida: Gram stain

Gram stain of purulent drainage from a wound on the finger

Courtesy of Harriet Provine.

Graphic 70953 Version 5.0

Uninfected dog bite

Graphic 56399 Version 12.0

An infected dog bite

Note the sutured hand wounds, including the puncture wound at

Graphic 74167 Version 12.0

Dog bite with fracture

Graphic 68154 Version 13.0

Children and infants >28

Amoxicillin-clavulanate 875/125 mg twice daily 7:1 formulation: 22.5 mg/kg

4:1 formulation: 10 mg/kg

14:1 formulation: Not ideal for

Alternate regimens include Δ :

One of the following agents with activity against Pasteurella multocida ◊ :