Health Promotion & Education cases with irregular wounds or signs of infection,9 and in cases that may involve

litigation, such as a wound inflicted by an unleashed dog.7

Dog Bite Prevention Tips

TABLE 1
Medical Conditions Associated with a High Risk of Infection After a Dog Bite
Annually more than four million Americans, approximately half of them children,
suffer dog bite injuries. Injury rates are highest among children between the
ages of five and nine, with boys being bitten more often than girls in the same Chronic disease
age group. The number of dog bite injuries increases between the months of Chronic edema of the extremity
April and September, with the peak occurring in July. Diabetes mellitus
Immunosuppression
Liver dysfunction
According to the CDC, as many as 800,000 people require medical attention for Previous mastectomy
dog bites annually. Of those, 368,000 are treated in hospital emergency Prosthetic valve or joint
departments and about a dozen die each year from dog bite injuries. Splenectomy
Systemic lupus erythematosus
Responsible dog ownership along with teaching children how to act around
dogs, are proven ways to prevent dog bites. Remember direct adult supervision
of children remains the hallmark of Injury Prevention.
Adapted with permission from Lewis KT, Stiles M. Management of cat and dog
bites. Am Fam Physician 1995;52:482.
Safety Tips for Adults and Children

Timely and copious irrigation with normal saline or Ringer's lactate solution may
 Never approach an unfamiliar dog. reduce the rate of infection markedly. Injection of the tissue with irrigant
 Never run from or scream around a dog. solution should be avoided, because this can spread the infection.5,7 Necrotic or
 If you believe a dog is about to attack you, try to place something devitalized tissues should be removed, but care must be taken not to debride so
between yourself and the dog, such as a backpack or a bicycle. much tissue as to cause problems with wound closure and appearance.9
 If a dog knocks you over, roll into a ball, cover your face and stay still. Baseline radiographs may be obtained, especially with puncture wounds near a
 Children should never play with dogs unless supervised by an adult. joint or bone.5
 Children should tell an adult if they see a stray dog or a dog acting
strangely.
The role of wound closure remains controversial. Puncture wounds, wounds that
 Don't look a dog directly in its eye.
appear clinically infected and wounds more than 24 hours old may have a better
 Don't disturb a dog that is sleeping, eating or caring for puppies.
outcome with delayed primary closure or healing by secondary intention.5,6
 Don't play with a dog without allowing him to see and sniff you first.
Some physicians close wounds that are less than eight hours old and wounds
Children should never approach a dog unless supervised by an adult.
located on the face.5 The success of closing facial wounds can probably be
 Adults should never leave an infant or young child alone with any
attributed to the enhanced blood supply to the face and the lack of dependent
dog, not even the family pet.
edema.5 Plastic surgery, general surgery or maxillofacial surgery may be
necessary for deep wounds or those requiring significant debridement and
closure. Cultures are usually not helpful unless the wound appears infected or is
If bitten by a dog: unresponsive to appropriate antibiotic therapy. When a culture is necessary,
aerobic and anaerobic cultures should be obtained and observed for a minimum
of seven to 10 days to allow for slow-growing pathogens.7 Orthopedic
 Seek medical attention immediately.
consultation should be considered for wounds that directly involve joints or
 Control bleeding and wash the area of the bite with soap and water.
other bony structures.
 Report the bite to your local county health department, animal
control agency or police.
 Provide authorities with an accurate description of the dog, the ANTIBIOTIC TREATMENT
circumstances surrounding the bite, and the dog owner's identity, if
known. Only 15 to 20 percent of dog bite wounds become infected. Crush injuries,
puncture wounds and hand wounds are more likely to become infected than
scratches or tears.9 Most infected dog bite wounds yield polymicrobial
organisms.8 Pasteurella multocida and Staphylococcus aureus are the most
common aerobic organisms, occurring in 20 to 30 percent of infected dog bite
wounds.4,5 Other possible aerobic pathogens include Streptococcus species,
Corynebacterium species, Eikenella corrodens and Capnocytophaga canimorsus
Management of Dog Bites (formerly known as DF-2).5,7,8 Anaerobic organisms, including Bacteroides
fragilis, Fuso-bacterium species and Veillonella parvula, have also been
INITIAL WOUND MANAGEMENT implicated in infected dog bites. One review article8 identified 28 species of
aerobic organisms and 12 species of anaerobic organisms isolated from dog bite
wounds.
After confirming that the victim is medically stable, physicians should begin a
primary assessment by taking a history. Several medical conditions place a
patient at high risk of wound and rabies virus infection from a dog bite (Table Treatment with prophylactic antibiotics for three to seven days is appropriate
1).7 Information that can help determine the patient's risk of infection includes for dog bite wounds, unless the risk of infection is low or the wound is
the time of the injury, whether the animal was provoked, and the general superficial.4,5,7 If frank cellulitis is evident, a 10- to 14-day course of treatment
health, immunization status and current location of the animal.7 In some is more appropriate.9 Amoxicillin-clavulanate potassium (Augmentin) is the
locations, notification of animal control or local law enforcement may be antibiotic of choice for a dog bite. For patients who are allergic to penicillin,
necessary. Also, the patient's tetanus immunization status, current medications doxycycline (Vibramycin) is an acceptable alternative, except for children
and allergies must be noted in the record.7 During the physical examination, the younger than eight years and pregnant women. Erythromycin can also be used,
measurement and classification of the wound (laceration, puncture, crushing or but the risk of treatment failure is greater because of antimicrobial
avulsion), and the range of motion of the affected and adjacent areas should be resistance.7,10 Other acceptable combinations include clindamycin (Cleocin)
documented. Nerve, vascular and motor function, including pertinent negative and a fluoroquinolone in adults or clindamycin and trimethoprim-
findings, should be recorded. Diagrams and photographs are useful, especially in sulfamethoxazole (Bactrim, Septra) in children.11 When compliance is a
concern, daily intramuscular injections of ceftriaxone (Rocephin) are From Diphtheria, tetanus, and pertussis: recommendations for vaccine use and
appropriate.7 other preventive measures. Recommendations of the Advisory Committee on
Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 1991;40:21.
Occasionally, outpatient treatment of infection fails and the patient needs to be
hospitalized and treated intravenously with antibiotics. Reasons for Rabies immunization should begin within 48 hours after the bite, but it can be
hospitalization include systemic signs of infection; fever or chills; severe or subsequently discontinued if the animal is shown to be free of rabies virus.
rapidly spreading cellulitis or advancement of cellulitis past one joint; and Rabies immunization consists of an active immune response with a vaccine and a
involvement of a bone, joint, tendon or nerve.5 passive immune response with rabies immune globulin (RIG). Guidelines for
rabies immunization are given in Table 3.14
Consultation with a maxillofacial or plastic surgeon may be required if the
patient has a facial or other highly visible wound. For patients hospitalized with Three types of rabies vaccine are currently available in the United States: human
cellulitis or abscess formation in an extremity, surgical consultation should be diploid cell vaccine (HDCV), rabies vaccine adsorbed (RVA) and purified chick
considered immediately because of the risk of worsening infection and tissue embryo cell vaccine (PCEC). All are formulated for intramuscular use, but HDCV
damage. Depending on community practices and the location of the injury, is also available for intradermal use.14 All forms seem to have equivalent safety
general orthopedic surgery, hand surgery or general surgery consultation may and efficacy.14,15 Once the vaccine series has begun, it is usually completed
be appropriate. Tetanus immunization and tetanus immune globulin should be with the same vaccine type. Vaccine is administered on days 0, 3, 7, 14 and 28.
administered, if appropriate. Recommendations for tetanus prophylaxis are
given in Table 2.12
RIG is administered once and provides rapid immunity with a half-life of 21
days.14 RIG is not administered to patients who have been previously
ASSESSING THE RISK OF RABIES vaccinated.14

The patient's risk of infection with rabies virus must be addressed immediately. TABLE 3
Because of the serious risk to the public of a rabid animal on the loose, it is Guidelines for Rabies Immunization
important to document the conditions surrounding the attack. As a result of
widespread vaccination of dogs against rabies in the United States, the most Vaccination
common source of the rabies virus is now wild animals, specifically raccoons, status TreatmentRegimen*
skunks and bats.7 Nonetheless, there are still reported cases of rabies virus Not RIG Administer 20 IU per kg body weight. If anatomically
associated with a dog bite.13 Patients with a bite from a nonprovoked dog previously feasible, the fulldose should be infiltrated around the
should be considered at higher risk for rabies infection than patients with a bite vaccinated wound(s) and any remaining volume should be
from a provoked dog. If the dog owner is reliable and can confirm that the administered IM at an anatomic site distant from
animal's vaccination against rabies virus is current, the dog may be observed at vaccine administration. Also, RIG should not be
the owner's home. Observation by a veterinarian is appropriate when the administered in the same syringe as vaccine. Because
vaccination status of the animal is unknown. If the animal cannot be RIG may partially suppress active production of
quarantined for 10 days, the dog bite victim should receive rabies immunization. antibody, no more than the recommended dose should
be given.
TABLE 2 Vaccine HDCV, RVA, or PCEC 1 mL, IM (deltoid area†), once daily
Summary of ACIP Recommendations for Tetanus Prophylaxis in Routine Wound on days 0‡, 3, 7, 14 and 28
Management Previously RIG RIG should not be administered.
vaccinated§
Vaccine HDCV, RVA, or PCEC 1.0 mL, IM (deltoid area†), once
Clean, minor All other
daily on days 0‡ and 3
wounds wounds*
History of adsorbed tetanus toxoid
(doses) Td† TIG Td† TIG
Unknown or less than three Yes No Yes Yes RIG = rabies immune globulin; IU = immunizing unit; IM = intramuscularly; HDCV
Three or more‡ No§ No No∥ No = human diploid cell vaccine; RVA = rabies vaccine adsorbed; PCEC = purified
chick embryo cell vaccine.

ACIP = Advisory Committee on Immunization Practices; DTP = diphtheria tetanus *—These regimens apply to all age groups, including children.
and pertussis; Td = tetanus and diphtheria toxoids adsorbed (adult); TIG =
tetanus immune globulin (Hyper-Tet).
†—The deltoid area is the only acceptable site of vaccination for adults and
older children. For younger children, the outer aspect of the thigh may be used.
*—Including, but not limited to, wounds contaminated with dirt, feces, soil or Vaccine should never be administered in the gluteal area.
saliva; puncture wounds; avulsions; and wounds resulting from missiles,
crushing, burns and frostbite.
‡—Day 0 is the day the first dose of vaccine is administered.

†—For children younger than seven years, DTP (dT, if pertussis vaccine is
§—Any person with a history of preexposure vaccination with HDCV, RVA or
contraindicated) is preferred to tetanus toxoid alone. For persons seven years or
PCEC, prior postexposure prophylaxis with HDCV, RVA or PCEC, or previous
older, Td is preferred to tetanus toxoid alone. Diphtheria and tetanus toxoids
vaccination with any other type of rabies vaccine and a documented history of
and acellular pertussis vaccine (DTaP) may be used instead of DTP for the fourth
antibody response to the prior vaccination.
and fifth doses.

Reprinted from Human rabies prevention—United States, 1999.

‡—If only three doses of fluid toxoid have been received, then a fourth dose of
Recommendations of the Advisory Committee on Immunization Practices (ACIP).
toxoid, preferably an adsorbed toxoid, should be given to complete the series.
MMWR Morb Mortal Wkly Rep 1999;48(RR-1):1–21 [Published erratum appears
in MMWR Morb Mortal Wkly Rep 1999;48:16].
§—Yes, if it has been more than 10 years since the last dose.
FOLLOW-UP
∥—Yes, if it has been more than five years since the last dose. (More frequent
boosters are not needed and can accentuate side effects.)
Patients who have been bitten by a dog should be instructed to elevate and Immediately report stray dogs or dogs with unusual behavior.
immobilize the involved area. Most bite wounds should be reexamined in 24 to Avoid direct eye contact with a dog.
48 hours, especially bites to the hands.9 Do not disturb a dog that is eating, sleeping or caring for puppies.
Do not pet a dog without letting it first sniff you.
Tell children to report a dog bite to an adult immediately.
TABLE 4
Breed-Specific Information About Aggressiveness*

Aggressive dogs (higher attack rate) Information from Sacks JJ, Lockwood R, Hornreich J, Sattin RW. Fatal dog attacks,
Bull Terrier German Shepherd dog 1989–1994. Pediatrics 1996;97:891–5.
Cocker Spaniel Great Dane
Chow Chow Pit bull
Educate children and adults to remain calm when threatened by a dog. Direct
Collie Rottweiler
eye contact should be avoided because the dog may interpret that as
Doberman PinscherSiberian Husky
aggression. Standing still (“like a tree”) with feet together, fists folded under the
Less aggressive dogs (“family dogs”)
neck, and arms placed against the chest is recommended. If knocked to the
Boxer Golden Retriever
ground by a dog, recommendations include lying face down and becoming still
Dalmatian Irish Setter
“like a log,” with legs together and fists behind the neck with forearms covering
English Setter Labrador Retriever
the ears. If a dog perceives no movement, it will lose interest and go away.
English Springer Spaniel

*—In alphabetical order.

Bee Sting Treatment

Information from Iazzetti L. Anticipatory guidance: having a dog in the family. J

Pediatr Health Care 1998;12:73–9, and Bradshaw JW, Goodwin D, Lea AM,
Whitehead SL. A survey of the behavioural characteristics of pure-bred dogs in Medical Author: Melissa Conrad Stoppler, MD
the United Kingdom. Vet Rec 1996;138:465–8. Medical Editor: William C. Shiel, Jr, MD, FACP, FACR

Prevention of Dog Bites When bees or wasps sting a person, they inject venom through their stinger into
the skin of the victim. Wasps, yellow jackets, and hornets have stingers without
barbs that are usually retracted upon stinging, and these insects can sting
WHEN FAMILIES ARE CONSIDERING GETTING A DOG
people multiple times. The honey bee has a barbed stinger that remains in the
victim's skin with its venom sack attached. About 3% of people stung by bees
Dogs can play an important role in family life. As the canine population grows, so and wasps have an allergic reaction to the sting, and up to 0.8% of bee sting
does the need for guidance to prevent dog bites. Prevention can begin with victims experience the severe and life-threatening allergic reaction known as
information from primary care professionals and veterinarians. Because a large anaphylaxis.
percentage of dog bite victims are younger than 14 years, it is appropriate to
begin prevention education with children and parents. Families acquiring a pet
Most people will have only a localized reaction to a bee sting. In the normal
should consider their home environment and be told that a dog younger than
reaction to a bee sting, the skin is reddened and painful. Swelling and/or itching
four months is preferred. An older dog should not be introduced into a
may also occur, but the pain usually disappears over a few hours. In the so-
household with children because the dog's behavior cannot be predicted.
called large local reaction to an insect sting, the swelling, redness, and pain may
Prospective dog owners should obtain breed-specific information before getting
persist for up to a week. Areas adjacent to the site of the skin may also be
a new dog.
involved in the large local reaction.

Some breeds of dogs are more likely to attack despite training. Other breeds
In a systemic allergic reaction, the entire body is affected. The victim may
seem to be accepted more as “family dogs” (Table 4).4,16 Families should be
develop hives, redness, or swelling at sites on the body distant from the site of
educated to avoid “humanizing” their dog (e.g., allowing it to sleep on the
the sting. Symptoms can also include:
furniture and to beg for food at the dinner table) and treating the dog as a child
or a substitute for a mate.4 This type of behavior makes it more difficult for the
animal to distinguish between animal and master and may increase the risk of  vomiting,
the dog biting.  nausea ,
 diarrhea, and
BEHAVIOR TO PREVENT A BITE  dizziness.

Measures for preventing dog bites are given in Table 5.2 Dogs have a tendency In anaphylactic reactions, victims experience wheezing, difficulty breathing, and
to chase a moving object. Therefore, children need to learn to avoid running and a drop in blood pressure that leads to shock if not treated promptly. Around 50
screaming in the presence of a dog. Dogs should not be greeted by presenting people are killed each year in the U.S. due to severe anaphylactic reactions to
an outstretched hand. Do not pet a dog without letting it sniff you first. Hugging bee stings. These type of reactions usually occur within minutes of the bee sting.
and “kissing” a dog express a sense of submission to the animal, which is Since most people who have allergies to bee stings will have a worsened
confusing because the animal is used to viewing humans as being in charge.4 reaction to every subsequent sting, those individuals with bee sting allergies
This confusion may lead to more aggressive behavior by the animal. should talk to their doctor about taking special precautions, including carrying
an injectable form of the drug epinephrine (used to treat anaphylactic reactions)
at all times.
TABLE 5
Measures for Preventing Dog Bites
If you are stung by a bee:

Never approach an unfamiliar dog.

Never run from a dog or scream in the presence of a dog. 1. Call emergency medical services if you have a history of severe
Be still, “like a tree,” when approached by a dog. reactions to insect stings or if you experience any severe symptoms
If knocked down, become “like a log.” as described above.
Children should never play with a dog without an adult present.
 2. Determine if the stinger is still present (look for a small black dot at
the sting site) and remove it immediately if is visible in the wound.
Many doctors recommend using a hard object like a credit card or
blunt knife to swipe over the area and remove the stinger. The honey
bee venom sack, which remains in the skin of the victim, can take 2-3
minutes to release all of its venom, so prompt removal of the stinger
can reduce the severity of the sting.

3. Apply ice or cold packs to the area to reduce the body's

inflammatory response.

4. Clean the area with soap and water, then apply hydrocortisone
cream to the site to decrease the severity of the reaction. Alternative
treatments include a paste made of unseasoned meat tenderizer and
water (the enzyme in meat tenderizer can break down bee venom) or
a paste of baking soda and water.

5. Taking an antihistamine such as Benadryl (diphenhydramine) in

tablet form and/or nonprescription pain relievers such as ibuprofen
or acetaminophen can also provide relief of symptoms.

Stings in the mouth or nose, even in persons not known to be allergic to bee
stings, also require emergency medical attention, since they can lead to swelling
that can interfere with breathing