The correct answer is:

Irrigate, then suture the wound with 6.0 nonabsorbable material and prescribe amoxicillin/clavulanate

Educational Objective:

Discuss the management and controversies of dog bites to the face.

Key Point:

Facial dog bites do NOT require antibiotics if the wound is allowed to close by secondary intention (unless other high-risk features are present). However, antibiotic prophylaxis is recommended for ANY dog bite that undergoes primary closure, regardless of location of the bite (see Rosen 2018, chapter 54, Table 54.2).

Explanation:

Two separate controversies around the management of dog bites are often confused with each other:

1. the controversy of whether or not to primarily close a bite wound  
2. the controversy of whether or not to give prophylactic antibiotics

Controversy #1 - Primary Closure

Usually, it is recommended to NOT primarily close mammalian bites. Dog bites have a lower propensity for getting infected and therefore have a few exceptions to this rule. Indications for primary closure of a dog bite include a location on the face or scalp, a wound treated within 6 hours of injury, the possibility of a single layer closure, a lack of underlying fracture, and immunocompetent status. Facial dog bites are typically closed with a 6.0 non-absorbable monofilament. In facial wounds, debridement should be minimal because preserving the subcutaneous fat prevents the scar from sinking and, thus, preserves normal facial contour. Sutures should be removed in 5 days.

Controversy #2 - Antibiotic Prophylaxis

Many authors/guidelines state that antibiotics are not needed unless high risk factors are present. However, the “fine print” is often overlooked: primary closure of a dog bite (or any mammalian bite) moves the wound into a HIGH RISK category, regardless of the bite’s location on the body.

In other words: a facial dog bite is SAFE without antibiotics if it undergoes delayed closure or SAFE with antibiotics if it undergoes primary closure. A facial dog bite is – by most guidelines – NOT safe for primary closure PLUS also withholding antibiotics. Since most clinicians would primarily close facial dog bites for cosmetic reasons, most patients with facial dog bites end up on a short course of antibiotics. Some authors (Roberts and Hedges) will endorse primary closure without antibiotics, but they are the exception.

Postexposure antibiotic prophylaxis for dog bites is currently advised for:

• ANY primarily closed wound, regardless of location on the patient’s body (the above case),
• Hand wounds,
• Wounds close to a bone or joint,
• Deep tissue/crush/puncture-type injuries,
• Immunocompromised patients.

Even though dog bites look like lacerations, there typically is a crush component to the bite (in contrast to cat bites) that results in devitalized tissue (not appreciable upon presentation) and creates an ischemic microenvironment that fosters infection.

When prophylaxis is indicated, amoxicillin/clavulanate for 5 days is recommended. Adult patients allergic to penicillin should be provided alternative therapy that can include clindamycin plus a fluoroquinolone; pediatric patients allergic to penicillin should be given clindamycin plus trimethoprim/sulfamethoxazole. Antibiotics without activity against Pasteurella multocida such as first-generation cephalosporins or macrolides should not be used alone.

If the dog is healthy and able to be observed for 10 days, then rabies postexposure prophylaxis is not recommended. Provoked attacks by dogs whose vaccines are up to date are unlikely to transmit rabies. If the dog has escaped or is unknown, then the local public health department should be consulted and local rabies prevalence taken into consideration. If postexposure prophylaxis is indicated, then rabies immunoglobulin and human diploid cell rabies vaccine should be administered as soon as possible.

Pearl:

Another frequently overlooked high-risk indication for antibiotics: a child on steroids for reactive airway disease.

References:

Eilbert WP, Mammalian Bites (Chapter 54) In: Walls R, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 19th ed., 2018:690-697e2.

Simon BC, Hern HJ Jr. Wound Management Principles. (Chapter 52) In: Walls R, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 19th ed., 2018:659-673e2.

Doud Galli SK. Animal Bites Treatment & Management.  updated Jan 27 2017. Accessed June 7, 2018.

Lammers RL, Kim NA. Principles of wound management. In: Roberts JR, et al. Roberts and Hedges’ Clinical Procedures in Emergency Medicine. 7th ed., 2019: 621-654.e2.

Swaminathan A. Medical Myths in the Management of Dog Bites. July 17, 2014. Accessed November 19, 2020.