What is the post-exposure prophylaxis (PEP) protocol for someone exposed to a bat that may carry rabies?

Rabies Post-Exposure Prophylaxis Protocol for Bat Exposures

Any potential exposure to a bat requires immediate rabies post-exposure prophylaxis (PEP) unless the bat is available for testing and confirmed negative for rabies. 1

Assessment of Bat Exposures

• Any direct contact between a human and a bat should be evaluated for potential rabies exposure 2
• Bat bites often cause minimal injury compared to larger carnivores, making them difficult to detect but still dangerous 1
• Consider PEP in the following situations:
  • Any bite, scratch, or mucous membrane exposure to a bat 2, 1
  • Finding a bat in the same room as a person who might be unaware that a bite occurred:
    • A deeply sleeping person who awakens to find a bat in the room
    • A bat in a room with an unattended child
    • A bat in a room with a mentally disabled person
    • A bat in a room with an intoxicated person 2, 1

PEP Protocol for Previously Unvaccinated Persons

1. Wound Treatment:

   • Thoroughly wash and flush all wounds with soap and water for about 15 minutes 3
   • Apply iodine-containing or similarly viricidal topical preparation to the wound 3
   • Provide tetanus prophylaxis and antibacterial treatment as indicated 3

2. Rabies Immune Globulin (RIG):

   • Administer 20 IU/kg body weight of human RIG 4
   • Infiltrate as much as possible into and around the wound(s) 4
   • Administer any remaining volume intramuscularly at a site distant from vaccine administration 4
   • If not administered on day 0 with the first vaccine dose, RIG can be given up to and including day 7 of the PEP series 4

3. Rabies Vaccine:

   • Administer a 4-dose vaccination series intramuscularly in the deltoid area 3
   • Schedule: Day 0 (first dose), Day 3, Day 7, and Day 14 3
   • Do not delay initiating treatment while waiting for bat testing results; treatment can be discontinued if the bat tests negative 1

PEP Protocol for Previously Vaccinated Persons

• For persons who have previously received complete pre-exposure or post-exposure vaccination with a cell culture vaccine, or who have documented rabies virus neutralizing antibody titers:
  • Administer only vaccine (no RIG) 4, 3
  • Give two 1.0 mL doses of vaccine intramuscularly, one immediately and one 3 days later 2

Important Considerations

• Timing: PEP should be initiated as soon as possible after exposure; it is a medical urgency, not an emergency 2, 4

• Bat Testing: If possible, the bat should be safely captured and submitted for rabies testing 1

  • Approximately 94% of submitted bats will not be rabid, potentially avoiding unnecessary PEP 2
  • Do not delay PEP while waiting for test results 1

• Consultation: Consult local or state public health officials for guidance on specific cases 4, 3

Common Pitfalls to Avoid

• Failing to recognize minimal bat bites: Bat bites may cause minor injury that can go undetected but still transmit rabies 1, 5
• Delaying treatment: Do not wait for bat testing results before initiating PEP; treatment can be discontinued if the bat tests negative 1
• Overlooking non-bite exposures: Consider PEP for situations where a bat is found in a room with someone who cannot reliably report a bite (sleeping person, child, etc.) 2, 1
• Underestimating risk: Of 34 bat-associated human rabies cases reported in the US from 1990-2007, only 6 had documented bites, while 15 had physical contact but no detected bite 1, 6