Bite and Scratch Wound Antibiotic Prophylaxis Without a 48-Hour Recheck

By Dr. Jamie Wilkey, PharmD, Director of Clinical Education 
Medically reviewed and edited by Kristen Carpenter, PA-C

September is National Preparedness Month, and at Jase we love this month. I’d like to focus today on something most preparedness aids skip: animals. This is part one of our two-part Animals + Disaster series. Part one covers the attacks, the bites and scratches from animals and how a delay of care can affect their treatment. And we will end the article with a rabies and TDAP refresher because no bite and scratch article would be complete without that part. Part two covers stings, which behave nothing like bites: the reaction that gets mistaken for an infection, and the one that actually needs epinephrine.

You already know how to manage a bite or a scratch. What makes them interesting in a disaster is the last line of the guideline, the one that says see them back in 48 hours. That initial check and/or recheck delay makes a big difference. Today we’re talking about how that decision changes when you have to make the whole call up front. This is decision support for you as a clinician, not a self-treatment guide for your patients.

The first 48 hours of a bite wound (for cats and dogs)

Let’s start with the fresh, ouchy animal bite wound itself. A cat bite is a narrow, deep puncture that seeds bacteria under the skin and closes over the top, which is why cat bites infect around 30% of the time against 2 – 25% for dog bites.¹ Cleaning the wound well is key here. Irrigate with a syringe or a high-pressure system, 1% to 5% povidone iodine in normal saline, or potable water when you’re out of hospital.¹ Then leave it open. Closure is for cosmetic wounds (mostly the face), and cat bites stay open regardless.¹ None of that really needs a clinic. What you lose without a clinic though is an expert eye’s second look.

Now onto the recheck. Forty-eight hours isn’t some arbitrary number. Bite infections declare early, cat bites typically inside 12 to 18 hours, showing up as erythema, induration, pain and purulent drainage.¹ Most of what’s going to turn has turned inside those first 48 hours. Observation doesn’t prevent infection. It catches it while it’s still small and still local. With a provider, that look is yours to catch early. Without one, someone in the household is doing it. 

When nobody sees it at all

In a real disaster most of these wounds never get a clinician right away, either. Which makes the brief you give patients ahead of time worth more than anything you’d do at the visit. It’s short.

Wash the wound right away and thoroughly, soap and running water, and potable water is fine when there’s nothing sterile.¹ ² Leave it open, don’t tape or butterfly it closed.¹ Write down what bit them and whether the animal can be found again, because that answer is the difference between observing a dog for 10 days and starting a rabies series. ³

Then give them a very, very specific watch list (not just, ‘if it gets worse, call me’): spreading redness, swelling, warmth, pus, or a red streak running up the limb.¹ Those signs can be muted in an immunocompromised patient.¹ Also fever and pain way out of proportion to what is expected. When Kristen (the article reviewer) is in clinic, she’s watching bites around joints (especially hands) way more carefully than soft tissue (osteomyelitis risk). Cat bites tend to declare within 12 to 18 hours, so the first day is the one to keep an eagle eye on it.¹

And be clear about what the trigger does. If the bite gets worse, the best move is reaching a clinician, however far or inconvenient that is, not resorting to medications on hand and guessing. 

Who gets antibiotics when you can’t see them again

Normally you give antibiotics after a bite to a short list of patients and watch everybody else. IDSA’s list: immunocompromised or asplenic, advanced liver disease, a bite area already swelling, a moderate to severe wound especially on the hand or face, or a wound that may have gone into periosteum or joint capsule. A three to five day course for this group.⁴ Everyone else gets cleaned up and watched.

If a recheck isn’t available in 48 hours add hand bites to the antibiotic list. It’s the one bite site (hey, that rhymes!) where prophylaxis is proven, cutting infection from 28% to 2%.⁵ ⁶ Past that, the list shouldn’t grow much. The studies never showed antibiotics help an ordinary dog or cat bite,⁵ ⁷ and every course spent on a small, clean one is a course that’s now gone when a bad, messy one shows up.

Amoxicillin-clavulanate is the first line treatment, 875/125 mg twice daily in adults ⁶ and 22.5 mg/kg twice daily in kids.⁸ If you don’t have it, then please know that cephalexin, dicloxacillin and erythromycin have inadequate activity against Pasteurella and should be avoided. ⁹ For penicillin allergy, adults get clindamycin 300 mg three times daily plus ciprofloxacin 500 mg twice daily, or doxycycline. Children get clindamycin 10 to 25 mg/kg divided every 6 to 8 hours plus TMP-SMX. Pregnant and penicillin-allergic, azithromycin 250 to 500 mg daily, watched closely, because the failure rate is high. ⁶

Scratches don’t follow the 48-hour rule

A fresh cat scratch mostly needs soap and water.² There’s no prophylaxis decision to make, because what goes wrong with a scratch takes longer than the 48 hour bite window.

Cat scratch disease (CSD or cat scratch fever) runs on a much longer schedule. A papule comes up at the scratch and sits there 1 to 3 weeks, and a swollen node upstream develops over 1 to 2 weeks.² The patient you see on day two has nothing to find because it hasn’t fully developed yet. What looks like a little scratch on day 2 can turn into a pretty impressive axillary node weeks later and by then they’ve forgotten all about that darn kitty.

Then it mostly handles itself. CSD resolves with supportive care in 90 to 95% of children, though resolving means 2 to 4 months of that node slowly going down.² Azithromycin shrinks the node faster without meaningfully shortening the illness, if you want it: 10 mg/kg on day 1 then 5 mg/kg days 2 through 5, adult max 500 then 250.² The patients who genuinely need treating are the immunocompromised, to keep it from going systemic.²

So the counseling right up front is going to be more helpful than an Rx. A lump may come up in a few weeks, it’s expected and totally normal, and it isn’t a reason to spend an antibiotic course you may need for something worse. One exception: a scratch from a fox or a raccoon is a rabies question. ¹⁰ Let’s get into that next!

Nobody is too late for rabies PEP

Now, this article would be wildly incomplete without bringing up rabies. The CDC says start PEP regardless of how long it’s been, as long as the patient isn’t already showing signs of rabies.¹¹ 

Rabies lives in bats, raccoons, skunks and foxes, at 35%, 29%, 17% and 8% of reported animal cases. ¹⁰ Of the ones that get close enough to expose somebody, about 10% of raccoons are rabid, and more than 20% of skunks and foxes are too. ¹⁰

Rodents and rabbits are the opposite story. Squirrels, chipmunks, rats, mice and their relatives are rarely infected and have never been known to give rabies to a person, so those bites almost never need PEP. ³ The exception is the groundhog, which accounted for about 92% of rabid rodents and lagomorphs reported from 2011 to 2020.¹² Even so, no human rabies death in the US has ever been traced to a rodent or a lagomorph (rabbit, etc).¹²

Before committing to a PEP series, ask whether the animal can be found. A healthy domestic dog, cat or ferret can be confined and observed for 10 days instead. ³ Especially when vaccine and HRIG are hard to reach, that’s the first question. 

Where this fits

In every scenario above, what the patient needed first was clinical decisions: 

• is this the wound that gets treated?
• is this the drug that covers Pasteurella?
• is this the node that’s going to be fine on its own?
• is this an animal that commonly carries rabies?

Right now that decision is all or nothing. Either they reach a clinician and get it made, or they’re alone with a wound, a hodgepodge medicine cabinet and an internet search.

Jase works on the narrow layer in between: the clinical thinking done ahead of time, by a licensed provider who reviews the request and writes the prescription, for a short list of predictable problems, for emergency use only and after first trying to reach a qualified provider. That’s what we mean by appropriate medical preparation. It’s in no way a replacement for primary care. It’s for the days when primary care isn’t reachable.

We’ll keep publishing how we draw these lines, including the ones we’re still arguing about, because this is grey space and clinicians should be the ones charting it.

The bottom line

When the recheck disappears, the wound hasn’t changed. The safety net did.

So clean it properly, treat IDSA’s short list and add the hand, and hold the line on everything else, because the course you don’t spend today is the one still available next week. Send them out knowing what a turning wound looks like, who to call when they see it, and that a node coming up three weeks later is usually nothing to spend a prescription on. And if rabies is on the table, nobody has missed the window.

Sources

1. Indramohan G, Marietta M, Collier SA. Animal Bites. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Updated July 5, 2026. https://www.ncbi.nlm.nih.gov/books/NBK430852/
2. Sabir S, Daley SF, Huang B. Cat Scratch Disease. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Updated December 13, 2025. https://www.ncbi.nlm.nih.gov/books/NBK482139/
3. Centers for Disease Control and Prevention. Human Rabies Prevention, United States, 2008: Recommendations of the Advisory Committee on Immunization Practices. MMWR Recommendations and Reports. 2008;57(RR-3). https://www.cdc.gov/mmwr/pdf/rr/rr57e507.pdf
4. Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJC, Gorbach SL, Hirschmann JV, Kaplan SL, Montoya JG, Wade JC. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2014;59(2):e10-e52. https://academic.oup.com/cid/article/59/2/e10/2895845
5. Medeiros I, Saconato H. Antibiotic prophylaxis for mammalian bites. Cochrane Database of Systematic Reviews. 2001;(2):CD001738. https://www.cochrane.org/evidence/CD001738_antibiotics-reducing-rate-infection-after-bites-mammals-such-humans
6. Ellis R, Ellis C. Dog and Cat Bites. American Family Physician. 2014;90(4):239-243. https://www.aafp.org/pubs/afp/issues/2014/0815/p239.html
7. Grillo R, Brozoski MA, Moreira SB, da Silva YS, Borba AM, Naclério-Homem MG. Antibiotic prophylaxis for animal inflicted maxillofacial injuries: a systematic review and meta-analysis. Frontiers of Oral and Maxillofacial Medicine. 2024. https://fomm.amegroups.org/article/view/80777/html
8. Dannenberg MA, Herigon J. Wise Use of Antibiotics: Management Strategies for Common Animal Bites. The Link, Children’s Mercy Department of Evidence Based Practice. April 2025. https://www.childrensmercy.org/health-care-providers/refer-or-manage-a-patient/connect-with-childrens-mercy/newsletter-the-link/the-link-2025/the-link—april-2025/wise-use-of-antibiotics-management-strategies-for-common-animal-bites/
9. Hasan J, Hug M. Pasteurella Multocida. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Updated May 16, 2023. https://www.ncbi.nlm.nih.gov/books/NBK557629/
10. Centers for Disease Control and Prevention. Rabies in the United States: Protecting Public Health. https://www.cdc.gov/rabies/php/protecting-public-health/
11. Centers for Disease Control and Prevention. Rabies Post-Exposure Prophylaxis: Clinical Care for Healthcare Providers. https://www.cdc.gov/rabies/hcp/clinical-care/post-exposure-prophylaxis.html 
12. Rabies in Rodents and Lagomorphs in the USA, 2011-20. Journal of Wildlife Diseases. 2023;59(4):734-742. doi:10.7589/JWD-D-23-00036. https://bioone.org/journals/journal-of-wildlife-diseases/volume-59/issue-4/JWD-D-23-00036/RABIES-IN-RODENTS-AND-LAGOMORPHS-IN-THE-USA-201120/10.7589/JWD-D-23-00036.full