From the Guidelines
The treatment for Rabies virus infection involves prompt and thorough wound cleansing followed by passive rabies immunization with human rabies immune globulin (HRIG) and vaccination with a cell culture rabies vaccine.
Treatment Regimen
- For persons who have never been vaccinated against rabies, postexposure antirabies vaccination should always include administration of both passive antibody (HRIG) and vaccine (human diploid cell vaccine [HDCV] or purified chick embryo cell vaccine [PCECV]) 1.
- A regimen of 5 1-mL doses of HDCV or PCECV should be administered intramuscularly to previously unvaccinated persons, with the first dose administered as soon as possible after exposure (day 0), and additional doses on days 3,7,14, and 28 after the first vaccination 1.
- HRIG is administered only once (i.e., at the beginning of antirabies prophylaxis) to previously unvaccinated persons to provide immediate, passive, rabies virus neutralizing antibody coverage until the patient responds to HDCV or PCECV by actively producing antibodies 1.
Key Considerations
- The decision to initiate rabies postexposure prophylaxis depends on the type of exposure, epidemiology of animal rabies in the area, and circumstances of the exposure incident 1.
- Clinicians should seek assistance from local or state public health officials for evaluating exposures or determining the need for postexposure management in situations that are not routine 1.
From the Research
Treatment Options for Rabies
- There is no established therapy that is effective for patients who develop rabies encephalomyelitis 2
- Treatment of clinical rabies consists of medical support in an intensive care unit, using a multifaceted approach that includes supportive care, heavy sedation, analgesics, anticonvulsants, and antivirals 3
- The recently developed Milwaukee Protocol added induction of therapeutic coma to supportive care measures and antivirals; however, its use has shown inconsistent outcomes 3
- Therapeutic coma should be abandoned for the therapy of rabies, and new approaches such as therapeutic hypothermia should be evaluated, in combination with other therapeutic agents 2
Post-Exposure Prophylaxis
- Postexposure prophylaxis consists of a multimodal approach to decrease an individual's likelihood of developing clinical rabies after a possible exposure to the virus 3
- Regimens depend on the vaccination status of the victim and involve a combination of wound cleansing, administration of the rabies vaccine, and administration of human rabies immune globulin 3
- If used in a timely and accurate fashion, postexposure prophylaxis is nearly 100% effective 3
Novel Therapeutic Approaches
- Monoclonal antibodies against rabies offer a potential novel therapeutic approach 4, 5
- Live-attenuated viruses, nucleic acid-based vaccines, or small interfering RNAs (siRNAs) interfering with virus replication could further add to the arena of strategies to combat rabies 5
- A combination of these novel modalities has the potential to achieve maximal anti-rabies efficacy, or may even have promising curative effects in the future 5