From the Guidelines
Post-exposure prophylaxis (PEP) for rabies should be initiated immediately after potential exposure to prevent this nearly always fatal disease, with the standard regimen consisting of wound cleansing, rabies immunoglobulin, and vaccination, as recommended by the Advisory Committee on Immunization Practices (ACIP) in 2010 1. The regimen includes thorough wound cleansing with soap and water for at least 15 minutes, followed by the application of a virucidal agent such as povidone-iodine or 70% alcohol.
- For immunoglobulin, human rabies immunoglobulin (HRIG) should be administered at 20 IU/kg body weight, with as much as possible infiltrated around the wound and any remaining volume given intramuscularly at a site distant from the vaccine.
- The rabies vaccine series consists of four doses of 1 mL given intramuscularly in the deltoid muscle (or anterolateral thigh in small children) on days 0, 3, 7, and 14, as outlined in the 2010 ACIP recommendations 1.
- For immunocompromised patients, a fifth dose is added on day 28, as specified in the guidelines 2, 1. The vaccine works by stimulating active immunity against the rabies virus, while the immunoglobulin provides immediate passive protection until vaccine-induced antibodies develop.
- PEP is highly effective when administered promptly and correctly, even after exposure to rabies, with the decision to initiate PEP considering the type of exposure, the animal involved, and the local epidemiology of rabies 3, 4, 5, 6, 7. The most recent and highest quality study, published in 2010, supports the use of a reduced 4-dose vaccine schedule for postexposure prophylaxis to prevent human rabies, which is the recommended regimen 1, 6.
From the FDA Drug Label
The essential components of rabies postexposure prophylaxis are prompt local treatment of wounds and administration of both HRIG and vaccine. A complete course of postexposure treatment for previously unvaccinated adults and children consists of a total of 5 doses of vaccine, each 1. 0 mL: one IM injection (deltoid) on each of Days 0, 3, 7, 14, and 28. For persons who have not previously been immunized against rabies, the schedule consists of an initial IM injection of HRIG exactly 20 IU/kg body weight in total If anatomically feasible, the FULL DOSE of HRIG should be thoroughly infiltrated in the area around and into the wounds. Any remaining volume of HRIG should be injected intramuscularly at a site distant from rabies vaccine administration. HRIG should never be administered in the same syringe or in the same anatomical site as the rabies vaccine HRIG is administered only once (for specific instructions for HRIG use, see the product package insert). The HRIG injection is followed by a series of 5 individual injections of RabAvert (1. 0 mL each) given intramuscularly on Days 0, 3, 7, 14, and 28.
The post-exposure prophylaxis (PEP) for rabies consists of:
- Prompt local treatment of wounds: immediate and thorough washing of all bite wounds and scratches with soap and water
- Administration of HRIG: an initial IM injection of 20 IU/kg body weight, with the full dose infiltrated into the wound if anatomically feasible
- Administration of vaccine: a series of 5 IM injections of 1.0 mL each on Days 0, 3, 7, 14, and 28 for previously unvaccinated individuals, or 2 IM injections on Days 0 and 3 for previously immunized individuals [8] [9] 10
From the Research
Post-Exposure Prophylaxis (PEP) for Rabies
The PEP for rabies consists of several steps, including:
- Washing the wound with water and soap for 15 minutes 11
- Assessing the need for rabies biologicals based on specific criteria 11
- Administering rabies immunoglobulin or monoclonal antibodies deep in and around all wounds, if required 11, 12
- Starting the WHO-recommended intradermal 1-week vaccination regimen, if necessary 11, 13
- Informing patients adequately throughout the PEP process to increase compliance and avoid dangerous misconceptions about animal bite treatment and rabies risk 11
Vaccination Schedules
Different vaccination schedules have been recommended, including:
- A 1-week, 2-site intradermal schedule, which has been found to be safe, immunogenic, and cost-effective 13
- A 4-dose schedule, administered on days 0, 3, 7, and 14, which has been supported by the United States Advisory Committee on Immunization Practices 14
- A 5-dose intramuscular series, which has been historically used but may be reduced to a 4-dose schedule in some cases 14, 13
Administration of Rabies Immunoglobulin
Rabies immunoglobulin is an essential component of PEP for category III animal exposures, providing neutralizing antibodies at the site of exposure until the body can produce vaccine-mediated antibodies 12