• Penetrating wounds involving arteries, joints, nerves, muscles, tendons, bones, or the central nervous system. Note: penetrating bites to the hands or feet are at particular risk of infection and serious complications.
• Facial wounds (excluding very minor wounds) or bites to poorly vascularized areas e.g. ear cartilage/nose cartilage.
• Devitalized wounds where debridement is required or where there is a possibility of a foreign body (e.g. a tooth) in the wound.
• Wounds which might benefit from closure, or need reconstructive surgery.
• Bites where the severity of the injury is difficult to assess.
• People with severe cellulitis, or with infected bite wounds that are not responding to treatment, or who are systemically unwell.
• People with an increased risk of infection — including those with diabetes or cirrhosis, those who are immunocompromised, and asplenic individuals (especially if they are not taking prophylactic penicillin).
• Children with scalp wounds (for X-ray).
• If an animal has bitten a child, consider the possibility of poor parenting and supervision. Follow local policies for referral of children considered at risk.
• People who may have been exposed to rabies — seek immediate advice from the Virus Reference Department of the Health Protection Agency.

In depth

• If possible remove any foreign bodies (e.g. teeth) from the wound.
• If the wound has just occurred encourage it to bleed, unless it is already bleeding freely.
• Irrigate thoroughly with warm, running water.
• Wound closure is rarely advised in primary care. For more information see When to close an animal bite wound.
• Advise analgesia (ibuprofen or paracetamol) for pain relief, if required.
• Prescribe prophylactic antibiotics if the wound is less than 48 hours old and the risk of infection is high.
• Consider if tetanus prophylaxis is required.

In depth

• Prescribe oral antibiotics for:
• All cat bites, animal bites to the hand, foot, and face; puncture wounds; wounds requiring surgical debridement; wounds involving joints, tendons, ligaments, or suspected fractures.
• Wounds that have undergone primary closure.
• People who are at risk of serious wound infection (e.g. those who are diabetic, cirrhotic, asplenic, or immunosuppressed).
• People with a prosthetic valve or a prosthetic joint.
• Antibiotics are not generally needed if the wound is more than 2 days old and there is no sign of local or systemic infection.

In depth

• For prophylaxis and treatment of an infected animal bite prescribe a 7–day course of co-amoxiclav.
• For people who are allergic to penicillin give metronidazole plus doxycycline, or metronidazole plus oxytetracycline.
• For children under 12 years old who are allergic to penicillin seek advice from a microbiologist.
• For animals not covered in this guidance (e.g. pigs) seek specialist advice for the most appropriate antibiotic.

In depth

• This follow-up advice only applies to people who have not been referred to hospital.
• If the bite wound is not infected — advise the person to check for signs of infection and if these develop to attend urgently for review.
• If the wound is infected — review at 24 and 48 hours to ensure the infection is responding to treatment. Advise the person to attend urgently for review if the infection worsens or if they feel increasingly unwell.
• Follow-up for people who have needed post-exposure prophylaxis for rabies should follow the regimen advised for them by the Virus Reference Department of the Health Protection Agency.

In depth