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

Rabies Post-Exposure Prophylaxis Protocol

The current recommended post-exposure prophylaxis (PEP) protocol for rabies consists of wound cleansing, human rabies immune globulin (HRIG) administration, and a 4-dose vaccine regimen administered on days 0,3,7, and 14 for previously unvaccinated individuals. 1

Immediate Wound Management

• Thorough wound cleansing: Immediately wash all bite wounds and scratches with soap and water for 15 minutes 1
• Apply a virucidal agent such as povidone-iodine solution if available 2
• Avoid suturing wounds when possible to prevent deeper contamination 3
• Local wound cleansing alone can markedly reduce the likelihood of rabies transmission 2, 1

PEP for Previously Unvaccinated Individuals

Human Rabies Immune Globulin (HRIG)

• Administer 20 IU/kg body weight 2
• If anatomically feasible, infiltrate the FULL DOSE around and into the wound(s) 3
• Any remaining volume should be administered intramuscularly at a site distant from vaccine administration 2
• HRIG can be given up to and including day 7 after the first vaccine dose 3
• HRIG should never be administered in the same syringe or anatomical site as the rabies vaccine 3

Vaccine Administration

• Administer 1.0 mL of Human Diploid Cell Vaccine (HDCV) or Purified Chick Embryo Cell Vaccine (PCECV) intramuscularly 2
• 4-dose regimen: Days 0,3,7, and 14 2, 1
• Special case: For immunocompromised individuals, use a 5-dose regimen on days 0,3,7,14, and 28 2, 1
• Injection site: Deltoid area for adults and older children; anterolateral thigh acceptable for young children 2
• Never administer in the gluteal area as it results in diminished immune response 2, 1

PEP for Previously Vaccinated Individuals

• Administer 1.0 mL of HDCV or PCECV intramuscularly on days 0 and 3 only (2-dose regimen) 2, 1
• HRIG is not administered to previously vaccinated individuals 2, 1
• Injection site: Deltoid area 2

Timing of PEP

• Begin PEP as soon as possible after exposure, ideally within 24 hours 1
• Important: There is no absolute time limit for starting treatment 1
• Even with significant delays after exposure, PEP should still be administered 1, 3

Special Considerations

• For bat exposures: Consider PEP for persons who were in the same room as a bat and might be unaware of direct contact (e.g., sleeping person awakens to find a bat in the room) 3
• PEP is not indicated for contact with blood, urine, or feces of a rabid animal 3
• When initiated promptly and administered correctly, PEP is nearly 100% effective in preventing rabies 1, 4

Common Pitfalls to Avoid

1. Incorrect HRIG administration: Failure to infiltrate wounds properly with HRIG 2
2. Improper injection site: Administering vaccine in the gluteal area instead of deltoid 2, 1
3. Delayed initiation: Waiting too long to start PEP after exposure 1
4. Incomplete vaccination: Not completing the full regimen 2
5. Inadequate wound cleansing: Not thoroughly cleaning the wound immediately 2, 1

Remember that rabies is almost invariably fatal once clinical symptoms appear, making proper and timely PEP administration critical for preventing mortality 1, 5.