What is the recommended rabies post-exposure prophylaxis (PEP) for a person scratched by a pitbull?

Rabies Post-Exposure Prophylaxis for Pitbull Scratches

For a scratch by a pitbull, immediate wound cleansing followed by both rabies immune globulin and rabies vaccine series is recommended as the complete post-exposure prophylaxis (PEP) protocol to prevent this fatal disease. 1

Immediate Wound Management

1. Thoroughly wash and flush the scratch wound with soap and water for at least 15 minutes 2
2. Apply a virucidal agent such as povidone-iodine solution to the wound 1
3. Avoid suturing the wound when possible to prevent deeper inoculation of the virus 1
4. Assess need for tetanus prophylaxis and antibiotics for bacterial infection 1

Risk Assessment Factors

• Type of exposure: Even scratches constitute a non-bite exposure that warrants full PEP 3
• Animal status:
  • If the pitbull is available and appears healthy, it should be confined and observed for 10 days 1
  • If the pitbull is stray/unavailable or showing signs of rabies, immediate full PEP should be initiated 1
• Provoked vs. unprovoked attack: Unprovoked attacks carry higher risk of rabies 1
• Vaccination status of the dog: A properly vaccinated dog has minimal chance of transmitting rabies 3

Post-Exposure Prophylaxis Protocol

For previously unvaccinated individuals:

1. Human Rabies Immune Globulin (HRIG):

   • Dose: 20 IU/kg body weight 1
   • Administration: Infiltrate the full dose around and into the wound area if anatomically feasible 1
   • Any remaining volume should be injected intramuscularly at a site distant from vaccine administration 1
   • Must be given only once at the beginning of PEP (or up to day 7 after first vaccine dose) 1

2. Rabies Vaccine:

   • Schedule: 5 doses on days 0,3,7,14, and 28 1, 2
   • Administration: Intramuscular injection in the deltoid area (never in gluteal area) 1
   • For children, anterolateral thigh is also acceptable 1

For previously vaccinated individuals:

• Only vaccine is required (2 doses on days 0 and 3)
• No HRIG is needed 2

Critical Considerations

• PEP should be initiated as soon as possible after exposure 1
• Even if there is a delay since exposure, PEP should still be administered regardless of time elapsed 1
• The combination of proper wound cleansing, HRIG, and complete vaccine series is nearly 100% effective in preventing rabies 4, 5
• Poor compliance with the full vaccination schedule is a major concern, with completion rates ranging from 60-77% 6

Common Pitfalls to Avoid

1. Delaying treatment: Rabies is virtually 100% fatal once symptoms appear, making immediate PEP crucial 7
2. Inadequate wound cleansing: Thorough wound washing significantly reduces viral load 1
3. Improper HRIG administration: The full calculated dose should be infiltrated around the wound when possible 1
4. Incomplete vaccination: Failure to complete all 5 doses puts the patient at risk 7, 6
5. Administering vaccine in gluteal area: This results in lower antibody titers 1

Remember that rabies post-exposure prophylaxis is a medical urgency, not an emergency, but decisions should not be delayed as proper and timely PEP is virtually 100% effective in preventing this fatal disease.