Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

uninfected wounds

1st line – wound care

Back
ACUTE
|
uninfected wounds
1st line – 

wound care

The affected skin surface should be cleaned, and the unclosed wound copiously irrigated with water, normal saline, or lactated Ringer solution under high pressure (with an 18- or 19-gauge needle or catheter tip and large syringe).[39][40] Irrigation with a dilute povidone iodine solution may also be considered, particularly if the animal is believed to be rabid.[31][57] Devitalized or necrotic tissue should be debrided and abscesses drained.

Consider – wound closure and repair

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ACUTE
|
uninfected wounds
Consider – 

wound closure and repair

Treatment recommended for SOME patients in selected patient group

Wound closure is a controversial issue. There is general agreement that infected wounds, and those seen >24 hours after the bite, should be left open. Some physicians recommend consideration of wound closure after irrigation and debridement in patients presenting <8 hours after the injury, if there is no visible evidence of infection.

Wounds with a high risk of complication or infection, such as limb wounds, should be left open. In wounds where there are significant cosmetic concerns, such as facial wounds, primary closure is often undertaken by a plastic surgeon or other expert.[43][44][45][46]​ The decision around primary wound closure weighs function and cosmesis against infection, and should be shared between clinician and patient.[10] One 2019 Cochrane systematic review on dog bites found no indication that primary closure reduces infection rates or has an impact on cosmesis, based on weak evidence.[10][47]​​

If wounds include fractures, communication into the joint space, loss of a significant amount of tissue, serious hand bites, cranial bites, or disruption of deep anatomic structures, then orthopedic or surgical consultation is required.

Consider – tetanus prophylaxis

Back
ACUTE
|
uninfected wounds
Consider – 

tetanus prophylaxis

Treatment recommended for SOME patients in selected patient group

Risk of tetanus should be assessed for each bite victim. See Tetanus​.

Consider – rabies prophylaxis

Back
ACUTE
|
uninfected wounds
Consider – 

rabies prophylaxis

Treatment recommended for SOME patients in selected patient group

Postexposure prophylaxis against rabies should be considered. See Rabies.

Plus – prophylactic antibiotics

Back
ACUTE
|
uninfected wounds
|
wound or patient factors that increase risk of infection: not penicillin-allergic
Plus – 

prophylactic antibiotics

Treatment recommended for ALL patients in selected patient group

Prophylactic antibiotics are recommended in all cases of clenched fist injury and should be considered in patients with factors that increase the likelihood of infection or have serious implications of infection.[42] Wound factors include bites to the hand, head, neck, or genital region; puncture or crush wounds; deep structure involvement or requiring surgical repair; bite or laceration from a human or cat; wounds over or near joints; and limbs with impaired vasculature or lymphatic return. Patient factors include previous medical procedures, such as splenectomy or lymph node removal, or underlying medical conditions, such as advanced liver disease, diabetes mellitus, or other immunosuppressive conditions.[14][31][42][53]

Beta-lactam/beta-lactamase inhibitor combination antibiotics (e.g., amoxicillin/clavulanate) have a good spectrum of activity against suspected pathogens encountered in wounds (Pasteurella, Eikenella corrodens, Streptococcus, Staphylococcus, and anaerobes) and are considered the first-line agents. Penicillin and antistaphylococcal penicillins should not be given as single agents for treatment of bite wounds; P multocida and E corrodens are often resistant to antistaphylococcal penicillins, and penicillin is not effective against Staphylococcus.

Cephalosporins (e.g., cefuroxime) are well tolerated but may not provide adequate anaerobic coverage alone, so should be paired with an antibiotic that is effective against anaerobic organisms (e.g., clindamycin, metronidazole).

For pregnant women, azithromycin and metronidazole is an option. Always seek specialist advice before prescribing.[55]

Treatment course is 3 to 5 days.

Primary options

amoxicillin/clavulanate: children <3 months of age: 15 mg/kg orally twice daily; children ≥3 months of age and <40 kg body weight: 12.5 to 22.5 mg/kg orally twice daily; children ≥3 months of age and ≥40 kg body weight and adults: 875 mg orally twice daily

More

Secondary options

cefuroxime axetil: children: 10-15 mg/kg orally twice daily, maximum 1000 mg/day; adults: 500 mg orally twice daily

-- AND --

clindamycin: children: 25-40 mg/kg/day orally given in 3-4 divided doses, maximum 1800 mg/day; adults: 300 mg orally three times daily

or

metronidazole: children: 10 mg/kg orally three times daily, maximum 1500 mg/day; adults: 250-500 mg orally three times daily

OR

azithromycin: adults: 500 mg orally once daily on day 1, followed by 250 mg orally once daily for 4 days

and

metronidazole: adults: 250-500 mg orally three times daily

Plus – prophylactic antibiotics

Back
ACUTE
|
uninfected wounds
|
wound or patient factors that increase risk of infection: penicillin-allergic
Plus – 

prophylactic antibiotics

Treatment recommended for ALL patients in selected patient group

Prophylactic antibiotics are recommended in all cases of clenched fist injury and should be considered in patients with factors that increase the likelihood of infection or have serious implications of infection.[42] Wound factors include bites to the hand, head, neck, or genital region; puncture or crush wounds; deep structure involvement or requiring surgical repair; bite or laceration from a human or cat that punctures the skin; wounds over or near bone, tendons, ligaments, or joints; and limbs with impaired vasculature or lymphatic return. Patient factors include previous medical procedures, such as splenectomy or lymph node removal, or underlying medical conditions, such as advanced liver disease, diabetes mellitus or other immunosuppressive conditions.[14][31][42][53]

Clindamycin has good activity against Staphylococcus, Streptococcus, and anaerobes but decreased activity against Pasteurella multocida and Eikenella corrodens. It should not be used alone but in conjunction with another agent such as trimethoprim/sulfamethoxazole or a fluoroquinolone (e.g., ciprofloxacin, levofloxacin). There is an increased risk of Clostridium difficile colitis with clindamycin use.

Sulfonamides (e.g., trimethoprim/sulfamethoxazole) have good activity against aerobes but poor activity against anaerobes. They should not be used in late pregnancy, and should not be used alone. Sulfonamides should be paired with an agent active against anaerobic organisms (e.g., clindamycin, metronidazole).[42]

Tetracyclines have good activity against Eikenella species and Staphylococcus, with some anaerobic coverage. Combination of doxycycline plus metronidazole may be considered.[53][54]​ Not for use in children ages <8 years or pregnant women.

For pregnant women, azithromycin and metronidazole is an option. Always seek specialist advice before prescribing.[55]

Ciprofloxacin is well tolerated, with good bioavailability. It has good activity against P multocida but no or unreliable activity against Staphylococcus, Streptococcus, and anaerobes; therefore, it should not be used as a single agent. Newer extended-spectrum fluoroquinolones (i.e., moxifloxacin, levofloxacin) have good in-vitro activity against commonly encountered organisms. Moxifloxacin has additional activity against anaerobic organisms and can be used as a single agent.[42]

Fluoroquinolones have been associated with serious, disabling, and potentially irreversible adverse effects including tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.[58] In addition to these restrictions, the Food and Drug Administration has issued warnings about the increased risk of aortic dissection, significant hypoglycemia, and mental health adverse effects in patients taking fluoroquinolones.[59][60] 

Treatment course is 3 to 5 days.

Primary options

clindamycin: children: 25-40 mg/kg/day orally given in 3-4 divided doses, maximum 1800 mg/day; adults: 300 mg orally three times daily

or

metronidazole: children: 10 mg/kg orally three times daily, maximum 1500 mg/day; adults: 250-500 mg orally three times daily

-- AND --

sulfamethoxazole/trimethoprim: children ≥2 months of age: 8-10 mg/kg/day orally given in 2-4 divided doses; adults: 160 mg orally twice daily

More

OR

doxycycline: children ≥8 years of age: 2.2 mg/kg orally twice daily, maximum 200 mg/day; adults: 100 mg orally twice daily

and

metronidazole: children: 10 mg/kg orally three times daily, maximum 1500 mg/day; adults: 250-500 mg orally three times daily

Secondary options

clindamycin: children: 25-40 mg/kg/day orally given in 3-4 divided doses, maximum 1800 mg/day; adults: 300 mg orally three times daily

or

metronidazole: children: 10 mg/kg orally three times daily, maximum 1500 mg/day; adults: 250-500 mg orally three times daily

-- AND --

ciprofloxacin: children: 10-15 mg/kg orally twice daily, maximum 1500 mg/day; adults: 500-750 mg orally twice daily

or

levofloxacin: children: consult specialist for guidance on dose; adults: 750 mg orally once daily

OR

moxifloxacin: children: consult specialist for guidance on dose; adults: 400 mg orally once daily

OR

azithromycin: adults: 500 mg orally once daily on day 1, followed by 250 mg orally once daily for 4 days

and

metronidazole: adults: 250-500 mg orally three times daily

uncomplicated infected bite: not penicillin-allergic

1st line – wound care

Back
ACUTE
|
uncomplicated infected bite: not penicillin-allergic
1st line – 

wound care

Uncomplicated bites include single, localized, nonsevere infected bites.

The affected skin surface should be cleaned, and the unclosed wound copiously irrigated with water, normal saline, or lactated Ringer solution under high pressure (with an 18- or 19-gauge needle or catheter tip and large syringe).[39][40] Irrigation with a dilute povidone iodine solution may also be considered, particularly if the animal is believed to be rabid.[31][57] Devitalized or necrotic tissue should be debrided and abscesses drained.

Plus – oral antibiotics

Back
ACUTE
|
uncomplicated infected bite: not penicillin-allergic
Plus – 

oral antibiotics

Treatment recommended for ALL patients in selected patient group

Beta-lactam/beta-lactamase inhibitor combination antibiotics (e.g., amoxicillin/clavulanate) have a good spectrum of activity against suspected pathogens encountered in wounds (Pasteurella, Eikenella corrodens, Streptococcus, Staphylococcus, and anaerobes) and are considered the first-line agents. Penicillin and antistaphylococcal penicillins should not be given as single agents for treatment of bite wounds; P multocida and E corrodens are often resistant to antistaphylococcal penicillins, and penicillin is not effective against Staphylococcus.

Cephalosporins (e.g., cefuroxime) are well tolerated but may not provide adequate anaerobic coverage alone, so should be paired with an antibiotic that is effective against anaerobic organisms.

For pregnant women, azithromycin and metronidazole is an option. Always seek specialist advice before prescribing.[55]

Treatment course is 10 to 14 days.

Primary options

amoxicillin/clavulanate: children <3 months of age: 15 mg/kg orally twice daily; children ≥3 months of age and <40 kg body weight: 12.5 to 22.5 mg/kg orally twice daily; children ≥3 months of age and ≥40 kg body weight and adults: 875 mg orally twice daily

More

Secondary options

cefuroxime axetil: children: 10-15 mg/kg orally twice daily, maximum 1000 mg/day; adults: 500 mg orally twice daily

-- AND --

clindamycin: children: 25-40 mg/kg/day orally given in 3-4 divided doses, maximum 1800 mg/day; adults: 300 mg orally three times daily

or

metronidazole: children: 10 mg/kg orally three times daily, maximum 1500 mg/day; adults: 250-500 mg orally three times daily

OR

azithromycin: adults: 500 mg orally once daily on day 1, followed by 250 mg orally once daily for 4 days

and

metronidazole: adults: 250-500 mg orally three times daily

Consider – tetanus prophylaxis

Back
ACUTE
|
uncomplicated infected bite: not penicillin-allergic
Consider – 

tetanus prophylaxis

Treatment recommended for SOME patients in selected patient group

Risk of tetanus should be assessed for each bite victim. See Tetanus. 

Consider – rabies prophylaxis

Back
ACUTE
|
uncomplicated infected bite: not penicillin-allergic
Consider – 

rabies prophylaxis

Treatment recommended for SOME patients in selected patient group

Postexposure prophylaxis against rabies should be considered. See Rabies.

uncomplicated infected bite: penicillin-allergic

1st line – wound care

Back
ACUTE
|
uncomplicated infected bite: penicillin-allergic
1st line – 

wound care

Uncomplicated bites include single, localized, nonsevere infected bites.

The affected skin surface should be cleaned, and the unclosed wound copiously irrigated with water, normal saline, or lactated Ringer solution under high pressure (with an 18- or 19-gauge needle or catheter tip and large syringe).[39][40] Irrigation with a dilute povidone iodine solution may also be considered, particularly if the animal is believed to be rabid.[31][57] Devitalized or necrotic tissue should be debrided and abscesses drained.

Plus – oral antibiotics

Back
ACUTE
|
uncomplicated infected bite: penicillin-allergic
Plus – 

oral antibiotics

Treatment recommended for ALL patients in selected patient group

Clindamycin has good activity against Staphylococcus, Streptococcus, and anaerobes but decreased activity against Pasteurella multocida and Eikenella corrodens. It should not be used alone but in conjunction with another agent such as trimethoprim/sulfamethoxazole or a fluoroquinolone (e.g., ciprofloxacin, levofloxacin). There is an increased risk of Clostridium difficile colitis with clindamycin use.

Sulfonamides (e.g., trimethoprim/sulfamethoxazole) have good activity against aerobes but poor activity against anaerobes. They should not be used in late pregnancy, and should not be used alone. Sulfonamides should be paired with an agent active against anaerobic organisms (e.g., clindamycin or metronidazole).[42]

Tetracyclines have good activity against Eikenella species and Staphylococcus, with some anaerobic coverage. Combination of doxycycline plus metronidazole is recommended.[53][54]​ Not for use in children ages <8 years or pregnant women.

For pregnant women, azithromycin and metronidazole is an option. Always seek specialist advice before prescribing.[55]

Ciprofloxacin is well tolerated, with good bioavailability, and good activity against P multocida but no or unreliable activity against Staphylococcus, Streptococcus, and anaerobes; therefore, it should not be used as a single agent. Newer extended-spectrum fluoroquinolones (i.e., moxifloxacin, levofloxacin) have good in-vitro activity against commonly encountered organisms. Moxifloxacin has additional activity against anaerobes and can be used as a single agent.[42]

Fluoroquinolones have been associated with serious, disabling, and potentially irreversible adverse effects including tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.[58] In addition to these restrictions, the Food and Drug Administration has issued warnings about the increased risk of aortic dissection, significant hypoglycemia, and mental health adverse effects in patients taking fluoroquinolones.[59][60]

Treatment course is 10 to 14 days.

Primary options

clindamycin: children: 25-40 mg/kg/day orally given in 3-4 divided doses, maximum 1800 mg/day; adults: 300 mg orally three times daily

or

metronidazole: children: 10 mg/kg orally three times daily, maximum 1500 mg/day; adults: 250-500 mg orally three times daily

-- AND --

sulfamethoxazole/trimethoprim: children ≥2 months of age: 8-10 mg/kg/day orally given in 2-4 divided doses; adults: 160 orally twice daily

More

OR

doxycycline: children ≥8 years of age: 2.2 mg/kg orally twice daily, maximum 200 mg/day; adults: 100 mg orally twice daily

and

metronidazole: children: 10 mg/kg orally three times daily, maximum 1500 mg/day; adults: 250-500 mg orally three times daily

Secondary options

clindamycin: children: 25-40 mg/kg/day orally given in 3-4 divided doses, maximum 1800 mg/day; adults: 300 mg orally three times daily

or

metronidazole: children: 10 mg/kg orally three times daily, maximum 1500 mg/day; adults: 250-500 mg orally three times daily

-- AND --

ciprofloxacin: children: 10-15 mg/kg orally twice daily, maximum 1500 mg/day; adults: 500-750 mg orally twice daily

or

levofloxacin: children: consult specialist for guidance on dose; adults: 750 mg orally once daily

OR

moxifloxacin: children: consult specialist for guidance on dose; adults: 400 mg orally once daily

OR

azithromycin: adults: 500 mg orally once daily on day 1, followed by 250 mg orally once daily for 4 days

and

metronidazole: adults: 250-500 mg orally three times daily

Consider – tetanus prophylaxis

Back
ACUTE
|
uncomplicated infected bite: penicillin-allergic
Consider – 

tetanus prophylaxis

Treatment recommended for SOME patients in selected patient group

Risk of tetanus should be assessed for each bite victim. See Tetanus.

Consider – rabies prophylaxis

Back
ACUTE
|
uncomplicated infected bite: penicillin-allergic
Consider – 

rabies prophylaxis

Treatment recommended for SOME patients in selected patient group

Postexposure prophylaxis against rabies should be considered. See Rabies.

complicated bites: not penicillin-allergic

1st line – wound care

Back
ACUTE
|
complicated bites: not penicillin-allergic
1st line – 

wound care

Complicated bites include those with multiple or severe bite injuries, severe local infection, evidence of systemic infection, or joint or bone involvement and patients with severe underlying illnesses or immunocompromising conditions.

The affected skin surface should be cleaned, and the unclosed wound copiously irrigated with water, normal saline, or lactated Ringer solution under high pressure (with an 18- or 19-gauge needle or catheter tip and large syringe).[39][40]  Irrigation with a dilute povidone iodine solution may also be considered, particularly if the animal is believed to be rabid.[31][57] Devitalized or necrotic tissue should be debrided and abscesses drained.

Plus – parenteral antibiotics

Back
ACUTE
|
complicated bites: not penicillin-allergic
Plus – 

parenteral antibiotics

Treatment recommended for ALL patients in selected patient group

Beta-lactam/beta-lactamase inhibitor combination antibiotics (e.g., ampicillin/sulbactam, piperacillin/tazobactam) have a good spectrum of activity against suspected pathogens encountered in wounds (Pasteurella, Eikenella corrodens, Streptococcus, Staphylococcus, and anaerobes).

Cephalosporins (e.g., ceftriaxone) are well tolerated but may not provide adequate anaerobic coverage alone, so should be paired with an antibiotic that is effective against anaerobic organisms (e.g., clindamycin, metronidazole).

For pregnant women, azithromycin and metronidazole is an option. Always seek specialist advice before prescribing.[55]

Treatment course is 10 to 14 days.

Primary options

ampicillin/sulbactam: children ≥1 year of age and body weight <40 kg: 300 mg/kg/day intravenously given in divided doses every 6 hours, maximum 12 g/day; children ≥1 year of age and body weight ≥40 kg and adults: 1.5 g to 3 g intravenously every 6-8 hours

More

OR

piperacillin/tazobactam: children ≥2 months of age: 270 to 337.5 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 3.375 g/dose; adults: 3.375 g intravenously every 6-8 hours

More

Secondary options

ceftriaxone: children: 50-100 mg/kg/day intravenously given in divided doses every 12-24 hours; adults: 1 g intravenously every 12 hours

-- AND --

clindamycin: children: 20-40 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 2700 mg/day; adults: 600 mg intravenously every 6-8 hours

or

metronidazole: children: 22.5 to 40 mg/kg/day intravenously given in divided doses every 8 hours, maximum 1500 mg/day; adults: 500 mg intravenously every 8 hours

OR

azithromycin: adults: 500 mg intravenously once daily on day 1, followed by 250 mg orally once daily for 4 days

and

metronidazole: adults: 500 mg intravenously every 8 hours

Consider – tetanus prophylaxis

Back
ACUTE
|
complicated bites: not penicillin-allergic
Consider – 

tetanus prophylaxis

Treatment recommended for SOME patients in selected patient group

Risk of tetanus should be assessed for each bite victim. See Tetanus.

Consider – rabies prophylaxis

Back
ACUTE
|
complicated bites: not penicillin-allergic
Consider – 

rabies prophylaxis

Treatment recommended for SOME patients in selected patient group

Postexposure prophylaxis against rabies should be considered. See Rabies.

complicated bites: penicillin-allergic

1st line – wound care

Back
ACUTE
|
complicated bites: penicillin-allergic
1st line – 

wound care

Complicated bites include those with multiple or severe bite injuries, severe local infection, evidence of systemic infection, or joint or bone involvement and patients with severe underlying illnesses or immunocompromising conditions.

The affected skin surface should be cleaned, and the unclosed wound copiously irrigated with water, normal saline, or lactated Ringer solution under high pressure (with an 18- or 19-gauge needle or catheter tip and large syringe).[39][40] Irrigation with a dilute povidone iodine solution may also be considered, particularly if the animal is believed to be rabid.[31][57] Devitalized or necrotic tissue should be debrided and abscesses drained.

Plus – parenteral antibiotics

Back
ACUTE
|
complicated bites: penicillin-allergic
Plus – 

parenteral antibiotics

Treatment recommended for ALL patients in selected patient group

Clindamycin has good activity against Staphylococcus, Streptococcus, and anaerobes but decreased activity against Pasteurella multocida and Eikenella corrodens. It should not be used alone but in conjunction with another agent such as trimethoprim/sulfamethoxazole or a fluoroquinolone (e.g., ciprofloxacin, levofloxacin). There is an increased risk of Clostridium difficile colitis with clindamycin use.

Sulfonamides (e.g., trimethoprim/sulfamethoxazole) have good activity against aerobes but poor activity against anaerobes. They should not be used in late pregnancy, and should not be used alone. Sulfonamides should be paired with an agent active against anaerobic organisms (e.g., clindamycin, metronidazole).

Ciprofloxacin is well tolerated, with good bioavailability. It has good activity against P multocida but no or unreliable activity against Staphylococcus, Streptococcus, and anaerobes; therefore, it should not be used as a single agent. Newer extended-spectrum fluoroquinolones (i.e., moxifloxacin, levofloxacin) have good in-vitro activity against commonly encountered organisms. Moxifloxacin has additional activity against anaerobes and can be used as a single agent.

For pregnant women, azithromycin and metronidazole is an option. Always seek specialist advice before prescribing.[55]

Fluoroquinolones have been associated with serious, disabling, and potentially irreversible adverse effects including tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.[58] In addition to these restrictions, the Food and Drug Administration has issued warnings about the increased risk of aortic dissection, significant hypoglycemia, and mental health adverse effects in patients taking fluoroquinolones.[59][60]

Treatment course is 10 to 14 days.

Primary options

clindamycin: children: 20-40 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 2700 mg/day; adults: 600 mg intravenously every 6-8 hours

or

metronidazole: children: 22.5 to 40 mg/kg/day intravenously given in divided doses every 8 hours, maximum 1500 mg/day; adults: 500 mg intravenously every 8 hours

-- AND --

sulfamethoxazole/trimethoprim: children ages ≥2 months and adults: 5-10 mg/kg/day intravenously given in divided doses every 6-12 hours

More

Secondary options

clindamycin: children: 20-40 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 2700 mg/day; adults: 600 mg intravenously every 6-8 hours

or

metronidazole: children: 22.5 to 40 mg/kg/day intravenously given in divided doses every 8 hours, maximum 1500 mg/day; adults: 500 mg intravenously every 8 hours

-- AND --

ciprofloxacin: children: 15-30 mg/kg/day intravenously given in divided doses every 8-12 hours, maximum 1200 mg/day; adults: 400 mg intravenously every 12 hours

or

levofloxacin: children: consult specialist for guidance on dose; adults: 750 mg intravenously every 24 hours

OR

moxifloxacin: children: consult specialist for guidance on dose; adults: 400 mg intravenously every 24 hours

OR

azithromycin: adults: 500 mg intravenously once daily on day 1, followed by 250 mg orally once daily for 4 days

and

metronidazole: adults: 500 mg intravenously every 8 hours

Consider – tetanus prophylaxis

Back
ACUTE
|
complicated bites: penicillin-allergic
Consider – 

tetanus prophylaxis

Treatment recommended for SOME patients in selected patient group

Risk of tetanus should be assessed for each bite victim. See Tetanus.

Consider – rabies prophylaxis

Back
ACUTE
|
complicated bites: penicillin-allergic
Consider – 

rabies prophylaxis

Treatment recommended for SOME patients in selected patient group

Postexposure prophylaxis against rabies should be considered. See Rabies.

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer