What prophylaxis is recommended for a neonate scratched by a cat, regarding rabies or tetanus (Tetanus toxoid)?

Prophylaxis for Neonate Scratched by a Cat: Rabies and Tetanus Management

For a neonate scratched by a cat, both tetanus prophylaxis and rabies post-exposure prophylaxis should be administered, with immediate wound cleansing being the first critical step. 1, 2

Immediate Wound Management

• Thoroughly clean the scratch wound with soap and water for at least 15 minutes
• Apply a virucidal agent such as povidone-iodine solution
• This immediate cleansing is the most effective measure for preventing both tetanus and rabies 1

Tetanus Prophylaxis

For neonates who have not received tetanus vaccination:

• Administer Tetanus Immune Globulin (TIG) for passive immunization
• The recommended dose is 250 units intramuscularly 1
• Tetanus toxoid is not recommended for neonates as they have not started their primary vaccination series

Rationale for Tetanus Prophylaxis

• Cat scratches are considered non-clean, minor wounds that can harbor Clostridium tetani spores
• Neonates have no prior immunity to tetanus
• Tetanus can be fatal, with a 21% case-fatality rate reported 1

Rabies Post-Exposure Prophylaxis (PEP)

The decision for rabies PEP depends on several factors:

Assessment of the Cat

1. If the cat is available for observation:

   • Healthy domestic cat: Confine and observe for 10 days
   • If cat remains healthy after 10 days: No rabies PEP needed
   • If cat develops signs of rabies: Immediate PEP required 1, 2

2. If the cat is unavailable, stray, or suspected rabid:

   • Consult local public health officials immediately
   • Initiate rabies PEP without delay 1, 2

Rabies PEP Protocol for Neonates

If indicated based on the above assessment:

1. Rabies Immune Globulin (RIG):

   • Administer 20 IU/kg body weight
   • Infiltrate the full dose around and into the wound area if anatomically feasible
   • Inject any remaining volume intramuscularly at a site distant from vaccine administration 1

2. Rabies Vaccine:

   • Begin the 5-dose vaccination series (days 0,3,7,14, and 28)
   • Use Human Diploid Cell Vaccine (HDCV) or Purified Chick Embryo Cell Vaccine (PCECV) 1

Important Considerations

• Rabies PEP is a medical urgency, not an emergency, but should not be delayed
• The combination of wound cleansing, RIG, and vaccine is nearly 100% effective in preventing rabies
• Even if there is a delay after exposure, PEP should still be administered as rabies can have long incubation periods 1
• Cat scratches can also transmit Bartonella henselae (cat-scratch disease), but this is typically self-limiting in immunocompetent hosts 3
• Failure of rabies prophylaxis has been reported in cases where RIG was not administered, highlighting the importance of complete prophylaxis 4

Follow-up Care

• Monitor the wound site for signs of infection (increasing redness, swelling, warmth)
• Complete the full course of rabies vaccination if initiated
• Begin standard childhood immunizations including tetanus-containing vaccines according to the recommended schedule when the infant reaches the appropriate age

Remember that both tetanus and rabies are potentially fatal diseases with high mortality rates, making proper prophylaxis essential even though the risk may be low in many domestic cat exposure cases.