What is the recommended prophylaxis for rabies exposure?

Rabies Exposure Prophylaxis

For rabies exposure, immediate wound cleansing followed by rabies immune globulin (RIG) and vaccination is essential for previously unvaccinated individuals, while previously vaccinated individuals require only two vaccine doses without RIG. 1, 2

Post-Exposure Prophylaxis for Previously Unvaccinated Persons

Immediate Wound Management

• Thoroughly wash and flush all wounds immediately with soap and water for approximately 15 minutes 2
• Apply an iodine-containing or similarly virucidal topical preparation to the wound 2
• Thorough wound cleansing alone can markedly reduce the likelihood of rabies 1

Specific Treatment Protocol

1. Human Rabies Immune Globulin (HRIG)

   • Administer 20 IU/kg body weight 1
   • Infiltrate the full dose around and into the wound(s) if anatomically feasible 1
   • Any remaining volume should be injected intramuscularly at a site distant from vaccine administration 1
   • Must be given with the first dose of vaccine, or up to day 7 of the vaccination series if not given initially 2

2. Vaccination Schedule

   • Administer 5 doses of human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) 1
   • 1.0 mL per dose, intramuscularly in the deltoid area 1
   • Doses given on days 0,3,7,14, and 28 1
   • The deltoid area is the only acceptable site for vaccination in adults and older children; never administer in the gluteal area 1

Post-Exposure Prophylaxis for Previously Vaccinated Persons

• Previously vaccinated persons are those who have received one of the recommended pre-exposure or post-exposure regimens with a cell culture vaccine, or those who have received another vaccine and have documented rabies antibody titers 1, 2
• Administer two 1.0 mL doses of vaccine intramuscularly, one immediately and one 3 days later 1
• RIG is unnecessary and should not be administered to these individuals 1, 2

Pre-Exposure Prophylaxis

Who Should Receive Pre-Exposure Vaccination

• High-risk groups: veterinarians and staff, animal handlers, rabies researchers, laboratory workers 1
• Persons with frequent contact with potentially rabid animals (bats, raccoons, skunks, etc.) 1
• International travelers likely to contact animals in rabies-endemic areas with limited access to medical care 1, 3
• Not recommended for general population or routine travelers to areas where rabies is not endemic 1

Pre-Exposure Vaccination Protocol

• Three 1.0 mL injections of HDCV or PCECV administered intramuscularly in the deltoid area 1
• Schedule: one injection each on days 0,7, and 21 or 28 1, 4
• Intradermal pre-exposure prophylaxis is no longer available in the United States 1

Booster Doses

• For continuous risk category (lab workers, vaccine production): check antibody titers every 6 months 1
• For frequent risk category (veterinarians, animal control officers in endemic areas): check titers every 2 years 1
• Administer a booster if titer falls below complete neutralization at 1:5 serum dilution by RFFIT 1

Animal Exposure Assessment

Types of Exposure

• Bite exposure: Any penetration of skin by teeth 1, 2
• Non-bite exposure: Scratches, abrasions, open wounds or mucous membranes contaminated with saliva or neural tissue from a rabid animal 1, 2
• Contact with blood, urine, feces, or petting a rabid animal does not constitute exposure requiring prophylaxis 1, 2

Animal Risk Assessment

• Dogs, cats, and ferrets: If healthy and available for 10-day observation, prophylaxis can be delayed unless animal develops signs of rabies 2
• Wild carnivores (skunks, raccoons, foxes) and bats: Consider rabid unless proven negative by laboratory testing; immediate prophylaxis recommended 2
• Small rodents (squirrels, hamsters, guinea pigs, rats, mice): Rarely require prophylaxis 2

Common Pitfalls and Caveats

• Delaying post-exposure prophylaxis, especially with severe wounds to face and head 1
• Administering vaccine in the gluteal area instead of the deltoid area 1
• Inadequate wound cleansing 1
• Insufficient infiltration of RIG around the wound site 1
• Considering post-exposure prophylaxis a medical emergency rather than a medical urgency; while prompt administration is important, proper technique is equally crucial 1
• Failure to recognize bat bites, which may be minor and undetected 1
• Not considering prophylaxis for any physical contact with bats when bite or scratch cannot be excluded 2

Post-exposure prophylaxis with modern cell culture vaccines and HRIG has been 100% effective in preventing human rabies when properly administered 5, 6. Rabies is nearly always fatal once clinical symptoms develop, making proper prophylaxis essential 3, 5.