From the Guidelines
The management of rabies involves immediate wound care, post-exposure prophylaxis, and supportive care, with the primary goal of preventing mortality and reducing morbidity. For any potential rabies exposure, thoroughly clean the wound with soap and water for at least 15 minutes, then apply either povidone-iodine, alcohol, or other virucidal agents.
Post-Exposure Prophylaxis
Post-exposure prophylaxis includes rabies immunoglobulin (RIG) and vaccination, as recommended by the Advisory Committee on Immunization Practices (ACIP) 1. Human RIG should be administered at 20 IU/kg body weight, with as much as possible infiltrated around the wound and the remainder given intramuscularly.
Vaccination Schedule
The rabies vaccine series consists of a regimen of 5 1-mL doses of human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) administered intramuscularly to previously unvaccinated persons, with the first dose administered as soon as possible after exposure (day 0), and additional doses on days 3,7,14, and 28 after the first vaccination 1.
Previously Vaccinated Individuals
For previously vaccinated individuals, only 2 doses of vaccine are necessary, administered on days 0 and 3 1.
Pre-Exposure Vaccination
Pre-exposure vaccination is recommended for high-risk individuals, such as veterinarians, laboratory workers, and travelers to endemic areas, consisting of three 1.0-mL injections of HDCV or PCECV administered intramuscularly on days 0,7, and 21 or 28 1.
Supportive Care
Once clinical symptoms appear, rabies is nearly always fatal, so treatment focuses on supportive care, including sedation, analgesia, anti-anxiety medication, and management of complications. The Milwaukee Protocol, involving induced coma and antiviral medications, has had limited success 1. Key considerations in the management of rabies exposure include:
- Type of exposure
- Epidemiology of animal rabies in the area where the contact occurred and species of animal involved
- Circumstances of the exposure incident
- Availability of the exposing animal for observation or rabies testing 1.
From the Research
Management Approach to Rabies
The management approach to rabies involves a combination of preventive measures and treatment strategies.
- Preexposure prophylaxis is recommended for individuals at high risk of exposure to rabies, such as laboratory workers, veterinarians, and animal control workers, and entails the administration of a three-dose series of the rabies vaccine 2.
- Postexposure prophylaxis consists of a multimodal approach, including wound cleansing, administration of the rabies vaccine, and administration of human rabies immune globulin, and is nearly 100% effective if used in a timely and accurate fashion 2, 3.
- Treatment of clinical rabies is limited and typically involves medical support in an intensive care unit, using a multifaceted approach that includes supportive care, heavy sedation, analgesics, anticonvulsants, and antivirals 2, 4.
Novel Therapeutic Approaches
Novel therapeutic approaches, such as live-attenuated viruses, monoclonal antibody-based approaches, nucleic acid-based vaccines, and small interfering RNAs, are being explored for the treatment of rabies 5.
- Live-attenuated viruses have shown promise as a practical and effective approach for immunizing and controlling rabies.
- Monoclonal antibody-based approaches and nucleic acid-based vaccines may also have potential as therapeutic strategies for rabies.
Safety and Efficacy of Rabies Immunoglobulin
Rabies immunoglobulin has been shown to be safe and effective in pediatric patients with suspected exposure to rabies 6.
- A clinical trial evaluating human rabies immunoglobulin (HRIG150) as part of post-exposure prophylaxis in patients under 17 years old found that it was well tolerated and effective in preventing rabies infection.
- The study demonstrated that HRIG150 is safe and effective in pediatric patients as a component of post-exposure prophylaxis.