What is the recommended approach for wound closure following a dog bite?

Wound Closure for Dog Bites

Primary Recommendation

Primary wound closure is NOT recommended for most dog bite wounds, with the critical exception of facial wounds, which should be closed after copious irrigation, cautious debridement, and preemptive antibiotics. 1, 2 For non-facial wounds, approximation (bringing edges together without formal closure) may be acceptable, but formal primary closure carries increased infection risk, particularly for hand wounds. 1

Algorithmic Approach to Wound Closure Decision

Step 1: Identify Wound Location

Facial wounds (including ears):

• Primary closure IS recommended after thorough wound preparation 1, 2
• The rich vascular supply of the face reduces infection risk and makes closure both safe and cosmetically necessary 2, 3
• Infection rates remain <1% with proper management 1
• Close within 12-24 hours of injury for optimal outcomes 2

Hand and finger wounds:

• Primary closure is NOT recommended due to significantly higher infection rates compared to other body locations 1, 2, 4, 5
• Hand wounds specifically showed higher infection rates when closed versus other anatomical sites 1, 5
• Wound approximation without formal closure may be considered as a compromise 1

Other body locations:

• Primary closure generally not recommended 1
• May approximate edges without formal suturing 1
• Consider delayed closure for high-risk wounds 3

Step 2: Essential Pre-Closure Wound Preparation (All Wounds)

Irrigation:

• Use copious sterile normal saline with a 20-mL or larger syringe 2, 6
• Thorough mechanical cleansing is equally important as antibiotics for infection prevention 3

Debridement:

• Cautiously debride only devitalized tissue 1, 2
• Preserve maximum viable tissue, especially on face and ears where tissue loss affects cosmesis 2
• Explore wound for tendon, bone involvement, and foreign bodies 6

Step 3: Mandatory Antibiotic Prophylaxis

First-line therapy:

• Amoxicillin-clavulanate 875/125 mg orally twice daily for 3-5 days prophylaxis 1, 2, 3
• This covers Pasteurella multocida, Staphylococcus aureus, Streptococcus species, Eikenella corrodens, and anaerobes 1, 3

Penicillin-allergic patients:

• Doxycycline 100 mg twice daily 2, 4
• Alternative: Fluoroquinolone (ciprofloxacin or levofloxacin) plus metronidazole, or moxifloxacin alone 1, 3

Critical pitfall to avoid:

• Never use first-generation cephalosporins, macrolides, clindamycin, or aminoglycosides alone as they lack activity against Eikenella corrodens and Pasteurella multocida 1, 2

Step 4: Tetanus Prophylaxis

• Administer tetanus toxoid if >5 years since last dose for dirty wounds like dog bites 1, 2, 4
• Tdap preferred over Td if not previously given 1, 2, 4

Step 5: Rabies Assessment

• Consult local health officials to determine need for rabies post-exposure prophylaxis 2, 4
• If dog is healthy and available, confine and observe for 10 days 4

Evidence Quality and Nuances

The recommendation against primary closure for non-facial wounds is based on strong guideline consensus from the Infectious Diseases Society of America, though the underlying evidence quality is low 1. A 2013 randomized trial found primary closure associated with 6.7% infection rate versus 5% for delayed closure (not statistically significant), but primary closure yielded superior cosmetic outcomes (55% optimal scores versus 33.3%) 7. However, a 1988 controlled trial showed no significant difference in infection rates between sutured (7.6%) and unsutured (7.8%) wounds overall, but hand wounds had significantly higher infection rates in both groups 5.

The key clinical takeaway: The anatomic location drives the decision—facial wounds are the explicit exception where cosmetic and functional outcomes justify primary closure with appropriate antibiotic coverage, while hand wounds represent the highest-risk scenario where closure should be avoided 1, 2, 5.

Common Pitfalls

• Delaying closure of facial wounds leads to poorer cosmetic outcomes 2
• Closing hand/finger wounds significantly increases infection risk 1, 5
• Inadequate irrigation and debridement is the most common error—mechanical cleansing is as important as antibiotics 2, 3
• Using inappropriate antibiotics that lack Pasteurella or Eikenella coverage 1, 2
• Closing already infected wounds—if discharge is present, control infection first before considering delayed closure 2