In a non‑immunocompromised, non‑diabetic patient presenting within 8 hours with a clean linear dog‑bite laceration on the face, should the wound be closed primarily with sutures?

Should Dog Bites Be Sutured?

Yes, facial dog bite wounds presenting within 8 hours should be sutured after copious irrigation, cautious debridement, and with concurrent prophylactic antibiotics—this approach achieves infection rates below 1% while optimizing cosmetic outcomes. 1, 2, 3

Algorithmic Approach to Dog Bite Wound Closure

Step 1: Assess Wound Location and Timing

Facial wounds (including ears):

• Primary closure is strongly recommended after proper preparation, even though this contradicts the general rule against closing bite wounds 1, 2, 3
• The rich vascular supply of facial tissue significantly reduces infection risk and makes closure both safe and cosmetically necessary 3, 4
• Can be closed even beyond 8 hours if properly managed with antibiotics 5, 3
• A prospective randomized trial of 600 facial dog bite cases demonstrated that immediate primary closure resulted in only 6.3% infection rate versus 8.3% for wounds left open (not statistically different), while significantly shortening healing time from 9.12 days to 6.57 days 6

Non-facial wounds (especially hands/fingers):

• Do NOT close primarily due to significantly higher infection rates 1, 2
• May approximate wound edges with Steri-Strips but avoid formal suture closure 1, 5
• Hand wounds carry particularly high infection risk and may penetrate periosteum or joint capsules 1, 2

Step 2: Mandatory Pre-Closure Wound Preparation

Irrigation protocol:

• Use copious sterile normal saline with a 20-mL or larger syringe to generate adequate pressure for mechanical cleansing 2, 3, 7
• Mechanical irrigation is as critical as antibiotic therapy for preventing infection 2

Debridement technique:

• Remove only devitalized tissue while preserving maximum viable tissue, especially on the face and ears 2, 3
• Explore for foreign bodies, tendon involvement, and bone penetration 8, 7
• Inadequate irrigation and debridement is the most common preventable error 2, 3

Step 3: Mandatory Prophylactic Antibiotics

First-line therapy:

• Amoxicillin-clavulanate 875/125 mg orally twice daily for 3-5 days 1, 2, 3
• This covers Pasteurella multocida (present in dog saliva), Staphylococcus aureus, Streptococcus species, and anaerobes 2, 3

Penicillin-allergic patients:

• Doxycycline 100 mg twice daily with excellent Pasteurella coverage 1, 2, 3

Critical antibiotic pitfalls to avoid:

• Never use first-generation cephalosporins, macrolides, clindamycin, or aminoglycosides alone—they lack activity against Pasteurella multocida and Eikenella corrodens 2, 3
• This is the second most common preventable error after inadequate wound preparation 2

Step 4: Additional Required Interventions

Tetanus prophylaxis:

• Administer if last dose was >5 years ago for contaminated wounds like dog bites 1, 3
• Tdap is preferred over Td if not previously given 1

Rabies evaluation:

• Consult local health officials to determine if rabies postexposure prophylaxis is indicated 1, 3
• If indicated, administer both rabies immunoglobulin and vaccine series (days 0,3,7,14) for unvaccinated individuals 3, 7

Step 5: Post-Closure Monitoring

Follow-up protocol:

• Monitor within 24 hours for signs of infection: increasing pain, redness, swelling, or purulent discharge 3
• Elevate the injured area to reduce swelling and accelerate healing 1, 3
• If complications develop (osteomyelitis, septic arthritis, perichondritis), extend antibiotics to 2-4 weeks 3

Key Evidence Nuances

The IDSA guidelines explicitly state that facial wounds are the exception to the general recommendation against primary closure of bite wounds 1. This recommendation is supported by:

• A study showing <1% infection rates with primary closure of dog bite lacerations when properly managed 1
• A 2025 case series demonstrating zero infections in eight deep facial dog bite lacerations treated with immediate primary closure 4
• A 2013 randomized trial of 600 facial dog bites showing no increase in infection with immediate closure 6

The evidence consistently shows that delaying closure of facial wounds leads to poorer cosmetic outcomes without reducing infection risk when proper wound preparation and antibiotics are used 2, 3, 6.

Common Pitfalls Summary

1. Closing hand/finger wounds increases infection risk significantly 1, 2
2. Using inappropriate antibiotics without Pasteurella coverage 2, 3
3. Inadequate irrigation before closure 2, 3
4. Leaving facial wounds open unnecessarily compromises cosmetic outcomes 2, 3, 6
5. Closing wounds with purulent discharge or established infection 5, 3