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Dog and cat bites: Intravenous antibiotic regimens for empiric treatment

Dog and cat bites: Intravenous antibiotic regimens for empiric treatment
Antibiotic Adults Children and infants >28 days old[1]
Preferred regimens include:
Monotherapy with a beta-lactam/beta-lactamase inhibitor, such as one of the following:
Ampicillin-sulbactam 3 g every 6 hours 50 mg/kg (based on ampicillin component; maximum 2 g per dose) every 6 hours
Piperacillin-tazobactam 3.375 g every 6 to 8 hours 100 mg/kg (based on piperacillin component; maximum 3 g per dose) every 8 hours
OR
A third-generation cephalosporin, such as:
Ceftriaxone 1 g every 12 hours or 2 g every 24 hours 50 to 75 mg/kg every 24 hours or 50 mg/kg every 12 hours (maximum 1 g per dose)
PLUS
One of the following agents with anaerobic activity:
Metronidazole 500 mg every 8 hours 10 mg/kg every 8 hours (maximum 500 mg per dose)
Clindamycin* 600 mg every 6 to 8 hours 10 to 13 mg/kg every 8 hours (maximum 900 mg per dose)
Alternative regimens include:
A fluoroquinolone, such as one of the following:
Ciprofloxacin 400 mg every 12 hours Use with caution in children <18 years of age: 10 to 15 mg/kg twice daily (maximum 400 mg per dose)
Levofloxacin 750 mg daily

Use with caution in children <18 years of age:

≥6 months old and <50 kg: 8 to 10 mg/kg every 12 hours (maximum 375 mg per dose)

>50 kg: 500 mg every 24 hours (maximum 750 mg per day)
PLUS
One of the following agents with anaerobic activity:
Metronidazole 500 mg every 8 hours 10 mg/kg every 8 hours (maximum 500 mg per dose)
Clindamycin* 600 mg every 6 to 8 hours 10 to 13 mg/kg every 8 hours (maximum 900 mg per dose)
OR
Monotherapy with a carbapenemΔ, such as one of the following:
Imipenem-cilastatin 500 mg every 6 hours 15 to 25 mg/kg every 6 hours (maximum 500 mg per dose)
Meropenem 1 g every 8 hours 20 mg/kg every 8 hours (maximum 1 g per dose)
Ertapenem 1 g daily

Children <13 years old: 15 mg/kg every 12 hours (maximum 500 mg per dose)

Children ≥13 years old: 1 g daily
OR
Monotherapy with a fluoroquinolone: 
Moxifloxacin◊  400 mg daily Not recommended; insufficient experience
The doses recommended above are intended for patients with normal renal function; the doses of some of these agents must be adjusted in patients with renal insufficiency. When a range of doses is given, the higher dose is used for more severe infections. Additional coverage for certain gram-positive pathogens may also be warranted (eg, if the patient has risk factors for colonization with community-acquired MRSA). Refer to the UpToDate topics on soft tissue infections due to dog and cat bites and MRSA treatment for recommendations.
MRSA: methicillin-resistant Staphylococcus aureus.
* Clindamycin may also be active against MRSA; if it is used for MRSA, confirm susceptibility.
¶ Use of fluoroquinolones in children should be limited to the treatment of infections for which no safe and effective alternative exists or in situations where oral therapy is a reasonable alternative to intravenous therapy with a different class of antibiotics.[1]
Δ Carbapenems should not be used routinely in patients with a history of hypersensitivity to beta-lactams; skin testing and graded challenge may be useful for assessment of immediate-type hypersensitivity reactions. For guidance, refer to the UpToDate topic on carbapenem use in penicillin-allergic patients.
◊ Moxifloxacin has good anaerobic activity and can be used as a monotherapy.[2]
Data from:
  1. American Academy of Pediatrics. Red Book: 2021-2024 Report of the Committee on Infectious Diseases, 32nd ed, Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH (Eds), American Academy of Pediatrics, Itasca, IL 2021.
  2. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis 2014; 59:147.
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