What is the recommended rabies (Rabies virus) post-exposure prophylaxis (PEP) dosage and vaccination schedule?

Rabies Post-Exposure Prophylaxis (PEP) Dosage and Vaccination Schedule

The current recommended rabies post-exposure prophylaxis for previously unvaccinated individuals consists of thorough wound cleansing, human rabies immune globulin (HRIG) at 20 IU/kg body weight, and a 4-dose vaccine schedule administered on days 0,3,7, and 14. 1, 2, 3

Components of Rabies PEP

Wound Care

• All PEP should begin with immediate thorough cleansing of all wounds with soap and water for 15 minutes 2, 4
• If available, a virucidal agent (e.g., povidine-iodine solution) should be used to irrigate the wounds 1, 2

Human Rabies Immune Globulin (HRIG)

• Administer 20 IU/kg body weight for previously unvaccinated individuals 1, 5
• If anatomically feasible, the full dose should be infiltrated around and into the wound(s) 1, 3
• Any remaining volume should be administered intramuscularly at an anatomical site distant from vaccine administration 1, 5
• HRIG should not be administered in the same syringe as vaccine 1, 5
• HRIG can be given up to and including day 7 of the PEP series if not administered at the beginning 2, 3

Vaccination Schedule

For Previously Unvaccinated Persons:

• Human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV), 1.0 mL per dose 1, 2
• Administer intramuscularly in the deltoid area (or anterolateral thigh in young children) 1, 2
• 4-dose schedule: days 0,3,7, and 14 (day 0 is the day the first dose is administered) 1, 2, 6
• Important: The gluteal area should never be used for vaccine administration as it may result in diminished immune response 1, 2

For Previously Vaccinated Persons:

• HDCV or PCECV 1.0 mL, intramuscular (deltoid area), 1 each on days 0 and 3 1, 3
• HRIG should not be administered 1, 3

For Immunocompromised Patients:

• A 5-dose schedule is recommended (days 0,3,7,14, and 28) 1, 2, 3

Clinical Considerations

Timing of PEP

• PEP should be initiated as soon as possible after exposure 3, 7
• Even with delayed recognition of exposure, PEP is indicated as incubation periods of greater than 1 year have been reported 3
• When administered promptly and appropriately, PEP is nearly 100% effective in preventing human rabies 2, 7

Special Populations

• The same vaccine dose (1.0 mL) should be used for both adults and children 1
• Pregnant women should receive the standard PEP regimen as rabies vaccination during pregnancy is safe and effective 8
• Serologic testing to confirm seroconversion is not necessary in immunocompetent individuals but is recommended for immunosuppressed patients 2

Common Pitfalls and How to Avoid Them

• Incorrect administration site: Always use the deltoid area for adults and older children; anterolateral thigh may be used for younger children. Never use the gluteal area. 1, 2
• Improper HRIG administration: Ensure HRIG is infiltrated around all wounds first, with remaining volume given IM at a site distant from vaccine. 1, 3
• Incomplete vaccination series: Emphasize the importance of completing the full vaccination schedule to ensure adequate protection. 4
• Delayed initiation: Begin PEP as soon as possible after exposure; however, PEP should be administered regardless of the time elapsed since exposure. 3, 7
• Mixing HRIG and vaccine: Never administer HRIG and vaccine in the same syringe or at the same anatomical site. 1, 5

The 4-dose vaccine schedule (reduced from the previous 5-dose schedule) has been shown to be safe, effective, and cost-saving while maintaining efficacy in preventing this fatal disease. 1, 6