What is the recommended protocol for post-exposure rabies (Rabies Virus) prophylaxis, including wound cleaning, rabies immune globulin (RIG) administration, and rabies vaccine series?

Post-Exposure Rabies Prophylaxis Protocol

The recommended protocol for post-exposure rabies prophylaxis consists of immediate wound cleansing with soap and water for 15 minutes, followed by administration of rabies immune globulin (20 IU/kg) infiltrated around all wounds, and a 4-dose vaccine series administered on days 0,3,7, and 14 for immunocompetent individuals. 1

Wound Cleaning

• All post-exposure prophylaxis should begin with immediate thorough cleansing of all wounds with soap and water for approximately 15 minutes 1, 2
• If available, a virucidal agent (e.g., povidone-iodine solution) should be used to irrigate the wounds 1, 3
• Proper wound cleansing alone has been shown to markedly reduce the likelihood of rabies infection 1
• Tetanus prophylaxis and measures to control bacterial infection should be administered as indicated 3

Rabies Immune Globulin (RIG) Administration

• For previously unvaccinated persons, administer human rabies immune globulin (HRIG) at a dose of 20 IU/kg body weight 1, 4
• If anatomically feasible, the full dose should be infiltrated around and into all wounds 1, 4
• Any remaining volume should be administered intramuscularly at an anatomical site distant from vaccine administration 1, 4
• HRIG should never be administered in the same syringe as the vaccine or at the same anatomical site 1, 4
• HRIG can be administered up to and including day 7 of the PEP series if not given at the time of the first vaccine dose 4
• Beyond day 7, HRIG is not indicated as an antibody response to the vaccine is presumed to have occurred 4
• Because HRIG might partially suppress active production of antibody, no more than the recommended dose should be administered 1

Vaccine Administration

For Previously Unvaccinated Persons:

• Administer a 4-dose regimen of human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) 1
• Give 1.0 mL intramuscularly in the deltoid area (or anterolateral thigh in young children) 1
• Administer doses on days 0,3,7, and 14 1
• The gluteal area should never be used for vaccine administration as it may result in diminished immune response 1
• For immunosuppressed persons, administer a 5-dose regimen (days 0,3,7,14, and 28) 1

For Previously Vaccinated Persons:

• Administer only vaccine (no HRIG) 1, 4
• Give two 1.0 mL doses of HDCV or PCECV intramuscularly in the deltoid on days 0 and 3 1

Special Considerations

• The combination of RIG and vaccine is recommended for both bite and nonbite exposures, regardless of the time interval between exposure and initiation of treatment 1, 3
• If post-exposure prophylaxis has been initiated and appropriate laboratory testing confirms the animal was not rabid, prophylaxis can be discontinued 5
• The intradermal 1-week vaccination regimen recommended by WHO carries cost-, dose-, and time-sparing benefits in some settings but may not be the standard in all countries 2

Common Pitfalls and Caveats

• Failure to infiltrate all wounds with HRIG has been associated with rare PEP failures 4
• Administering vaccine in the gluteal area can result in diminished immune response and should be avoided 1
• Exceeding the recommended dose of HRIG may suppress the active production of antibodies 1, 4
• Delaying PEP initiation can increase mortality risk - treatment should begin as soon as possible after exposure 1, 6
• Clear communication with patients about the importance of completing the full vaccine series is essential for treatment success 2

Human rabies is nearly 100% fatal once clinical symptoms develop, making proper and timely administration of post-exposure prophylaxis critical for preventing mortality 6, 7.