What is the recommended rabies medication for post-exposure prophylaxis?

Rabies Post-Exposure Prophylaxis Medications

For rabies post-exposure prophylaxis (PEP), the recommended medications include both rabies immune globulin (RIG) and rabies vaccine, administered according to a specific schedule based on vaccination history. 1

Components of Rabies PEP

1. Wound Care

• Immediate and thorough wound cleansing with soap and water for at least 15 minutes
• Apply povidone-iodine solution if available to irrigate wounds 1
• Proper wound care is essential and can significantly reduce rabies risk 2

2. Rabies Immune Globulin (RIG)

• Administered once at 20 IU/kg body weight
• Infiltrate in and around the wound(s) with any remaining volume injected intramuscularly at a site distant from vaccine administration
• Given at the time of the first vaccine dose (day 0) or up to day 7 if not given initially 1, 2
• Provides immediate passive immunity until vaccine-induced antibodies develop 3

3. Rabies Vaccine

For previously unvaccinated individuals:

• 4-dose regimen of rabies vaccine (1.0 mL each in the deltoid) on days 0,3,7, and 14 4, 1
• This reduced schedule (previously 5 doses) has been shown to be safe and effective 5

For immunocompromised individuals:

• 5-dose regimen on days 0,3,7,14, and 28 1

For previously vaccinated individuals:

• Only 2 doses (1.0 mL each in the deltoid) on days 0 and 3
• No RIG administration necessary 1

Administration Considerations

Timing

• PEP should begin as soon as possible after exposure, ideally within 24 hours
• However, it 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 1

Anatomical Site

• Vaccine should be administered intramuscularly in the deltoid muscle
• RIG should be infiltrated into and around the wound(s) when anatomically feasible 6
• Studies show only 56% of eligible patients receive proper wound infiltration of RIG, highlighting an area for improvement in clinical practice 6

Common Pitfalls to Avoid

1. Improper RIG administration: Failure to infiltrate wounds with RIG when anatomically possible 6, 7
2. Delayed initiation: PEP should begin immediately after exposure
3. Incorrect dosing: Ensure accurate weight-based dosing of RIG (20 IU/kg) 6
4. Skipping components: All components (wound care, RIG, and vaccine) are essential for previously unvaccinated individuals
5. Improper risk assessment: Consult public health officials when uncertain about the need for PEP 2

Special Populations

• Pregnancy is not a contraindication to PEP 1
• Corticosteroids and immunosuppressive agents can interfere with vaccine response and should be avoided during PEP unless essential 1
• Immunocompromised patients require serologic testing after vaccination to confirm adequate antibody response 1

Rabies PEP with proper wound care, RIG infiltration, and the recommended vaccine schedule is nearly 100% effective in preventing this otherwise fatal disease when administered correctly 1, 3.