What is the recommended protocol for administering rabies vaccine and rabies immune globulin after an animal bite?

Post-Bite Rabies Vaccination Protocol

For previously unvaccinated persons, immediately begin wound cleansing followed by rabies immune globulin (20 IU/kg) infiltrated into and around the wound, plus rabies vaccine (HDCV or PCECV) given intramuscularly on days 0,3,7, and 14. 1

Step-by-Step Protocol

1. Immediate Wound Care (Day 0)

• Thoroughly wash all bite wounds and scratches for 15 minutes with soap and copious water 2, 3
• Apply povidone-iodine solution or similar virucidal agent if available 1
• Administer tetanus prophylaxis and antibiotics as indicated 2

2. Determine Vaccination Status

For Previously UNVACCINATED Persons:

Rabies Immune Globulin (HRIG):

• Dose: 20 IU/kg body weight 1, 2
• Infiltrate as much as anatomically feasible into and around ALL wounds 1, 2
• Any remaining volume: inject IM at a site distant from vaccine administration 1
• Never administer in the same syringe as vaccine 1
• Can be given up to day 7 if not administered on day 0 1

Volume guidance for wound infiltration:

• <1 cm wound: approximately 1 mL
• 1-5 cm wound: approximately 3 mL

• 5 cm wound: approximately 5 mL 4

Rabies Vaccine:

• 4-dose regimen: Days 0,3,7, and 14 1, 5
• Dose: 1.0 mL intramuscularly each time
• Site: Deltoid area for adults and older children; anterolateral thigh for young children 1
• NEVER use gluteal area (diminished immune response) 1
• Use HDCV or PCECV 1

For Previously VACCINATED Persons:

Vaccine Only:

• 2 doses: Days 0 and 3 1
• 1.0 mL IM (deltoid) each dose
• Do NOT give HRIG (may inhibit anamnestic response) 1
• Still perform thorough wound cleansing 1

"Previously vaccinated" means: prior complete pre-exposure or post-exposure prophylaxis with cell-culture vaccine, OR other vaccine with documented rabies antibody titer 1

3. Special Populations

Immunocompromised Patients:

• Use 5-dose vaccine schedule: Days 0,3,7,14, and 28 1
• Still give HRIG on day 0 1

All age groups (including children):

• Same vaccine dose volume as adults (1.0 mL) 1

Critical Pitfalls to Avoid

1. Never skip HRIG in unvaccinated persons - provides immediate passive protection while vaccine generates active immunity 6, 1

2. Do not exceed 20 IU/kg of HRIG - excess may suppress active antibody production 1, 2

3. Do not give HRIG to previously vaccinated persons - unnecessary and may inhibit immune response 1

4. Avoid gluteal injection site - associated with vaccine failure 1

5. Infiltrate wounds adequately - only 56% of eligible patients receive proper wound infiltration in practice, yet this is critical for preventing local viral replication 7

6. Do not delay treatment - begin immediately regardless of time since exposure 1, 2

Rationale

The 2010 ACIP guidelines reduced the vaccine schedule from 5 doses to 4 doses based on evidence showing no PEP failures occurred before day 28, and the regimen saves approximately $16.6 million annually in the U.S. healthcare system without compromising safety or efficacy 1. The combination of immediate passive immunity (HRIG) and active immunity (vaccine) is uniformly effective when properly administered 6, 2.

Human rabies is nearly 100% fatal once symptoms appear, making proper PEP administration literally life-saving 3, 8. The regimen has proven safe and effective with proper adherence to dosing, timing, and anatomical site recommendations 7, 5.