What is the recommended rabies prophylaxis after a dog (canine) bite?

From the Guidelines

For rabies prophylaxis after a dog bite, immediate wound cleansing with soap and water is essential, followed by both passive and active immunization if risk assessment warrants it, with a recommended regimen of 4 doses of vaccine on days 0,3,7, and 14 for immunocompetent individuals, as outlined in the most recent guidelines 1.

Key Considerations

• The wound should be thoroughly cleaned with soap and water, and a virucidal agent such as povidine-iodine solution should be used if available 1.
• Rabies immune globulin (RIG) should be administered at a dose of 20 IU/kg, with the full dose infiltrated around and into the wound if anatomically feasible, and any remaining volume given intramuscularly at a site distant from the vaccine 1.
• The vaccine series consists of 4 doses of human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV), given on days 0,3,7, and 14, with each dose administered intramuscularly in the deltoid muscle (or anterolateral thigh in small children) 1.
• For individuals who have previously been vaccinated against rabies, a reduced regimen of 2 doses of vaccine on days 0 and 3 is recommended, with no administration of RIG 1.

Risk Assessment

• The geographic location, vaccination status of the dog, circumstances of the bite, and whether the animal can be observed for 10 days should all be considered in the risk assessment 1.
• In the United States, domestic dogs rarely transmit rabies, but in many other countries, dog bites remain a significant source of rabies exposure 1.

Outcome

• Prophylaxis is crucial because rabies is nearly always fatal once symptoms develop, but preventable with proper post-exposure treatment 1.
• The vaccine stimulates active immunity while RIG provides immediate passive protection until vaccine-induced antibodies develop 1.

From the FDA Drug Label

The essential components of rabies post-exposure prophylaxis are wound treatment and, for previously unvaccinated persons, the administration of both human rabies immune globulin (RIG) and vaccine. Local treatment of wounds Thorough washing and flushing (for about 15 minutes, if possible) with soap or a cleansing agent and copious amounts of water of all bite wounds and scratches should be done immediately or as early as possible. Post-exposure antirabies vaccination should always include administration of both passive antibody and vaccine, with the exception of persons who have ever previously received complete vaccination regimens (pre-exposure or post-exposure) with a cell culture vaccine or persons who have been vaccinated with other types of vaccines and have previously had a documented rabies virus neutralizing antibody titer.

Rabies Prophylaxis Post Dog Bite:

• Wound treatment: Immediate and thorough washing of the bite wound with soap and water.
• Post-exposure prophylaxis: Administration of both human rabies immune globulin (RIG) and vaccine for previously unvaccinated persons.
• Vaccination: Post-exposure antirabies vaccination should include administration of both passive antibody and vaccine, unless the person has previously received complete vaccination regimens.
• Consultation: Local or state public health officials should be consulted if questions arise about the need for rabies prophylaxis 2.

Key Considerations:

• The animal species involved
• The circumstances of the bite or other exposure
• The vaccination status of the animal
• The presence of rabies in the region 3
• The type of exposure (bite or non-bite) 4

From the Research

Rabies Prophylaxis Post Dog Bite

• The World Health Organization (WHO) recommends post-exposure prophylaxis (PEP) for individuals bitten by dogs to prevent rabies, which includes washing the wound with water and soap, administering rabies immunoglobulin or monoclonal antibodies, and starting a vaccination regimen 5.
• The WHO-recommended intradermal 1-week vaccination regimen is considered safe and effective, with benefits including cost-, dose-, and time-sparing 5, 6.
• Studies have shown that PEP recipients can develop robust one-year immunity after completing the vaccination regimen, with high levels of rabies virus neutralizing antibodies and T cell responses 7.
• The administration of rabies vaccine prepared in human cell cultures is also effective, with a recommended regimen of three 1-ml doses on days 0,7, and 21 for pre-exposure prophylaxis, and five intramuscular doses on days 0,3,7,14, and 28 for post-exposure prophylaxis 8.
• Abridged vaccination schedules, such as the 1-week, 2-site ID PEP schedule, have been found to be safe, immunogenic, and cost-effective, and may improve patient compliance and access to PEP 6.
• Education and outreach are important to emphasize the animal species and situations associated with a greater risk for rabies transmission, such as bites from rabies reservoir species or animals exhibiting signs of neurologic disease 9.

Steps for Rabies Prophylaxis

• Washing the wound with water and soap for 15 minutes 5
• Assessing the need for rabies biologicals based on specific criteria 5
• Administering rabies immunoglobulin or monoclonal antibodies deep in and around all wounds, if required 5
• Starting the WHO-recommended intradermal 1-week vaccination regimen, if necessary 5, 6
• Informing patients adequately throughout the PEP process to increase compliance and avoid misconceptions about animal bite treatment and rabies risk 5