What is the post-exposure prophylaxis (PEP) treatment for rabies?

From the Guidelines

Post-exposure prophylaxis (PEP) for rabies should include immediate and thorough wound cleansing, administration of rabies immune globulin (RIG), and a series of rabies vaccines, with the specific regimen depending on the individual's vaccination history, as outlined in the most recent guidelines 1. The standard approach for individuals not previously vaccinated against rabies involves wound cleansing, followed by the administration of RIG and vaccination with a cell culture rabies vaccine, such as human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) 1.

• For those not previously vaccinated, the regimen includes:
  • Wound cleansing with soap and water, and if available, a virucidal agent such as povidine-iodine solution.
  • Administration of 20 IU/kg body weight of HRIG, with as much as possible infiltrated into and around the wound, and any remaining volume given intramuscularly at a site distant from vaccine administration.
  • Vaccination with HDCV or PCECV, 1.0 mL, intramuscularly (deltoid area), on days 0,3,7, and 14.
• For previously vaccinated individuals, the regimen is simplified to wound cleansing and vaccination with HDCV or PCECV on days 0 and 3, without the need for HRIG 1. It is crucial to initiate PEP as soon as possible after exposure, ideally within 24 hours, though it should still be given even if delayed, as it is nearly 100% effective when administered promptly and correctly, preventing the rabies virus from reaching the central nervous system, where it causes fatal encephalitis 1. Without PEP, rabies is almost universally fatal once symptoms appear, highlighting the importance of prompt and appropriate prophylaxis 1.

From the FDA Drug Label

The following recommendations are only a guide. In applying them, take into account the animal species involved, the circumstances of the bite or other exposure, the vaccination status of the animal, and presence of rabies in the region. Local Treatment of Wounds: Immediate and thorough washing of all bite wounds and scratches with soap and water is perhaps the most effective measure for preventing rabies. Active Immunization: Active immunization should be initiated as soon as possible after exposure (within 24 hours). Passive Immunization: A combination of active and passive immunization (vaccine and immune globulin) is considered the acceptable postexposure prophylaxis except for those persons who have been previously immunized with rabies vaccine and who have documented adequate rabies antibody titer. Rabies Immune Globulin (Human) should be used in conjunction with rabies vaccine and can be administered through the seventh day after the first dose of vaccine is given.

The post-exposure prophylaxis (PEP) treatment for rabies includes:

• Immediate thorough cleansing of the wound with soap and water
• Active immunization with rabies vaccine as soon as possible after exposure (within 24 hours)
• Passive immunization with Rabies Immune Globulin (Human) in conjunction with rabies vaccine, administered through the seventh day after the first dose of vaccine is given
• Tetanus prophylaxis and measures to control bacterial infection should be given as indicated 2

From the Research

Post-Exposure Prophylaxis (PEP) Treatment for Rabies

The post-exposure prophylaxis (PEP) treatment for rabies involves a series of vaccinations and, in some cases, the administration of human rabies immunoglobulin (HRIG) [ 3 ]. The key aspects of PEP treatment are outlined below:

• Vaccine Schedule: The Advisory Committee on Immunization Practices recommends a 4-dose schedule for postexposure prophylaxis using human diploid cell vaccine or purified chick embryo cell vaccine, administered on days 0,3,7, and 14 after the first dose [ 3 ].
• HRIG Administration: HRIG is administered on day 0, in addition to the first dose of vaccine, for individuals with category III exposures [ 4 ].
• Route of Administration: Vaccines can be administered via intramuscular (IM) or intradermal (ID) routes, with similar immunogenicity and safety profiles [ 4 ].
• Interchangeability of Vaccines: Studies have shown that interchangeability of rabies vaccines, either by route of administration or brand/type, is safe and immunogenic [ 5 ].
• Importance of Prompt Treatment: Prompt administration of PEP is crucial, as rabies is almost entirely preventable if suspected exposures are identified and managed promptly and properly [ 6 ].

Key Considerations

Some key considerations for PEP treatment include:

• Wound Treatment: Proper wound treatment is essential to prevent rabies, and improper wound treatment is common among animal bite victims [ 7 ].
• Delay of PEP: Delaying the initiation of PEP can increase the risk of rabies, and educational programs and awareness-raising campaigns are necessary to prevent delays [ 7 ].
• Immune Suppression: Individuals with immune suppression may require a 5-dose regimen of vaccine [ 3 ].