Dog, cat and human bites
Wash with soap and water for 15 minutes, leave punctures open, give co-amoxiclav when needed, and decide on rabies vaccine and immunoglobulin for every mammal bite.
An 8-year-old boy was bitten on the calf by a stray dog in the street an hour ago. There are two puncture wounds that bled. The dog ran away.
A 26-year-old man has a small cut over his right middle knuckle after punching someone in the mouth 2 days ago. The hand is now swollen and he can't fully bend the finger.
What does the boy need today for rabies, and why is the man's small cut serious?
- Wash the woundSoap and running water for 15 minutes, then povidone-iodine or alcohol. The most important first step for rabies.
- Assess the woundDepth, tendons, joints, nerves, vessels. X-ray for teeth or fracture.
- Rabies categoryCategory III (bite or scratch breaking the skin, licks on broken skin or mucosa): vaccine plus rabies immunoglobulin.
- Category IINibbling of uncovered skin, minor scratches without bleeding: vaccine alone.
- TetanusBooster if not up to date, immunoglobulin for dirty wounds if not immunised.
- AntibioticsCo-amoxiclav for high-risk wounds (hand, face, deep punctures, cat bites, human bites, immunosuppressed).
- Leave most bite wounds openExcept the face, after thorough cleaning.
- Fight bite over a knuckle
- Signs of joint or tendon involvement
- Spreading infection or sepsis
- Facial or genital bites
- Severe bites in children
- Any category III exposure without access to immunoglobulin
- Rabies exposure under-treated
- Fight bite (septic arthritis, tendon infection)
- Retained tooth
- Tetanus
- Capnocytophaga sepsis in splenectomy or alcohol misuse
| Category I | Touching, feeding, licks on intact skin: no prophylaxis |
| Category II | Nibbling, minor scratch without bleeding: vaccine |
| Category III | Bite or scratch through skin, licks on broken skin or mucosa, bat exposure: vaccine plus immunoglobulin |
| Rabies vaccine (IM) | Days 0, 3, 7 and 14 (4-dose Essen) or per local schedule |
| Rabies vaccine (intradermal) | 0.1 mL at 2 sites on days 0, 3 and 7 (WHO 1-week ID) |
| Rabies immunoglobulin | Human 20 IU/kg or equine 40 IU/kg, infiltrated into and around the wound |
| Co-amoxiclav prophylaxis | 3–5 days, treatment of infection 5–7 days or longer |
Check every dose against a current drug reference and your hospital protocol.
On this page
Rabies in Pakistan
Rabies is almost always fatal once symptoms start, and dog bites are the main source. Post-exposure prophylaxis given promptly is highly effective. Start immediately whatever the time since the bite, even if the animal looks healthy, unless the animal is known to be vaccinated and can be observed for 10 days (still start, and stop if it stays well).
No prophylaxis
Wound wash plus vaccine
Wound wash plus vaccine plus rabies immunoglobulin
Rabies immunoglobulin: infiltrate as much as possible into and around every wound. Give on day 0 with the first vaccine dose (up to day 7). Not needed if the patient had full pre-exposure vaccination (they need 2 booster vaccine doses).
Wound care
- WashSoap and running water for 15 minutes.
- AntisepticPovidone-iodine or alcohol.
- ExploreUnder local anaesthetic: depth, tendons, joints, foreign bodies (teeth).
- DebrideDead tissue.
- ClosureMost bites left open or delayed closure. Facial wounds usually closed after thorough cleaning (cosmetic). Infiltrate immunoglobulin before closing.
- Elevate and reviewHand bites: review at 24–48 hours.
Human bites and fight bites
A fight bite is a cut over a knuckle from a punch to the mouth. The tooth goes through skin, tendon and into the joint with the fist clenched. When the hand opens, the tendon slides and seals the track.
- Treat as an open joint injury.
- X-ray (fracture, tooth fragment).
- Hand surgeons for exploration and washout.
- IV antibiotics if infected.
- Organisms: mouth flora including Eikenella and anaerobes.
- Consider hepatitis B, C and HIV risk.
Cat bites
Deep, narrow punctures; high infection risk (Pasteurella). Give prophylactic antibiotics for all cat bites that break the skin.
Who needs antibiotics?
- Human bites that break the skin.
- Cat bites that break the skin.
- Dog bites to the hand, foot, face, genitals, near a joint, or deep punctures.
- Wounds needing debridement or closure.
- Diabetic, immunosuppressed, splenectomised, cirrhotic or prosthetic valve patients.
Investigations
| Test | Why |
|---|---|
| X-ray | Teeth, fracture, joint involvement |
| Wound swab | Only if infected |
| FBC, CRP, blood cultures | Systemic infection |
| Hepatitis B, C, HIV baseline | Human bites with blood exposure |
Treatment
Common mistakes
- Skipping the 15-minute wash.
- Delaying rabies vaccine to "wait and see" the dog.
- Giving vaccine alone for a category III bite.
- Injecting all the immunoglobulin into the buttock instead of the wounds.
- Suturing a deep hand bite.
- Sending home a fight bite without exploration.
Frequently asked questions
What should be done first after a dog bite?
Wash the wound with soap and running water for 15 minutes, then apply povidone-iodine or alcohol.
Who needs rabies immunoglobulin?
Category III exposures: bites or scratches that break the skin, licks on broken skin or mucosa, and bat exposures, in people not previously vaccinated.
Why is a fight bite serious?
The tooth can enter the knuckle joint and tendon sheath, causing septic arthritis and tendon infection from mouth bacteria.
Do cat bites need antibiotics?
Yes, if they break the skin, because deep punctures have a high infection risk.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A child has a bleeding dog bite on the face and no previous rabies vaccine. What WHO category is this?
Answer: Category III. Category III needs vaccine plus rabies immunoglobulin.
- Category II: No bleeding.
- No category: Bites are classified.
- Category I: Intact skin only.
- Category IV: Doesn't exist.
2. Where is rabies immunoglobulin given?
Answer: Infiltrated into and around the wound. Infiltrate as much as possible into and around the wounds.
- Into the deltoid with the vaccine: No.
- Only into the buttock: Wound infiltration is essential.
- Orally: No.
- IV: No.
3. What is the most important first aid for an animal bite?
Answer: Washing with soap and water. Thorough washing reduces rabies and infection risk.
- Tight bandage: No.
- Applying chilli or herbs: Harmful.
- Immediate suturing: Usually left open.
- Ice: No.
4. A child in Karachi is bitten on the face by a stray dog, with bleeding puncture wounds. He has never been vaccinated. What is needed?
Answer: Wound wash + rabies vaccine + RIG. WHO category III exposure (transdermal bites, licks on broken skin, any bat exposure): thorough wound washing with soap and water for 15 minutes, rabies immunoglobulin infiltrated into and around the wound, and a full vaccine course (e.g. intradermal 1-week, 2-site regimen on days 0, 3, 7). Category II (minor scratches without bleeding): vaccine only. Face/head bites are high-risk because of short incubation. Once symptoms begin, rabies is almost always fatal.
- Rabies vaccine only: Category III exposure needs RIG as well as vaccine.
- Antibiotics alone: Antibiotics give no protection against rabies.
- Observe the dog for 10 days first: Observing the dog delays treatment; start PEP now.
5. A 7-year-old in Larkana was bitten on the face by a stray dog; the wound bled. What is required in addition to wound washing?
Answer: Rabies vaccine plus immunoglobulin. WHO rabies exposure categories: I — touching/feeding, licks on intact skin (no PEP); II — nibbling, minor scratches without bleeding (vaccine); III — bites/scratches breaking skin, licks on broken skin/mucosa, bat exposure (vaccine + rabies immunoglobulin infiltrated into wound). Wash wound with soap and water for 15 minutes immediately. Face/head bites are high risk (short incubation). Pakistan has a high dog-bite burden; intradermal regimens save vaccine.
- Rabies vaccine only: Category III exposure needs RIG as well.
- Observe the dog for 10 days only: Observing the dog alone delays PEP.
- Antibiotics only: Antibiotics do not prevent rabies.
6. After a dog bite, which step is most important to prevent rabies in an unvaccinated person with a deep wound?
Answer: Washing, vaccine and immunoglobulin. Rabies is almost always fatal once symptoms appear, so post-exposure prophylaxis must start at once: wash the wound with soap and water for 15 minutes, give rabies immunoglobulin (infiltrated around the wound) for category III exposures, and start the vaccine course. Avoid primary suturing when possible.
- Antibiotics alone: Do not prevent rabies.
- Tetanus toxoid alone: Prevents tetanus, not rabies.
- Vaccinate only if symptoms appear: Too late; rabies is fatal once symptomatic.
- Suture the wound tightly at once: Tight suturing may help virus spread; delay if possible.
7. An unvaccinated man is bitten on the face by a stray dog. In addition to wound washing and rabies vaccine, what should be given and where?
Answer: Rabies immunoglobulin into the wound. Category III exposure (transdermal bites, licks on broken skin or mucosa, and especially bites on the face, head and hands with short nerve paths to the brain) needs: thorough washing with soap and water for 15 minutes, a rabies vaccine course (active immunity, which takes 7–14 days), and rabies immunoglobulin (passive, immediate neutralising antibody) infiltrated as much as possible into and around the wound, with any remainder given intramuscularly at a site distant from the vaccine. Immunoglobulin and vaccine are never mixed or given at the same site, as the antibody would neutralise the vaccine. Tetanus prophylaxis and antibiotics are also considered.
- Tetanus toxoid only: Insufficient.
- Oral antibiotics only: Insufficient.
- Immunoglobulin mixed with vaccine: Never mixed; the antibody neutralises vaccine.
- Nothing more for face bites: Category III requires immunoglobulin.
References and dose sources
- WHO fact sheet: Rabies
- NICE NG184 — Human and animal bites: antimicrobial prescribing
- UKHSA — Rabies post-exposure treatment
- Rabies vaccine dosing: Drugs.com: Rabies vaccine dosage (see also our rabies vaccine dose page)
- Rabies immunoglobulin (RIG) dosing: Drugs.com: Rabies immune globulin dosage (see also our rabies immunoglobulin (rig) dose page)
- Co-amoxiclav (amoxicillin with clavulanic acid) dosing: Drugs.com: Amoxicillin/clavulanate dosage (see also our co-amoxiclav (amoxicillin with clavulanic acid) dose page)
- Doxycycline dosing: Drugs.com: Doxycycline dosage (see also our doxycycline dose page)
- Tetanus toxoid and immunoglobulin dosing: Drugs.com: Tetanus toxoid dosage (see also our tetanus toxoid and immunoglobulin dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.