What is the post-exposure prophylaxis (PEP) schedule for rabies after a dog bite?

Rabies Post-Exposure Prophylaxis Schedule After Dog Bite

The current recommended post-exposure prophylaxis (PEP) schedule for rabies after a dog bite consists of wound cleansing, human rabies immune globulin (HRIG) administration, and a 4-dose vaccine regimen on days 0,3,7, and 14 for previously unvaccinated individuals. 1

Initial Assessment and Wound Management

• All rabies PEP should begin with immediate and thorough cleansing of all wounds with soap and water for about 15 minutes 2, 3
• If available, a virucidal agent such as povidone-iodine solution should be used to irrigate the wounds 1, 3
• Tetanus prophylaxis and measures to control bacterial infection should be administered as indicated 1, 2
• The decision to suture large wounds should consider cosmetic factors and potential for bacterial infections; suturing should be avoided when possible 1

PEP Components for Previously Unvaccinated Individuals

1. Human Rabies Immune Globulin (HRIG)

• Administer 20 IU/kg body weight of HRIG on day 0 1, 3
• If anatomically feasible, infiltrate the full dose around and into the wound(s) 1
• Any remaining volume should be administered intramuscularly at a site distant from vaccine administration 1, 3
• HRIG can be administered up to and including day 7 of the PEP series if not given on day 0 1, 3
• HRIG should never be administered in the same syringe or at the same anatomic site as the first vaccine dose 1

2. Rabies Vaccine

• Administer Human Diploid Cell Vaccine (HDCV) or Purified Chick Embryo Cell Vaccine (PCECV) 1
• Dosage: 1.0 mL, intramuscularly in the deltoid area (for adults and older children) or anterolateral thigh (for younger children) 1
• Schedule: 4 doses on days 0,3,7, and 14 1
• Note: For immunosuppressed individuals, a 5-dose schedule is still recommended (days 0,3,7,14, and 28) 1
• The gluteal area should never be used for vaccine administration 1

PEP for Previously Vaccinated Individuals

• Wound cleansing as described above 1
• HRIG should NOT be administered 1
• Administer 2 doses of vaccine (1.0 mL each, IM in deltoid area) on days 0 and 3 1
• This applies to persons with a history of pre-exposure vaccination with cell culture vaccines or documented adequate antibody response to prior vaccination 1

Special Considerations

• PEP should be initiated as soon as possible after exposure, but can be started regardless of the time interval since exposure if clinical signs of rabies are not present 1
• The animal's vaccination status and circumstances of the bite should be considered when determining the need for PEP 1, 2
• A healthy domestic dog that bites a person may be confined and observed for 10 days; PEP can be delayed unless the animal develops signs of rabies 1, 2
• For stray or unwanted dogs, immediate euthanasia and testing or immediate initiation of PEP is recommended 1, 2
• In areas where dog rabies is endemic (parts of Asia, Africa, Central and South America), immediate initiation of PEP may be warranted 1

Common Pitfalls to Avoid

• Delaying wound cleansing, which is crucial for reducing rabies virus transmission 1
• Administering vaccine in the gluteal area, which can result in diminished immune response 1
• Using more than the recommended dose of HRIG, which can suppress active antibody production 1, 3
• Failing to infiltrate HRIG around the wound when anatomically feasible 1
• Discontinuing PEP prematurely without confirming the animal is not rabid 2

The 4-dose vaccine schedule (reduced from the previous 5-dose regimen) has been shown to be effective and provides cost savings while maintaining safety 1. This recommendation is based on evidence that most rabies PEP failures occurred before day 28 when the fifth dose would have been administered 1.

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