INTRODUCTION

Background

Dog bites represent a significant global public health challenge, particularly impacting vulnerable populations such as children and older adults [1,2]. The consequences of these incidents span a wide spectrum, ranging from minor lacerations to severe infections, psychological trauma, and, in some cases, death [3,4]. The issue is substantial, with an estimated 100 million dog bites occurring worldwide annually [5]. These events account for a large proportion of all animal-related injuries (60%–80%) [6,7] and approximately 1% of all emergency room visits [7–9].

Despite the widespread occurrence and potential severity of dog bites, no consensus has been reached regarding the most effective prevention and treatment strategies [10,11]. Current approaches vary considerably, encompassing methods such as behavioral training for dogs, public education campaigns, and an array of medical interventions [12,13]. This diversity underscores the pressing need for a systematic evaluation to identify the most efficacious practices for mitigating the risks associated with dog bites.

Historically, research in dog bite prevention and treatment has been characterized by sporadic efforts and, at times, reliance on anecdotal evidence. Although numerous studies have proposed various preventive and therapeutic measures, the effectiveness of these interventions has often been inadequately quantified. Many studies lack validation through rigorous scientific methods, particularly randomized controlled trials (RCTs), which are considered the gold standard for evidence-based research [14].

Objectives

Given these challenges, this systematic review aimed to consolidate and analyze the available RCTs examining the effectiveness of interventions designed to prevent and treat dog bites. By focusing exclusively on RCTs, this review seeks to provide clear, evidence-based conclusions to inform policymaking and clinical practice. The ultimate goal is to develop more effective strategies to reduce the incidence and impact of dog bites, thereby improving public health outcomes in this key area.

METHODS

This systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines (Supplementary Material 1) [15] and the AMSTAR 2 (A Measurement Tool to Assess Systematic Reviews 2) (Supplementary Material 2) [16].

Eligibility criteria

This systematic review applied stringent eligibility criteria to ensure the inclusion of high-quality evidence. Studies were required to meet the following conditions. Regarding study design, only RCTs were considered, given their status as the gold standard for evaluating intervention effectiveness. For the population, individuals of any age or demographic background who had experienced a dog bite were included. Interventions were categorized into two groups: prevention interventions (including educational programs, behavioral interventions, and policy-based approaches aimed at preventing dog bites) and treatment interventions (including medical and surgical approaches for managing dog bite wounds, such as wound closure techniques, negative pressure wound therapy [NPWT], and hyperbaric oxygen therapy [HBOT]). For the control condition, each study included a group that received no intervention, a placebo, or an alternative treatment. Primary outcomes included the infection rate and recovery time for dog bites, the effectiveness of interventions in preventing or reducing bite severity, and associated health outcomes. Secondary outcomes included cosmetic outcomes, participant satisfaction, operation time, complications, and the number of dressing changes. To ensure relevance and timeliness, only studies published in English within the last 10 years were included.

Information sources

Relevant studies were identified by searching the CINAHL, Embase, MEDLINE, Web of Science, and PubMed databases. Search strategies were tailored to each database to optimize the retrieval of pertinent studies, with the search period limited to the last 10 years to focus on the most recent evidence.

Search strategy

The search, conducted in May 2024, employed the participants, intervention, comparison, outcome, and study design framework. Given the prevalence of qualitative studies in this area, a broad search for dog bite–related topics was performed with a focus on participants and study design elements to identify relevant RCTs. The complete search strategy for each database is provided in Supplementary Material 3.

Selection process

Study selection was rigorous and was conducted in two distinct phases. In the initial screening phase, two independent reviewers evaluated titles and abstracts to identify potentially eligible studies, with discrepancies resolved through discussion or consultation with a third reviewer. In the full-text review phase, the same reviewers independently assessed the full texts of the selected articles for eligibility. Reasons for exclusion were systematically documented to ensure transparency and reproducibility.

Data collection process

Data were extracted using a standardized form that captured key information such as study characteristics, participant demographics, intervention details, outcomes, and findings. To minimize errors, two researchers independently conducted data extraction, and discrepancies were resolved through consensus.

Data items

The specific data items extracted from each study were selected to provide a comprehensive overview of the research. The primary outcomes were infection rate and recovery time. Infection rate was defined as the presence of clinical signs of infection, including erythema, increased local temperature, purulent discharge, or systemic signs (fever) within 30 days posttreatment, confirmed by bacterial culture when available. Recovery time referred to the period from initial treatment to complete wound healing, defined as full epithelialization without drainage or the need for additional dressing changes.

Secondary outcomes included cosmetic outcomes (assessed using standardized scar assessment tools or patient satisfaction scales at follow-up visits), patient satisfaction (measured using validated patient-reported outcome measures or satisfaction questionnaires), operation time (duration of the initial treatment procedure), complications (any adverse events or unexpected outcomes reported during treatment or follow-up), and the number of dressing changes (frequency of wound dressing changes required during treatment). Additional data items included study setting/location, referring to the context and geographical area where the research was conducted; participant characteristics, namely demographic details such as age, sex, and health status; intervention details, describing the specific measures implemented, including any procedural or treatment specifics; outcome measures, detailing the primary and secondary endpoints assessed; results for these outcomes, including both efficacy and any observed adverse effects; and follow-up periods, or the durations over which outcomes were monitored, which provided insights into the long-term effects of the interventions.

Study risk of bias assessment

The risk of bias in individual studies was assessed using the Cochrane Collaboration tool for assessing risk of bias in randomized trials [17]. This tool evaluated domains including random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other potential sources of bias.

Effect measures

Risk ratio was used to assess the infection rate of dog bites. The primary effect measure for continuous data was the mean difference, presented with a 95% confidence interval (CI). This measure facilitated comparisons of intervention effects across studies that employed different measurement scales.

Synthesis methods

Data were synthesized using a random-effects meta-analysis model to account for potential variability between studies. Heterogeneity was assessed using the I² statistic to determine the appropriateness of the meta-analysis.

Reporting bias assessment

Conventionally, potential reporting bias is assessed by examining the symmetry of funnel plots for publication bias, provided that a sufficient number of studies (typically 10 or more) are available.

RESULTS

Study selection

A total of 49 studies were identified from the five databases (Fig. 1). Microsoft Excel (Microsoft Corp) was used to identify duplicates, resulting in the exclusion of 19 studies. Additionally, 22 studies did not meet the inclusion criteria and were subsequently excluded. After a full-text review, three studies were excluded because of inappropriate study designs and participant eligibility (Supplementary Table 1). Ultimately, this systematic review included five studies [18–22].

Risk of bias in studies

The pilot test, which achieved a 100% agreement rate, yielded the following results. For random sequence generation, three studies had low risk [19,20,22], one had high risk [21], and one had an uncertain risk of bias [18]. For allocation concealment, two had low risk [19,22] and three uncertain risk [18,20,21]. Regarding blinding of participants and personnel, all five studies had an uncertain risk of bias [18–22]. For blinding of the outcome assessment, three studies had low risk [18–20] and two uncertain risk [21,22]; for incomplete outcome data, two had low risk [18,22] and three high risk [19–21]; for selective reporting, all five had uncertain risk [18–22]; and for other bias, one had low risk [22] and the remaining four had uncertain risk [18–21] (Fig. 2).

Results of individual studies

Prevention interventions

Shen et al. [21] evaluated a video-based testimonial intervention for dog bite prevention in rural Chinese children. This RCT included 280 third- and fourth-grade students and assessed the effectiveness of educational video testimonials. Children who watched the testimonials on dog bite prevention exhibited increased safety knowledge, displayed higher perceived vulnerability, and engaged in less risky simulated behaviors with dogs relative to the comparison group. Mediation analysis revealed that the intervention successfully altered children’s simulated behaviors through greater safety knowledge and increased perceived vulnerability.

Treatment interventions

Primary outcomes

Lisong et al. [18] evaluated the use of medical glue after negative pressure sealing drainage for maxillofacial dog bites in children, finding no significant difference in infection rates compared with conventional suturing. Paschos et al. [19] investigated primary suturing versus non-suturing for dog bite wounds and observed no significant difference in infection rates between groups. Rui-Feng et al. [20] demonstrated that NPWT for serious dog bites of the extremities reduced infection rates and shortened recovery times compared with open wounds. They also found that early treatment (within 8 hours) resulted in low infection rates regardless of closure method. Tian et al. [22] reported that HBOT for grade III exposed dog bite wounds promoted wound healing and reduced infection rates compared with routine treatment. The study characteristics are summarized in Table 1 [18–22].

Secondary outcomes

Analysis of secondary outcomes revealed varying levels of reporting across studies. For cosmetic outcomes, two studies provided data. Paschos et al. [19] observed significantly better cosmetic appearance in the primary suture group compared with the non-suturing group. Lisong et al. [18] reported comparable cosmetic results between the medical glue and conventional suturing groups. Regarding patient satisfaction, only Lisong et al. [18] evaluated this outcome, demonstrating improved satisfaction scores with medical glue compared to conventional suturing. The study also reported a significantly shorter operation time with medical glue.

Complications were reported in three studies [18,20,22], with no significant differences in complication rates observed between the intervention and control groups. Regarding dressing changes, Tian et al. [22] found that HBOT necessitated fewer dressing changes compared with routine treatment.

Results of syntheses

Due to the distinct nature of prevention and treatment interventions, meta-analyses were conducted only for treatment studies. The single prevention study (Shen et al. [21]) was analyzed narratively. Five studies, involving 1,148 patients with dog bite injuries, were analyzed [18–22]. Notably, the treatment interventions included in this meta-analysis (medical glue, NPWT, and HBOT) represent clinically distinct approaches with different mechanisms of action. While they were combined statistically to provide an overall assessment of treatment effects, the results should be interpreted in light of this clinical heterogeneity. In this review, infection rate and recovery time were selected as common outcome measures. For infection rate, four studies were analyzed (risk ratio, 0.69; 95% CI, 0.27–1.77; I²=62%; Z=0.77; P=0.44) (Fig. 3) [18–20,22]. Recovery time was analyzed using the mean difference between interventions (mean difference, 11.25 days; 95% CI, 8.44–14.07 days; I²=99%; Z=7.84; P<0.001) (Fig. 4) [20,22].

Reporting biases

Five studies met the eligibility criteria and were included in this meta-analysis [18–22]. In accordance with the guidelines of the Cochrane Review [23], publication bias was not evaluated, as it is typically not recommended to analyze publication bias among fewer than 10 studies.

DISCUSSION

This systematic review and meta-analysis of RCTs examining interventions for the prevention and treatment of dog bites provides critical insights for emergency medicine practitioners, traumatologists, and public health officials. The synthesis of five high-quality RCTs encompassing 1,148 participants [18–22] offers a foundation for evidence-based approaches to managing this pervasive public health issue. However, it also underscores the paucity of robust research in this field and highlights areas that require further investigation.

The studies included in this review examined a range of medical interventions, each showing promise for specific aspects of dog bite management. The investigation by Lisong et al. [18] in the use of medical glue after negative pressure sealing drainage for maxillofacial dog bites in children is particularly noteworthy. While the study did not demonstrate a significant reduction in infection rate compared with conventional suturing, the shorter operation time observed and improvement in patient satisfaction are crucial considerations in emergency department settings, where efficiency and patient experience are paramount. From an emergency medicine perspective, the shorter operation time is especially meaningful [24]. In high-volume emergency departments, where the ability to quickly and effectively treat patients can greatly impact overall patient flow and outcomes, the use of medical glue could prove transformational. This finding aligns with broader research on tissue adhesives in emergency wound care, which has shown that tissue adhesives are quick, painless, and effective alternatives to sutures for small wounds [25,26].

The work of Rui-Feng et al. [20] on NPWT for serious dog bites to the extremities offers valuable insights into the management of complex wounds. Their findings of a reduced infection rate and shorter recovery time compared with open wound management align with the broader literature on NPWT in complex wound care. As emergency physicians, we must weigh the long-term benefits of such interventions against the initial investments in equipment and training. The application of NPWT in emergency department settings for dog bites represents a paradigm shift in wound management. Traditionally, complex dog bite wounds, especially those involving deep tissue damage, have been managed with prolonged courses of antibiotics and multiple surgical debridements. The potential of NPWT to reduce infection rates and shorten recovery times could significantly decrease the burden on both patients and healthcare systems [27,28].

A study by Tian et al. [22] on HBOT for grade III exposed dog bite wounds presents an intriguing option for severe cases. The reported improvements in wound healing, cure rates, and infection rates, along with a reduction in the number of dressing changes required, suggest that HBOT may be a valuable adjunct therapy when available. From an emergency medical standpoint, the potential of HBOT to lower infection rates in cases of severe dog bite is particularly promising. Grade III dog bites, which involve deep tissue damage and often require extensive surgical intervention, are associated with high infection rates and prolonged recovery times [29]. If HBOT can reduce infection rates and promote faster healing, it could significantly decrease the need for repeated surgical interventions and extended courses of antibiotics.

The comparison of primary suturing versus non-suturing for dog bite wounds by Paschos et al. [19] addresses a longstanding debate in emergency wound care. The lack of a significant difference in infection rates between the two approaches challenges the traditional dogma of leaving all dog bite wounds open. However, the superior cosmetic outcomes in the primary suturing group introduce important quality-of-life considerations. Emergency physicians must balance immediate wound management with long-term patient outcomes, including the psychological impact of scarring. The finding that primary closure does not significantly increase infection risk is particularly relevant in cases of facial and hand injuries, where cosmetic outcomes can profoundly affect a patient’s quality of life. This observation is corroborated by reviews conducted by Eliya-Masamba and Banda [30] and Xiaowei et al. [31], which indicated no significant difference in infection rates between primary and delayed closure of mammalian bite wounds.

A video-based testimonial intervention for dog bite prevention in rural Chinese children, as studied by Shen et al. [21], offers a promising approach for public health education. Improved safety knowledge, increased perceived vulnerability, and a reduction in risky simulated behaviors with dogs demonstrate the potential of such targeted educational interventions. In public health emergency medicine, prevention is always preferable to treatment. The potential of this intervention to reduce the incidence of dog bites could have far-reaching implications for emergency department visit rates and overall public health. This aligns with broader research on health education interventions, such as a systematic review by Shen et al. [32], which found that narrative interventions can be effective in health promotion and disease prevention.

The meta-analysis of infection rates (risk ratio, 0.69; 95% CI, 0.27–1.77; I²=62%; P=0.44) suggests that the interventions studied may reduce infection risk, although the wide confidence interval and nonsignificant difference indicate that this finding should be interpreted with caution. The high heterogeneity (I²=62%) reflects significant variability among the studies, which may stem from differing outcome definitions as well as fundamental distinctions between intervention types. Each intervention—medical glue, NPWT, and HBOT—employs separate mechanisms and may be more appropriate for specific types of dog bite wounds. The analysis of recovery time (mean difference, 11.25 days; 95% CI, 8.44–14.07 days; I²=99%; P<0.001) provides stronger evidence for the efficacy of the studied interventions in reducing healing time. This finding has major implications for patient care and resource utilization in both emergency departments and follow-up care settings. Faster recovery times could reduce the need for follow-up visits, lower the risk of complications, and improve patient satisfaction. However, the high heterogeneity (I²=99%) in the recovery time analysis warrants careful interpretation. This finding likely reflects the diverse nature of the interventions and the varying definitions of “recovery” across studies. Thus, while our meta-analysis offers a statistical synthesis of the available evidence, clinical decision-making should carefully consider the specific characteristics of each intervention and its appropriateness for the individual case. Standardizing outcome measures in future research would greatly improve the ability to compare and synthesize findings across studies.

Limitations

Although our search strategy comprehensively identified RCTs comparing various interventions for dog bite management, it may have led to the exclusion of studies focused on specific treatment modalities, such as prophylactic antibiotics.

Additionally, while this systematic review provides valuable insights, it also highlights substantial gaps in current knowledge. The small number of RCTs meeting the inclusion criteria (n=5) underscores the need for more high-quality research in this field. Future studies should focus on larger, multicenter RCTs to increase the generalizability of findings; standardize outcome measures to facilitate more robust meta-analyses; incorporate long-term follow-up to assess the durability of treatment effects and the efficacy of preventive interventions over time; conduct cost-effectiveness analyses to inform policy decisions regarding the implementation of novel interventions; examine specific high-risk populations, such as children or individuals in areas with high stray dog populations; investigate combination therapies, such as NPWT in conjunction with HBOT for severe dog bite wounds; and explore novel preventive strategies, including the use of virtual reality for dog behavior education or smartphone apps for real-time risk assessment.

Based on the findings of this review, emergency physicians should consider using medical glue for the closure of appropriate dog bite wounds, particularly in pediatric maxillofacial injuries; implementing NPWT protocols for severe dog bite wounds where resources allow; referring patients for HBOT in cases of grade III exposed dog bite wounds when available; opting for primary closure of select dog bite wounds, particularly in cosmetically sensitive areas, with appropriate follow-up; and advocating for and participating in community-based dog bite prevention education programs. Crucially, however, these recommendations must be considered in the context of individual patient factors, wound characteristics, and local resources and guidelines.

Conclusions

This systematic review and meta-analysis provides a comprehensive overview of the current evidence on interventions for dog bite prevention and treatment. While the findings suggest potential benefits of several interventions, particularly in reducing recovery time, the limited number of high-quality RCTs highlights the need for further research. As emergency physicians, we must continue to advocate for evidence-based approaches to dog bite management while remaining adaptable to emerging therapies and preventive strategies. The ultimate goal is to reduce the complications associated with dog bites and optimize outcomes for those affected by this common and potentially serious injury.

ARTICLE INFORMATION

Author contributions

Conceptualization: YY, DK, HM; Data curation: DK, DL; Formal analysis: YY, DL, HM, JC; Investigation: all authors; Methodology: DL; Writing–original draft: YY, DK, JC; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data analyzed in this study are available from the corresponding author upon reasonable request.

Supplementary materials

Fig. 1.

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram.

Fig. 2.

Risk of bias summary.

Fig. 3.

Forest plot for risk ratio of infection rate. M-H, Mantel-Haenszel test; Random, random-effects model; CI, confidence interval.

Fig. 4.

Forest plot for risk ratio of recovery time (days). SE, standard error; IV, inverse variance; Random, random-effects model; CI, confidence interval. ^a)Wounds left open after debridement. Negative pressure wound therapy at ^b)125 mmHg and ^c)75 mmHg. ^d)Whole-body hyperbaric oxygen therapy. ^e)Routine treatment.

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Figure & Data

References

Citations

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