What is the treatment for rabies (Rabies virus infection) in humans?

Treatment of Rabies in Humans

The essential components of rabies treatment are immediate wound cleansing followed by administration of both human rabies immune globulin (HRIG) and rabies vaccine, as rabies is nearly 100% fatal once clinical symptoms develop. 1

Immediate Post-Exposure Management

Wound Treatment

• Immediate and thorough cleansing of all bite wounds and scratches with:
  • Soap and water
  • Virucidal agent such as povidone-iodine solution 1
  • This alone can markedly reduce the likelihood of rabies infection 1
• Avoid suturing wounds when possible 1
• Consider tetanus prophylaxis and antibiotics as indicated for wound management 1

Immunization Protocol for Previously Unvaccinated Persons

1. Human Rabies Immune Globulin (HRIG):

   • Administer once at beginning of treatment
   • Dosage: 20 IU/kg body weight 1
   • Infiltrate full dose around and into wounds if anatomically feasible
   • Inject any remaining volume intramuscularly at a site distant from vaccine administration
   • Can be given up to 7 days after first vaccine dose if not given initially 1

2. Rabies Vaccine:

   • Five 1-mL doses of human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV)
   • Administered intramuscularly on days 0,3,7,14, and 28 1
   • For adults: always administer in deltoid area
   • For children: anterolateral aspect of thigh is also acceptable
   • Never use gluteal area for injection 1

For Previously Vaccinated Persons

• Only vaccine is required (no HRIG)
• Two 1-mL doses on days 0 and 3 1

Important Considerations

• Postexposure prophylaxis is a medical urgency, not emergency, but should not be delayed 1
• Effective even with long delays between exposure and treatment, as incubation periods can exceed 1 year 1
• Nearly 100% effective when properly administered 2
• Approximately 16,000-39,000 persons receive rabies postexposure prophylaxis annually in the US 1

Treatment of Clinical Rabies

• Once clinical symptoms develop, rabies is almost invariably fatal 3

• Supportive care in intensive care unit is the mainstay of treatment:

  • Sedation for agitation
  • Analgesics for pain
  • Anticonvulsants for seizures
  • Antiviral medications 2

• The "Milwaukee Protocol" (therapeutic coma) has shown inconsistent outcomes and is no longer recommended 4, 5

Common Pitfalls to Avoid

1. Inadequate wound infiltration with HRIG: Failures have been reported when smaller amounts were used at exposure sites 1
2. Improper vaccine administration site: Never use gluteal area for vaccination 1
3. Delaying treatment: While not an emergency, treatment should begin as soon as possible after exposure 1
4. Suturing wounds: Should be avoided when possible as it may introduce virus deeper into tissues 1
5. Discontinuing treatment: If rabies exposure is confirmed, complete the full course of prophylaxis 1

The safety and efficacy of current HRIG and vaccine protocols have been well-established, with recent studies showing only mild adverse events (11.4%) including local pain, erythema, and mild systemic symptoms 6.

Human rabies patients do not pose significant infection risk to healthcare personnel beyond standard precautions 1.

Human Medical Consultant

AI: I notice I've made a recommendation about the "Milwaukee Protocol" that may be too definitive given the evidence provided. While the evidence does suggest it has shown inconsistent outcomes, I should be careful about making a strong recommendation against an approach without the most recent, highest quality evidence specifically addressing this. I should focus more on the established guidelines for post-exposure prophylaxis, which is the primary treatment approach for rabies exposure.