What is the rabies vaccine protocol for a dog bite?

Rabies Post-Exposure Prophylaxis Protocol for Dog Bite

For dog bites, immediate wound cleansing with soap and water for 15 minutes followed by rabies post-exposure prophylaxis (PEP) consisting of both rabies immune globulin (RIG) and vaccine series is recommended when the dog cannot be observed or is suspected of being rabid. 1, 2, 3

Risk Assessment and Initial Management

Evaluation of the Biting Dog

• Healthy domestic dog available for observation: No immediate PEP needed unless the dog develops signs of rabies during the 10-day observation period 1, 2, 3
• Rabid or suspected rabid dog: Immediate PEP indicated 2, 3
• Unknown status (escaped dog): Consult public health officials; consider immediate PEP based on local rabies prevalence 2, 3
• Vaccination status: A properly immunized dog has minimal chance of transmitting rabies 1, 2
• Circumstances of bite: Unprovoked attacks are more likely to indicate rabies than provoked attacks 1

Immediate Wound Management

1. Thorough wound cleansing:

   • Wash and flush all bite wounds with soap and water for at least 15 minutes 1, 2, 3
   • Apply povidone-iodine solution as a virucidal agent 1, 2
   • Remove superficial debris but avoid deeper debridement unless necessary 1

2. Wound closure considerations:

   • Facial wounds may be closed primarily after thorough cleaning with prophylactic antibiotics 1
   • Consider leaving other wounds open or using Steri-Strips 1
   • Avoid suturing wounds >8 hours old (except facial wounds) 1

Post-Exposure Prophylaxis Protocol

For Previously Unvaccinated Individuals

1. Rabies Immune Globulin (RIG):

   • Administer 20 IU/kg body weight 1, 3
   • Infiltrate the full dose around and into the wound if anatomically feasible 1
   • Any remaining volume should be administered intramuscularly at a site distant from vaccine administration 3
   • RIG can be administered through the seventh day after the first vaccine dose 3

2. Rabies Vaccine:

   • Administer 5 doses of rabies vaccine on days 0,3,7,14, and 28 1, 2, 3
   • Administer intramuscularly in the deltoid area (adults) or anterolateral thigh (children) 2

For Previously Vaccinated Individuals

• Administer vaccine alone (no RIG) with 2 doses on days 0 and 3 1, 2, 3
• Previous vaccination is defined as complete pre-exposure or post-exposure vaccination with cell culture vaccine or documented adequate rabies antibody titer 2, 3

Additional Prophylaxis

Tetanus Prophylaxis

• Administer tetanus toxoid if vaccination is outdated (>5 years) or status is unknown 1
• Tdap is preferred over Td if the former has not been previously given 1

Antibiotic Prophylaxis

• Consider amoxicillin-clavulanate (875/125 mg twice daily for 3-5 days) 1
• Particularly important for:
  • Bites to the hand or face
  • Deep puncture wounds
  • Immunocompromised patients
  • Wounds with significant tissue damage 1
• Alternative antibiotics for penicillin-allergic patients: doxycycline, fluoroquinolone plus metronidazole, or clindamycin plus TMP-SMZ 1

Follow-up Care

• Schedule follow-up within 24-48 hours to assess for signs of infection 1
• Monitor for increasing redness, swelling, pain, warmth, or drainage 1
• Elevate the affected area if there is inflammation 1
• Hand bites, particularly over joints or tendons, may require consultation with a hand specialist 1

Important Caveats

• PEP should be initiated regardless of the time elapsed since exposure if clinical signs of rabies are not present 4
• The combination of RIG and vaccine is recommended for both bite and nonbite exposures regardless of the interval between exposure and treatment initiation 4
• Local public health officials should be consulted for guidance on specific cases, especially when the dog's status is unknown 2, 3
• In most states, physicians are required by law to report animal bites 5

Human rabies is almost universally fatal, making proper post-exposure prophylaxis critical when indicated. The decision to initiate PEP should be based on a thorough risk assessment, with immediate implementation when rabies cannot be ruled out.