Is it recommended to suture a deep wound from a dog bite immediately?

Suturing Deep Dog Bite Wounds: Evidence-Based Approach

Deep dog bite wounds can be sutured after thorough irrigation and debridement, but the decision depends critically on wound location, time since injury, and patient risk factors—facial wounds should be closed primarily, while hand wounds and those in high-risk patients should generally not be sutured. 1, 2, 3

Location-Specific Closure Guidelines

Facial and Head/Neck Wounds (Including Ears)

• Primary closure is strongly recommended for facial lacerations after copious irrigation, cautious debridement, and initiation of preemptive antibiotics 1, 2
• The rich vascular supply of the face significantly reduces infection risk and makes closure both safe and cosmetically necessary 2, 3
• Studies demonstrate infection rates as low as 0.53-1.4% for properly managed facial dog bites with primary closure 4
• A randomized controlled trial of 168 patients showed no difference in infection rates between sutured and non-sutured wounds, but significantly better cosmetic outcomes with suturing (mean Vancouver Scar Scale score 1.74 vs 3.05, p=0.0001) 5

Hand Wounds

• Primary closure is NOT recommended for hand wounds due to higher infection rates in this location 6, 7
• Hand wounds should be approximated but not formally sutured 1

Other Body Locations

• Wounds may be approximated (brought together without formal closure) but primary suturing carries higher risk 1
• The decision should weigh cosmetic factors against infection potential 1

Critical Timing Considerations

• Wounds treated within 8 hours of injury demonstrate significantly lower infection rates (4.5%) compared to those treated after 8 hours (22.2%) 5
• Early presentation allows safer primary closure regardless of location 5

Absolute Contraindications to Primary Closure

Do not suture if any of the following are present:

• Wound is already infected at presentation (purulent discharge, erythema, warmth) 3
• Puncture wounds (high risk for deep infection) 3
• High-risk patient populations: immunocompromised, asplenic, advanced liver disease, or pre-existing edema 3
• Heavily contaminated wounds 6

Mandatory Pre-Closure Wound Preparation

Irrigation and Debridement

• Copious irrigation with sterile normal saline using a 20-mL or larger syringe is essential 2, 3
• Dilute povidone-iodine solution can be added as a virucidal agent 1
• Perform careful debridement of devitalized tissue only, preserving maximum viable tissue especially on the face 2, 3
• Assess for deep structure injury (nerves, tendons) which may require specialized repair 2

Antibiotic Prophylaxis (Required for All Closures)

• Amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days is the first-line preemptive therapy 2, 3
• This covers Pasteurella multocida, Staphylococcus aureus, Streptococcus species, and anaerobes commonly found in dog bites 2, 3
• For penicillin-allergic patients: doxycycline 100 mg twice daily 2

Common pitfall: Avoid first-generation cephalosporins, macrolides, or clindamycin alone—these have poor activity against Pasteurella multocida 2

Additional Required Interventions

Tetanus Prophylaxis

• Administer tetanus toxoid if vaccination is not current within the past 5 years for dirty wounds like dog bites 1, 2
• Tdap is preferred over Td if not previously given 1

Rabies Evaluation

• Consult local health officials to determine if rabies post-exposure prophylaxis is indicated 2, 3
• If indicated, administer both rabies immunoglobulin (20 IU/kg infiltrated around wound) and vaccine series 1

Post-Closure Monitoring

• Close follow-up within 24 hours is necessary to monitor for infection 2
• Watch for signs of infection: increasing pain, redness, swelling, or purulent discharge 2
• Elevate the injured area to reduce swelling 2, 3
• For ear wounds specifically, monitor for perichondritis (pain disproportionate to injury near cartilage) 2

Evidence Quality Note

The most recent high-quality guideline from the Infectious Diseases Society of America (2014) provides strong recommendations with low-quality evidence for the general principle of avoiding closure except for facial wounds 1. However, a 2014 randomized controlled trial of 168 patients directly challenges this dogma, showing equivalent infection rates between sutured and non-sutured wounds (8.3% overall) with superior cosmetic outcomes for sutured wounds 5. The key differentiator remains anatomic location and timing of presentation.