What is the recommended post-exposure prophylaxis (PEP) regimen for rabies?

Rabies Post-Exposure Prophylaxis (PEP) Recommendations

The recommended post-exposure prophylaxis regimen for rabies consists of immediate wound cleansing with soap and water, administration of human rabies immunoglobulin (HRIG) at 20 IU/kg body weight infiltrated around and into the wounds, and a 4-dose vaccination schedule administered on days 0,3,7, and 14 for previously unvaccinated individuals. 1, 2

Initial Assessment and Wound Care

• Immediately clean all wounds thoroughly with soap and water for at least 15 minutes 2, 3
• If available, apply a virucidal agent such as povidone-iodine solution to irrigate the wounds 1, 2
• Avoid suturing wounds when possible to prevent deeper contamination 4
• Evaluate tetanus status and provide prophylaxis if indicated 2, 4

PEP Protocol for Previously Unvaccinated Individuals

Human Rabies Immunoglobulin (HRIG) Administration:

• Administer 20 IU/kg body weight of HRIG as soon as possible after exposure 1, 2, 4
• If anatomically feasible, infiltrate the FULL dose of HRIG thoroughly around and into all wounds 2, 4
• Any remaining volume should be injected intramuscularly at a site distant from vaccine administration 1, 2
• HRIG can be administered up to 7 days after the first vaccine dose if not initially available 4
• HRIG should NEVER be administered in the same syringe or anatomical site as the rabies vaccine 2, 4

Vaccine Administration:

• Administer 1.0 mL of rabies vaccine (HDCV or PCECV) intramuscularly in the deltoid area on days 0,3,7, and 14 1, 2
• The deltoid area is the only acceptable site for adults and older children - NEVER use the gluteal area as it results in lower antibody titers 2
• For immunocompromised patients, a 5-dose regimen is recommended: days 0,3,7,14, and 28 2, 4

PEP for Previously Vaccinated Individuals

• Administer 1.0 mL of rabies vaccine intramuscularly in the deltoid area on days 0 and 3 only 1, 2
• Do NOT administer HRIG to previously vaccinated individuals as it may blunt their rapid memory response 1, 2, 4
• Previous vaccination is defined as having received a complete pre-exposure or post-exposure regimen with a cell culture vaccine, or having documented rabies antibody titers 4, 5

Timing of PEP

• PEP should begin as soon as possible after exposure, ideally within 24 hours 2
• However, PEP should be administered regardless of the time interval between exposure and treatment initiation, even months later, as long as clinical signs of rabies are not present in the exposed person 1, 2

Special Considerations

• Pregnancy is not a contraindication to PEP 2
• Corticosteroids and immunosuppressive agents can interfere with vaccine response and should be avoided during PEP unless essential 2
• Routine serologic testing is not necessary for healthy individuals but is recommended for immunocompromised patients 2
• Consult public health officials for exposures to uncommon species, when the animal cannot be tested, or for any questions about the need for rabies prophylaxis 2, 5

Common Pitfalls to Avoid

1. Inadequate wound cleansing - thorough washing with soap and water for 15 minutes is critical 2, 3
2. Improper HRIG administration - failing to infiltrate wounds thoroughly 2, 6
3. Administering HRIG in the same anatomical site as the vaccine 4
4. Using the gluteal area for vaccine administration instead of the deltoid 2
5. Administering HRIG to previously vaccinated individuals 1, 2, 4
6. Delaying PEP due to late presentation - PEP should be given regardless of time elapsed since exposure 1, 2
7. Discontinuing PEP prematurely - complete the full regimen unless the exposing animal tests negative for rabies 5

The 4-dose vaccine regimen (days 0,3,7, and 14) has replaced the previous 5-dose regimen based on evidence showing equivalent efficacy with cost savings and improved compliance 1, 2. This regimen has been endorsed by the Advisory Committee on Immunization Practices (ACIP) since 2010 and is considered the standard of care for rabies PEP in the United States.