Human and Animal Bites Antimicrobial Prescribing PDF 66142021681861

Human and animal bites:
antimicrobial prescribing
NICE guideline
Published: 4 November 2020
www.nice.org.uk/guidance/ng184
© NICE 2020. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-of-

rights).
Human and animal bites: antimicrobial prescribing (NG184)
Your responsibility
The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals and
practitioners are expected to take this guideline fully into account, alongside the individual needs,
preferences and values of their patients or the people using their service. It is not mandatory to
apply the recommendations, and the guideline does not override the responsibility to make
decisions appropriate to the circumstances of the individual, in consultation with them and their
families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be
applied when individual professionals and people using services wish to use it. They should do so in
the context of local and national priorities for funding and developing services, and in light of their
duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of
opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a
way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of implementing
NICE recommendations wherever possible.
© NICE 2020. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and- Page 2 of
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Contents
Overview ............................................................................................................................................................................ 4
Who is it for? ................................................................................................................................................................................... 4
Recommendations .......................................................................................................................................................... 5
1.1 Managing human and animal bites ................................................................................................................................. 5
1.2 Choice of antibiotic ............................................................................................................................................................... 9
Rationales ........................................................................................................................................................................... 15
Assessment ...................................................................................................................................................................................... 15
Antibiotic prophylaxis for uninfected human and animal bites .................................................................................. 15
Treating infected human and animal bites .......................................................................................................................... 18
Reassessment ................................................................................................................................................................................. 18
Referral and seeking specialist advice .................................................................................................................................. 19
Choice of antibiotic ...................................................................................................................................................................... 19
Context ................................................................................................................................................................................ 22
Summary of the evidence ............................................................................................................................................. 23
Antibiotic efficacy ......................................................................................................................................................................... 23
Choice of antibiotic ...................................................................................................................................................................... 24
Course length ................................................................................................................................................................................. 24
Route of administration.............................................................................................................................................................. 24
Other considerations ..................................................................................................................................................... 25
Medicines safety............................................................................................................................................................................ 25
Medicines adherence .................................................................................................................................................................. 25
Resource implications ................................................................................................................................................................. 26
Finding more information and committee details ............................................................................................. 27
Overview
This guideline sets out an antimicrobial prescribing strategy for human and animal bites (excluding
insect bites) in adults, young people and children aged 72 hours and over. It aims to optimise
antibiotic use and reduce antibiotic resistance.
See a 3-page visual summary of the recommendations, including tables to support prescribing
decisions.
The recommendations in this guideline were developed before the COVID-19 pandemic.
For treating infections associated with other bites and stings, see the NICE webpage on bites and
stings. We have also produced NICE guidelines on cellulitis and erysipelas and antimicrobial
stewardship: systems and processes for effective antimicrobial medicine use.
Who is it for?
• Healthcare professionals
• People with a human or animal bite, their families and carers
• It may also be relevant for veterinary professionals
Recommendations
1.1 Managing human and animal bites
Assessment
1.1.1 For people with a human or animal bite:
• assess the type and severity of the bite, including what animal caused the bite, the site
and depth of the wound, and whether it is infected (see the recommendation on taking
a swab in the section on treating infected bites)
• assess the risk of tetanus, rabies or a bloodborne viral infection and take appropriate
action
• manage the wound with irrigation and debridement as necessary
• be aware of potential safeguarding issues in vulnerable adults and children, for

example, as outlined in NICE's guidelines on child maltreatment, challenging behaviour
and learning disabilities and domestic violence and abuse.
Also see the recommendations on referral and seeking specialist advice.
1.1.2 Seek specialist advice from a microbiologist for bites from a wild or exotic
animal (including birds and non-traditional pets) because the spectrum of
bacteria involved may be different, and there may be a risk of other serious non-
bacterial infections.
1.1.3 Consider seeking specialist advice from a microbiologist for domestic animal
bites (including farm animal bites), that you are unfamiliar with.
For a short explanation of why the committee made these recommendations, see the rationale
section on assessment.
For more details, see the evidence review.
Antibiotic prophylaxis for uninfected bites

Human bites
1.1.4 Do not offer antibiotic prophylaxis to people with a human bite that has not
broken the skin.
1.1.5 Offer antibiotic prophylaxis (see the recommendations on choice of antibiotic)

to people with a human bite that has broken the skin and drawn blood.
1.1.6 Consider antibiotic prophylaxis for people with a human bite that has broken
the skin but not drawn blood if it:
• involves a high-risk area such as the hands, feet, face, genitals, skin overlying
cartilaginous structures or an area of poor circulation or
• is in a person at risk of a serious wound infection because of a comorbidity (such as

diabetes, immunosuppression, asplenia or decompensated liver disease).
Cat bites
1.1.7 Do not offer antibiotic prophylaxis to people with a cat bite that has not broken
the skin.

to people with a cat bite that has broken the skin and drawn blood.
1.1.9 Consider antibiotic prophylaxis for people with a cat bite that has broken the
skin but not drawn blood if the wound could be deep.
Bites from a dog or other traditional pet (excluding cat bites)

1.1.10 Do not offer antibiotic prophylaxis to people with a bite from a dog or other
traditional pet (excluding cat bites) that:
• has not broken the skin or
• has broken the skin but not drawn blood.

to people with a bite from a dog or other traditional pet (excluding cat bites) that
has broken the skin and drawn blood if it:
• has penetrated bone, joint, tendon or vascular structures or
• is deep, is a puncture or crush wound, or has caused significant tissue damage or
• is visibly contaminated (for example, if there is dirt or a tooth in the wound).
1.1.12 Consider antibiotic prophylaxis (see the recommendations on choice of

antibiotic) for people with a bite from a dog or other traditional pet (excluding
cat bites) that has broken the skin and drawn blood if it:
• involves a high-risk area such as the hands, feet, face, genitals, skin overlying
cartilaginous structures or an area of poor circulation or
• is in a person at risk of a serious wound infection because of a comorbidity (such as

diabetes, immunosuppression, asplenia or decompensated liver disease).
section on antibiotic prophylaxis for uninfected human and animal bites.
Treating iinfected
nfected bites
1.1.13 Take a swab for microbiological testing to guide treatment if there is discharge
(purulent or non-purulent) from the human or animal bite wound.
1.1.14 Offer an antibiotic (see the recommendations on choice of antibiotic) for people
with a human or animal bite if there are symptoms or signs of infection, such as
increased pain, inflammation, fever, discharge or an unpleasant smell.
section on treating infected human and animal bites.
Advice
1.1.15 Give advice to people with a human or animal bite about:
• possible adverse effects of antibiotics (if they have been offered antibiotics)
• seeking medical help if symptoms or signs of infection develop or worsen rapidly or

significantly at any time, or do not start to improve within 24 to 48 hours of starting
treatment.
Reassessment
1.1.16 Reassess the human or animal bite if:
• symptoms or signs of infection develop or worsen rapidly or significantly at any time,

or do not start to improve within 24 to 48 hours of starting treatment or
• the person becomes systemically unwell or
• the person has severe pain that is out of proportion to the infection.
1.1.17 Be aware that people who have difficulty communicating may have non-verbal
signs of pain, such as a change in behaviour.
1.1.18 If a skin swab has been sent for microbiological testing, review the choice of
antibiotic based on the swab results. If a change of antibiotic is needed, use a
narrow-spectrum antibiotic if possible.
section on reassessment.
Referral and seeking specialist advice

1.1.19 Refer people with a human or animal bite to hospital if they have:
• symptoms or signs suggesting a more serious illness or condition (these include severe
cellulitis, abscess, osteomyelitis, septic arthritis, necrotising fasciitis or sepsis) or
• a penetrating wound involving arteries, joints, nerves, muscles, tendons, bones or the
central nervous system.
1.1.20 Consider referral or seeking specialist advice for people with a human or animal
bite if:
• they are systemically unwell or
• they have developed symptoms or signs of infection after taking prophylactic

antibiotics or
• they have lymphangitis or
• they are at risk of a serious wound infection because of a pre-existing medical

condition or
• they cannot take oral antibiotics (in which case, explore with the specialist whether
locally available options for parenteral antibiotics at home or in the community, rather
than in hospital, are appropriate) or
• the bite is infected and is not responding to oral antibiotics or
• the bite is in an area of poor circulation.
section on referral and seeing specialist advice.
1.2 Choice of antibiotic

1.2.1 When prescribing an antibiotic for a bite from a human, cat, dog or other
traditional pet:
• follow table 1 for adults aged 18 years and over
• follow table 2 for children and young people under 18 years.
1.2.2 Give oral antibiotics if the person can take oral medicines, and the severity of
their condition does not need intravenous antibiotics.
1.2.3 If intravenous antibiotics are given, review within 48 hours and consider
switching to oral antibiotics if possible.
Table 1 Antibiotics for prophylaxis and treatment in adults aged 18 years and over
Antibiotic, dosage and course length for

Prophylaxis and treatment
prophylaxis (3 days) and treatment (5 days)
Co-amoxiclav
Co-amoxiclav:
First-choice oral antibiotic
250/125 mg or 500/125 mg three times a day
Doxycycline
Doxycycline:
Alternative first-choice oral antibiotics for 200 mg on first day, then 100 mg or 200 mg daily
penicillin allergy or if co-amoxiclav is with
unsuitable Metronidazole:
400 mg three times a day
Alternative first-choice oral antibiotics in

pregnancy for penicillin allergy or if Seek specialist advice
co-amoxiclav is unsuitable
First-choice intravenous antibiotic (if

Co-amoxiclav
Co-amoxiclav:
unable to take oral antibiotics or severely
1.2 g three times a day
unwell)
Cefuroxime (caution in penicillin allergy):

750 mg three times a day (increased to 750 mg
four times a day or 1.5 g three or four times a day
if infection is severe)
with
Alternative first-choice intravenous Metronidazole
Metronidazole:
antibiotics for penicillin allergy or if
Ceftriaxone (caution in penicillin allergy)
2 g once a day
with
Metronidazole
Metronidazole:
If cephalosporin is not appropriate Seek specialist advice
See the BNF and summary of product characteristics for appropriate use and dosing in specific
populations, for example, for people with hepatic or renal impairment, in pregnancy and
breastfeeding, and when administering intravenous (or, if appropriate, intramuscular) antibiotics.
A 5-day course is appropriate for treating most human or animal bites, but course length can be
increased to 7 days (with review) based on clinical assessment of the wound, for example, if there is
significant tissue destruction or it has penetrated bone, joint, tendon or vascular structures.
Table 2 Antibiotics for prophylaxis and treatment in children and young people under 18 years
Antibiotic, dosage and course length for prophylaxis

Prophylaxis and treatment
(3 days) and treatment (5 days)
Choice for children under 1 month Seek specialist advice
Co-amoxiclav
Co-amoxiclav:
1 month to 11 months: 0.25 ml/kg of 125/31
suspension three times a day
1 year to 5 years: 0.25 ml/kg or 5 ml of 125/31
First-choice oral antibiotic for children
6 years to 11 years: 0.15 ml/kg or 5 ml of 250/62
aged 1 month and over
12 years to 17 years: 250/125 mg or 500/125 mg
three times a day
Co-amoxiclav 400/57 suspension may also be
considered to allow for twice-daily dosing
Co-trimoxazole (off-label use):
Alternative first-choice oral antibiotic 6 weeks to 5 months: 120 mg or 24 mg/kg twice a day
for children under 12 years for 6 months to 5 years: 240 mg or 24 mg/kg twice a day
penicillin allergy or if co-amoxiclav is 6 years to 11 years: 480 mg or 24 mg/kg twice a day
unsuitable
See the BNF for Children for information on
monitoring
Antibiotic, dosage and course length for proph

prophylaxis
ylaxis
Proph
Prophylaxis
ylaxis and treatment
(3 da
days)
ys) and treatment (5 da
days)
ys)
Doxycycline
Doxycycline:
Alternative first-choice oral antibiotics 200 mg on first day, then 100 mg or 200 mg daily
for young people aged 12 to 17 years
with
for penicillin allergy or if co-amoxiclav
is unsuitable Metronidazole
Metronidazole:
Alternative first-choice oral antibiotics

in pregnancy for penicillin allergy or if Seek specialist advice
co-amoxiclav unsuitable
Co-amoxiclav
Co-amoxiclav:
First-choice intravenous antibiotic (if
1 month to 2 months: 30 mg/kg twice a day
unable to take oral antibiotics or
severely ill) 3 months to 17 years: 30 mg/kg three times a day
(maximum per dose 1.2g)
Antibiotic, dosage and course length for proph

prophylaxis
ylaxis
Proph
Prophylaxis
ylaxis and treatment
(3 da
days)
ys) and treatment (5 da
days)
ys)
Cefuroxime (caution in penicillin allergy):

1 month to 17 years: 20 mg/kg three times a day
(maximum 750 mg per dose), which can be increased to
50 mg/kg to 60 mg/kg three or four times a day
(maximum per dose 1.5 g)
with
Metronidazole
Metronidazole:
1 month: loading dose 15 mg/kg, then (after 8 hours)
7.5 mg/kg three times a day
2 months to 17 years: 7.5 mg/kg three times a day
Alternative first-choice intravenous (maximum per dose 500 mg)
antibiotics for penicillin allergy or if
Ceftriaxone (caution in penicillin allergy):
1 month to 11 years (up to 50 kg): 50 mg/kg to 80 mg/
kg once a day (maximum 4 g per day)
9 years to 11 years (50 kg and above) and 12 years to
17 years: 1 g to 2 g once a day
with
Metronidazole
Metronidazole:
1 month: loading dose 15 mg/kg, then (after 8 hours)
7.5 mg/kg three times a day
2 months to 17 years: 7.5 mg/kg three times a day
(maximum per dose 500 mg)
If a cephalosporin is not appropriate Seek specialist advice
See the BNF for Children and summary of product characteristics for appropriate use and dosing in
specific populations, for example, for people with hepatic or renal impairment, in pregnancy and
breastfeeding, and when administering intravenous (or, if appropriate, intramuscular) antibiotics.
A 5-day course is appropriate for treating most human or animal bites, but course length can be
increased to 7 days (with review) based on clinical assessment of the wound, for example, if there is
significant tissue destruction or it has penetrated bone, joint, tendon or vascular structures.
For off-label use, the prescriber should follow relevant professional guidance, taking full
responsibility for the decision. Informed consent should be obtained and documented. See the
General Medical Council's good practice in prescribing and managing medicines and devices for
further information.
section on choice of antibiotic.
For more details, see the summary of the evidence.
Rationales
The recommendations in this guideline are based on the evidence identified and the experience of
the committee.
Assessment
Why the committee made the recommendations
Recommendations 1.1.1 to 1.1.3
The committee agreed that it was good practice to assess and manage the wound in line with
NICE's clinical knowledge summary on human and animal bites. They also agreed that, for human
and animal bites, healthcare professionals should also consider potential safeguarding issues for
vulnerable adults and children in line with NICE guidelines.
There was only evidence on managing bites from humans, dogs and cats; no evidence was identified
for bites from other animal species. The committee agreed that it was reasonable to extrapolate
this evidence to bites from other animals traditionally kept as pets, such as rabbits and hamsters.
The committee agreed that specialist advice should be sought for bites from wild and exotic
animals (including birds and non-traditional pets), such as snakes, lizards, monkeys or bats. This was
because there may be a different spectrum of bacteria involved and a risk of other serious non-
bacterial infections. For example, monkey bites are associated with herpes B virus, which may have
serious consequences if not treated early, including fatal encephalomyelitis or severe neurological
impairment. Healthcare professionals may also wish to seek specialist advice for domestic animal
bites (including farm animal bites) they are not familiar with.
Return to the recommendations
Antibiotic prophylaxis for uninfected human and animal

bites
Evidence was only identified for antibiotic prophylaxis after a dog, cat or human bite, and it was
limited and of low quality. The committee agreed that, if a bite has not broken the skin, antibiotic
prophylaxis is not needed. Many bites are superficial abrasions, meaning that they break the skin
but do not draw blood. These bites are at low risk of infection because the dermis will not have
been penetrated, so do not always need antibiotic prophylaxis.
The committee went on to discuss and agree when antibiotic prophylaxis should either be offered,
considered, or not offered for a human, cat or dog (or other traditional pet) bite, based on the
evidence and their knowledge of the risk of infection.
The committee discussed the pooled evidence on human bites, which suggested that antibiotic
prophylaxis was more effective than placebo at reducing the incidence of infection. They discussed
that a human bite that has broken the skin is at high risk of infection and other serious
consequences because of the associated oral bacteria. However, they also discussed that the site
and depth of a bite affects the risk of infection. In a study of human bites to the hand, antibiotic
prophylaxis was particularly effective. The committee discussed that wounds to the hand have a
higher risk of infection because of the multiple small compartments and number of joints. The same
high level of infection risk applies to the feet and skin overlying cartilaginous structures.
The committee went on to discuss the evidence for human bites that are at lower risk of infection,
as outlined in Broder et al. (2004). These bites penetrated only the epidermis (that is, they broke
the skin but did not draw blood) and did not involve the high-risk areas of the hands, feet, or skin
overlying joints or cartilaginous structures. For this study, there was a very low rate of infection;
signs of infection were seen in 1 of 62 people in the placebo group and none of the 63 people taking
antibiotics.
The committee agreed that, if a human bite has not broken the skin, antibiotic prophylaxis should
not be offered. If it has broken the skin and drawn blood, antibiotic prophylaxis should be offered.
The committee agreed that, for people with a human bite that has broken the skin but not drawn
blood, antibiotic prophylaxis is not routinely needed. However, they agreed that it can be
considered for bites in high-risk areas or in people at risk of a serious wound infection because of a
comorbidity.
The committee went on to discuss when antibiotic prophylaxis should be offered for a cat bite. The
evidence on cat bites, which was based on a very small sample size of 11 did not show a statistically
significant difference between antibiotic prophylaxis and placebo in reducing the incidence of
infection in cat bites. Based on such limited data, the committee could not judge the certainty of the
evidence. However, based on their expertise and experience, they agreed that antibiotic
prophylaxis should be offered if a cat bite has broken the skin and drawn blood. Cat bites are at high
risk of infection because of cat oral bacteria and because the needle-like nature of the wounds
(small, deep punctures) is hard to irrigate. The committee went on to discuss that this type of
wound is often deeper than it appears, which can cause assessment difficulties. They also noted
that infection in deep skin structures is possible, which has serious consequences such as bone
infections. The committee agreed that antibiotic prophylaxis is not needed if a cat bite has not
broken the skin. However, it can be considered if the cat bite has broken the skin but not drawn
blood if, despite appearances and the lack of blood, the wound could still be deep.
The committee went on to discuss and agree situations when antibiotic prophylaxis should be
offered for a dog bite (or a bite from another traditional pet other than a cat). Evidence suggested
no difference between antibiotic prophylaxis and placebo in reducing the incidence of infection
based on the type and location of the dog bite wound. However, based on their experience, the
committee agreed that antibiotic prophylaxis should be offered for a dog bite (or a bite from
another traditional pet) if it:
• has broken the skin and penetrated bone, joint, tendon or vascular structures or
• is deep, a puncture or crush wound, or has caused significant tissue damage or
• is visibly contaminated (for example, if there is dirt or a tooth in the wound).
They also agreed that antibiotic prophylaxis could be considered for a dog bite (or a bite from
another traditional pet other than a cat) that has broken the skin and drawn blood if it involves a
high-risk area or is in a person at risk of a serious wound infection because of a comorbidity. The
committee agreed that the principles of the evidence from Broder et al. (2004) on human bites
could be extrapolated to bites from dogs or other traditional pets). The committee discussed that
antibiotic prophylaxis would only be considered for a dog bite (or a bite from another traditional
pet) fulfilling these criteria because, in their experience, these bites have a lower risk of infection
than human bites. This is supported by the evidence that showed no difference between antibiotic
prophylaxis and placebo in reducing the incidence of infection after a dog bite. Antibiotic
prophylaxis is not needed for a dog bite (or a bite from another traditional pet) that has not broken
the skin, or has only caused a superficial wound that has broken the skin but not drawn blood.
For more details, see the summary of the evidence on antibiotics.
Treating infected human and animal bites

There was no evidence on the treatment of human or animal bites. However, the committee agreed
that antibiotics should be offered for human or animal bites with symptoms or signs of infection
because of the potential consequences of not treating an infected bite.
The committee also agreed that, if there is discharge from the bite wound this should be swabbed
and sent for microbiological testing before antibiotics are taken. This includes purulent and non-
purulent discharge because certain bacteria associated with a human or animal bite, such as
Eikenella, may not form pus.
For more details, see the summary of the evidence on antibiotics.
Reassessment
The committee agreed that a human or animal bite should be reassessed if an infection develops or
worsens rapidly or significantly at any time or does not start to improve within 24 to 48 hours of
starting treatment because of the consequences of complications from an infection. Reassessment
is also recommended if the person becomes systemically unwell or has severe pain that is out of
proportion to the infection (which can be a symptom of necrotising fasciitis).
The committee agreed that it is good antimicrobial stewardship to review and potentially change
the antibiotic used when microbiological testing results are available. A narrow-spectrum antibiotic
should be used if appropriate.
They also discussed that reassessment is another opportunity to reconsider potential safeguarding
issues for vulnerable adults or children, and to consider non-verbal signs of pain, such as a change in
behaviour, in people who have difficulty communicating.
Referral and seeking specialist advice

The committee agreed that people with a human or animal bite should be referred to hospital if
they have symptoms or signs of a more serious illness or condition, or if they have penetrating
wounds with certain features because of the serious consequences of these.
The committee agreed other circumstances when the prescriber may want to refer the person or
seek specialist advice.
Choice of antibiotic

No evidence was found comparing different antibiotics to inform the choice of antibiotic for human
and animal bites. Therefore, the committee based these recommendations on their experience,
current practice, antimicrobial resistance, and the need to provide choices that cover the relevant
range of likely aerobic and anaerobic pathogens in human and animal bites.
The committee agreed that the same antibiotic choices should be available for both prophylaxis
and treatment because the pathogens will be the same.
Oral antibiotics
The committee agreed that the first-choice oral antibiotic for all people with a human or animal bite
is co-amoxiclav, which has good activity against the relevant range of likely pathogens.
The committee were aware of the BNF entry for co-amoxiclav. Advice was also sought from the UK
Teratology Information Service (UKTIS), which confirmed that the association between
co-amoxiclav and necrotising enterocolitis has only been identified in the context of prelabour
premature rupture of the membranes (PPROM). Outside of this, there is no evidence to show that
general co-amoxiclav use in pregnancy is associated with an increased risk of necrotising
enterocolitis. UKTIS advised that there should be no restriction around the use of co-amoxiclav in
pregnancy, provided it is not being given for PPROM. It was agreed that human or animal bites are a
suitable clinical indication for co-amoxiclav use in pregnancy.
If co-amoxiclav is unsuitable, the alternative first-choice oral antibiotics for adults and young
people over 12 years are doxycycline with metronidazole (an antibiotic with high activity against
anaerobic bacteria). If co-amoxiclav is unsuitable and a woman is pregnant, specialist advice should
be sought for an alternative antibiotic with good activity against Pasteurella.
The committee agreed that if co-amoxiclav is unsuitable, the alternative first-choice oral antibiotic
for children under 12 years is co-trimoxazole because this also has good activity against the range
of likely pathogens.
Intravenous antibiotics
The committee agreed that intravenous antibiotics should only be used if a person cannot take oral
antibiotics or the severity of their condition warrants intravenous antibiotics. The first-choice
intravenous antibiotic for all people with a human or animal bite is co-amoxiclav because it has
good activity against the relevant range of likely pathogens.
If co-amoxiclav is unsuitable, the alternative first-choice intravenous antibiotics for all people with
a human or animal bite are:
• cefuroxime with metronidazole
• ceftriaxone with metronidazole.
The committee agreed that both options have good activity against the relevant likely pathogens.
The cephalosporins, cefuroxime and ceftriaxone have a similar spectrum of activity but providing
more than 1 option allows for choice to be made locally. If a cephalosporin is not appropriate, for
example, in people with a history of immediate hypersensitivity to penicillins, the committee
agreed that a local microbiologist should be consulted to suggest a suitable alternative.
Dosage, course length and route of administration

There was no evidence comparing antibiotic dosage, course length and route of administration.
Therefore, the recommendations were based on the committee's experience and current practice.
The committee agreed that the shortest course that is likely to be effective should be prescribed to
reduce the risk of antimicrobial resistance and adverse effects. However, because the type and
severity of bites can vary, a longer course may be needed based on clinical assessment of the
wound.
The committee agreed that, for both oral and intravenous routes of administration (which would be
switched to oral antibiotics when possible), a course length of 3 days should be effective for
prophylaxis, and a course length of 5 days should be effective for treatment. However, the
committee discussed that because the type and severity of bites can vary, a longer course of up to
7 days (with review) may be needed. This would be based on a clinical assessment of the wound,
and whether it has, for example, caused significant tissue destruction or penetrated bone, joint,
tendon or vascular structures.
Context
Human and animal bites are at risk of infection. Human bites are most commonly infected by
Streptococcus, Staphylococcus aureus, Haemophilus, Eikenella corrodens, Bacteroides and other
anaerobes. Most infections from animal bites are polymicrobial and contain both aerobic and
anaerobic organisms. Causative organisms for infections from cat and dog bites (the most common
animal bites) include Pasteurella, Streptococcus, Staphylococcus, Neisseria, Corynebacterium,
Fusobacterium nucleatum and Bacteroides (Abrahamian et al. 2011).
Summary of the evidence

This is a summary of the evidence, for full details see the evidence review.
The evidence included 1 systematic review (Medeiros et al. 2001) and 2 randomised controlled
trials (Quinn et al. 2010, Broder et al. 2004). These studies considered various prophylactic
antibiotics compared with no antibiotic or placebo for managing animal and human bites. No
evidence was identified for choice of antibiotic, course length or route of administration.
Antibiotic efficacy
If no route of administration for an antibiotic is given in the evidence review, no details were
reported in the primary study.
For human bites

Prophylactic antibiotics (oral cefaclor, intravenous cefazolin, intravenous benzylpenicillin, and oral
cefalexin or penicillin) were shown to be more effective than placebo at reducing signs of infection
after human bites in adults.
For animal bites

There was no difference between prophylactic antibiotics (oral phenoxymethylpenicillin, oral
dicloxacillin, oxacillin, oral cefalexin, oral erythromycin, co-trimoxazole, cloxacillin and oral
co-amoxiclav) and no treatment or placebo in signs of infection after dog bites in adults, young
people and children.
One small study suggests that there was no difference between a prophylactic antibiotic (oxacillin)
and placebo in signs of infection after cat bites in adults.
By bite type
There was no difference between prophylactic antibiotics (oxacillin, oral phenoxymethylpenicillin,
oral dicloxacillin, oral cefalexin and oral erythromycin) and no treatment or placebo in the incidence
of infection in adults, young people and children when treating puncture, laceration or avulsion
wounds.
By bite location
There was no difference between prophylactic antibiotics (oral dicloxacillin, oral cefalexin, oral
erythromycin, oral phenoxymethylpenicillin, co-trimoxazole, oral cefaclor, intravenous cefazolin
and intravenous penicillin) and no treatment or placebo in the incidence of infection in adults,
young people and children when treating trunk, head and neck, hand or arm wounds.
Choice of antibiotic
There was no evidence identified about the choice of antibiotic.
Course length
There was no evidence identified about the course length of antibiotics.
Route of administration
There was no evidence identified about the route of administration of antibiotics.
Other considerations
Medicines safety
Antibiotic-associated diarrhoea is estimated to occur in 2% to 25% of people taking antibiotics,
depending on the antibiotic used (NICE clinical knowledge summary on diarrhoea – antibiotic
associated).
About 10% of the general population claim to have a penicillin allergy; this is often because of a skin
rash that occurred while taking a course of penicillin as a child. Fewer than 10% of people who think
they are allergic to penicillin are truly allergic. See the NICE guideline on drug allergy: diagnosis and
management for more information. People with a history of immediate hypersensitivity to
penicillins may also react to cephalosporins and other beta lactam antibiotics (BNF information on
phenoxymethylpenicillin).
Cholestatic jaundice can occur with co-amoxiclav, and is more common in people over 65 years and
in men; treatment should not usually exceed 14 days (BNF information on co-amoxiclav).
Tetracyclines (for example, doxycycline) can deposit in growing bone and teeth (by binding to
calcium) causing staining and occasionally dental hypoplasia. They should not be given to pregnant
or breastfeeding women, and use in children under 12 years is either contraindicated or there is a
caution for use only in severe or life-threatening infections when there are no alternatives (BNF
information on doxycycline).
Co-trimoxazole is associated with rare but serious side effects, including blood disorders and
Stevens–Johnson syndrome. There is caution for use in older people because there is an increased
risk of serious side effects. There is also caution for use in people with a predisposition to
hyperkalaemia. Monitoring of blood counts is recommended with prolonged treatment (BNF
information on co-trimoxazole).
See the summaries of product characteristics for information on contraindications, cautions and
adverse effects of individual medicines.
Medicines adherence
Medicines adherence may be a problem for some people taking antibiotics that need frequent
dosing or longer treatment duration (see the NICE guideline on medicines adherence).
Resource implications
Recommended antibiotics are available as generic formulations. See the NHS Drug Tariff for costs.
See the evidence review for more information.
Finding more information and committee details

You can see everything NICE says on this topic in the NICE Pathway on bites and stings –
antimicrobial prescribing.
To find NICE guidance on related topics, including guidance in development, see the NICE webpage
on bites and stings.
For full details of the evidence and the guideline committee's discussions, see the evidence review.
You can also find information about how the guideline was developed, including details of the
committee.
NICE has produced tools and resources to help you put this guideline into practice. For general help
and advice on putting our guidelines into practice, see resources to help you put NICE guidance
into practice.
ISBN: 978-1-4731-3900-8
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Human and animal bites:

© NICE 2020. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-of-

Commissioners and providers have a responsibility to promote an environmentally sustainable

Who is it for? ................................................................................................................................................................................... 4

1.1 Managing human and animal bites ................................................................................................................................. 5

1.2 Choice of antibiotic ............................................................................................................................................................... 9

Antibiotic prophylaxis for uninfected human and animal bites .................................................................................. 15

Treating infected human and animal bites .......................................................................................................................... 18

Referral and seeking specialist advice .................................................................................................................................. 19

Choice of antibiotic ...................................................................................................................................................................... 19

Summary of the evidence ............................................................................................................................................. 23

Antibiotic efficacy ......................................................................................................................................................................... 23

Choice of antibiotic ...................................................................................................................................................................... 24

Course length ................................................................................................................................................................................. 24

Other considerations ..................................................................................................................................................... 25

Medicines adherence .................................................................................................................................................................. 25

Resource implications ................................................................................................................................................................. 26

Finding more information and committee details ............................................................................................. 27

• People with a human or animal bite, their families and carers

• It may also be relevant for veterinary professionals

• manage the wound with irrigation and debridement as necessary

• be aware of potential safeguarding issues in vulnerable adults and children, for

Also see the recommendations on referral and seeking specialist advice.

For more details, see the evidence review.

Antibiotic prophylaxis for uninfected bites

1.1.5 Offer antibiotic prophylaxis (see the recommendations on choice of antibiotic)

• is in a person at risk of a serious wound infection because of a comorbidity (such as

1.1.8 Offer antibiotic prophylaxis (see the recommendations on choice of antibiotic)

Bites from a dog or other traditional pet (excluding cat bites)

• has not broken the skin or

• has broken the skin but not drawn blood.

1.1.11 Offer antibiotic prophylaxis (see the recommendations on choice of antibiotic)

has broken the skin and drawn blood if it:

• has penetrated bone, joint, tendon or vascular structures or

• is deep, is a puncture or crush wound, or has caused significant tissue damage or

• is visibly contaminated (for example, if there is dirt or a tooth in the wound).

1.1.12 Consider antibiotic prophylaxis (see the recommendations on choice of

• is in a person at risk of a serious wound infection because of a comorbidity (such as

For more details, see the evidence review.

For more details, see the evidence review.

• seeking medical help if symptoms or signs of infection develop or worsen rapidly or

• symptoms or signs of infection develop or worsen rapidly or significantly at any time,

• the person becomes systemically unwell or

For more details, see the evidence review.

Referral and seeking specialist advice

• they are systemically unwell or

• they have developed symptoms or signs of infection after taking prophylactic

• they have lymphangitis or

• they are at risk of a serious wound infection because of a pre-existing medical

• the bite is infected and is not responding to oral antibiotics or

• the bite is in an area of poor circulation.

For more details, see the evidence review.

1.2 Choice of antibiotic

• follow table 1 for adults aged 18 years and over

• follow table 2 for children and young people under 18 years.

Antibiotic, dosage and course length for

Alternative first-choice oral antibiotics in

First-choice intravenous antibiotic (if

Cefuroxime (caution in penicillin allergy):

If cephalosporin is not appropriate Seek specialist advice