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Dog and cat bites: Oral antibiotic regimens for prophylaxis and empiric treatment*

Dog and cat bites: Oral antibiotic regimens for prophylaxis and empiric treatment*
Antibiotic Adults Children and infants >28 days old[1]
Agent of choice
Amoxicillin-clavulanate 875/125 mg twice daily

7:1 formulation: 22.5 mg/kg (amoxicillin component) twice daily (maximum 875 mg amoxicillin and 125 mg clavulanate per dose)

OR

4:1 formulation: 10 mg/kg (amoxicillin component) 3 times daily (maximum 500 mg amoxicillin and 125 mg clavulanate per dose)

OR

14:1 formulation: Not ideal for this use unless clinician increases the amoxicillin component dose to 45 mg/kg twice daily
Alternate regimens includeΔ:
One of the following agents with activity against Pasteurella multocida◊:
Doxycycline§ 100 mg twice daily 1 to 2 mg/kg twice daily (maximum 100 mg per dose)¥
TMP-SMX§ 1 double-strength tablet twice daily 4 to 6 mg/kg (trimethoprim component) twice daily (maximum 160 mg trimethoprim per dose)
Penicillin V 500 mg 4 times daily 12.5 mg/kg 4 times daily (maximum 500 mg per dose)
Cefuroxime 500 mg twice daily 10 to 15 mg/kg twice daily (maximum 500 mg per dose)
Ciprofloxacin 500 to 750 mg twice daily

Use with caution in children <18 years of ageǂ:

10 to 15 mg/kg twice daily (maximum 750 mg per dose)
Levofloxacin 750 mg daily

Use with caution in children <18 years of ageǂ:

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

≥50 kg: 750 mg once daily
PLUS
One of the following agents with anaerobic activity:
Metronidazole 500 mg 3 times daily 10 mg/kg 3 times daily (maximum 500 mg per dose)
Clindamycin§ 300 to 450 mg 3 times daily 10 mg/kg 3 times daily (maximum 600 mg per dose)
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. 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 animal bites and MRSA treatment for recommendations.
TMP-SMX: trimethoprim-sulfamethoxazole; MRSA: methicillin-resistant Staphylococcus aureus.
* The duration of antibiotic prophylaxis is 3 to 5 days; the duration of antibiotic therapy for established infection is 5 to 14 days.
¶ The use of increased doses of amoxicillin-clavulanate may be considered in pediatric patients with infected bite wounds.
∆ The preferred regimen for children allergic to penicillin is TMP-SMX OR extended-spectrum cephalosporin PLUS clindamycin. Alternative regimens for adults allergic to penicillin or beta-lactams include doxycycline, OR TMP-SMX, OR a fluoroquinolone (ciprofloxacin or levofloxacin) PLUS metronidazole, OR moxifloxacin (may be used as monotherapy).
◊ The following agents have poor activity against P. multocida and should be avoided: cephalexin, dicloxacillin, and erythromycin.
§ Doxycycline, TMP-SMX, and clindamycin may also be active against MRSA. If clindamycin is used for MRSA, confirm susceptibility.
¥ Teeth staining can occur with repeated course of doxycycline among young children (<8 years); use with caution.
‡ 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]
† Moxifloxacin has good anaerobic activity and can be used as 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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