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Three Part Question

In [dog bite wounds] does [primary closure with sutures] have any impact on [wound outcome].

Clinical Scenario

A patient who works as a model, presents to the A&E with dog bite lacerations to the hand and arms. You check tetanus status and clean and irrigate the wounds. Having recently read the Cochrane review on not providing prophylactic antibiotics in dog bites, you wonder whether this also means you can primarily close the wounds.

Search Strategy

1. Medline via Ovid interface (1946 to date)
2. Embase (1980 to date)
3. Cochrane Library Database
4. Google Scholar (keywords; suturing , closure dog bites)
5. Bibliography review of identified papers

([dog] OR [canine] OR [mama*] AND [bite] OR [wound] OR [injury]) OR [“dog bite”] AND ([sutur*] OR [Stich*] OR [manag*] OR [Clos*]) NOT [rabies]
NB: Some minor differences in Medline with terms exploded.]

Search Outcome

571 paper identified
475 excluded from title
76 Excluded from abstract
6 additional papers identified from reference searching.
17 Excluded as not answering clinical question
3 Excluded as retrospective review
3 Papers included in the review as RCT's

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Rui-feng et al 2013 China	600 pts. 1-64 years. 300 sutured, 300 non-sutured. No antibiotics	Randomised controlled trial	Infection rate	Sutured group 6.3% Non-sutured group was 8.3% (P>0.05)	No power calculation Single centre - applicability
			Recovery time	Recovery time less in sutured group (<0.05)
Paschos et al 2014 Greece	168 adult patients, 82 sutured 86 non-sutured. All received antibiotics	Randomised controlled trial	Infection rate	Sutured 9.7%, non-sutured 6.9% p=0.51	Per protocol analysis Limited to adults Powered for cosmetic difference, not infection.
			Cosmesis (Vancouver scar scale)	Sutured: 1.74, Non-sutured: 3.05 p=0.0001
Maimaris & Quinton UK 1988	96 ED patients 2-83yrs with 169 lacerations. 92 sutured 77 non-sutured No antibiotics	Randomised controlled trial	Infection rate	Overall infection rate was 7.7%, the sutured rate 6.6% (nil sig) Hand wound infection was higher(p<0.01)	No randomisation method stated No power calculation Lack of statistics No validated cosmesis scale used
			Cosmesis	Scar width 1-5mm in closed group, 2-6 in open.

Comment(s)

The literature is in support of primary closure of dog bites and although only Paschos et al. addressed cosmesis of wounds adequately, in the absence of increasing infection leading to complications, it can be assumed that primary closure of dog bites will only serve to improve cosmetic appearance. To achieve these results in our current practice we must apply the principles used in all these studies, copious irrigation, would cleaning and debridement. Hand wounds will always have higher infection rates regardless and the decision to close them should be based on individual clinical acumen, depending on the extent of devitalised tissue and nature of the wound (puncture/laceration). Most of the studies excluded immune-compromised patients and this should be kept in mind when dealing with these patients.

Clinical Bottom Line

Primary closure of dog bites can be recommended in the ED providing they are adequately debrided and irrigated.

References

1. Rui-feng C, Li-song H, Ji-bo Z, Li-qiu W. Emergency treatment on facial laceration of dog bite wounds with immediate primary closure:a prospective randomized trial study. BMC Emergency Medicine 2013, 13(suppl 1):S2
2. Paschos NK, Makris EA, Gantos A, Georgoulis AD. Primary closure versus non-closure of dog bite wounds. A randomised controlled trial. Injury. Injury. Int J. Care Injured 45 (2014) 237-240
3. Maimaris C, Quinton DN Dog-bite lacerations: a controlled trial of primary wound closure. Archives of Emergency medicine 1988; 5:156-161