What is the treatment for rabies exposure?

Treatment for Rabies Exposure

For previously unvaccinated persons with rabies exposure, immediately administer both human rabies immune globulin (HRIG) at 20 IU/kg infiltrated into and around all wounds plus a 4-dose rabies vaccine series on days 0,3,7, and 14; previously vaccinated persons require only 2 vaccine doses on days 0 and 3 without HRIG. 1, 2

Immediate Wound Management (Critical First Step)

• Wash all bite wounds and scratches immediately and thoroughly with soap and water for approximately 15 minutes – this single intervention markedly reduces rabies risk in animal studies 1, 3
• Irrigate the wound with a virucidal agent such as povidone-iodine solution if available 1
• Administer tetanus prophylaxis and antibiotics as indicated for bacterial infection control 1, 2
• Avoid suturing wounds when possible to allow drainage 4

Postexposure Prophylaxis for Previously Unvaccinated Persons

Human Rabies Immune Globulin (HRIG)

• Administer HRIG at exactly 20 IU/kg body weight as a single dose on day 0 1, 2
• Infiltrate the full dose of HRIG thoroughly around and into all wounds if anatomically feasible – this provides immediate passive immunity while the vaccine induces active immunity 1, 2
• Administer any remaining HRIG intramuscularly at a site distant from vaccine administration 4
• Never exceed the recommended dose, as this may suppress the active immune response 4

Rabies Vaccine

• Administer rabies vaccine (HDCV, PCECV, or RVA) as a 4-dose series on days 0,3,7, and 14 1
• Never administer vaccine in the gluteal area – this results in lower neutralizing antibody titers and has been associated with treatment failures 1
• Administer intramuscularly in the deltoid area for adults and anterolateral thigh for young children 4
• Give vaccine and HRIG at different anatomical sites 4, 2

Postexposure Prophylaxis for Previously Vaccinated Persons

• Administer only 2 doses of vaccine on days 0 and 3 for persons who have previously received complete pre-exposure or postexposure vaccination with a cell culture vaccine 4, 1
• Do not administer HRIG – it is unnecessary and may blunt the rapid anamnestic antibody response 4, 1
• Previously vaccinated persons include those who received recommended pre-exposure or postexposure regimens with HDCV, RVA, or PCEC, or those with documented rabies antibody titers 4

Timing and Urgency

• Postexposure prophylaxis is a medical urgency, not a medical emergency – decisions should be made promptly but need not be delayed for consultation 4, 1, 2
• Administer prophylaxis regardless of delay, even months after exposure, provided the person shows no clinical signs of rabies, as incubation periods exceeding 1 year have been documented 4, 1
• Do not delay treatment while awaiting animal testing results unless the animal is a healthy domestic dog, cat, or ferret that can be observed for 10 days 4, 2

Animal-Specific Considerations

Dogs, Cats, and Ferrets

• Healthy domestic dogs, cats, and ferrets should be confined and observed for 10 days – animals that remain healthy throughout this period could not have been shedding virus at the time of the bite 4, 2
• Do not begin prophylaxis unless the animal develops clinical signs of rabies during observation 2
• If the animal is rabid, suspected rabid, or unavailable for observation, begin prophylaxis immediately 2

Wild Animals (Bats, Skunks, Raccoons, Foxes)

• Regard as rabid unless proven negative by laboratory testing 2
• Consider immediate prophylaxis – do not wait for testing results given the high rabies prevalence in these species 2
• Bats warrant special attention as bites can be minor and undetected 4

Rodents and Lagomorphs

• Bites from squirrels, hamsters, guinea pigs, gerbils, chipmunks, rats, mice, rabbits, and hares almost never require prophylaxis 2
• Consult public health officials for large rodents (woodchucks, beavers) and livestock 2

Efficacy and Treatment Outcomes

• The combination of wound care, HRIG, and vaccine is nearly 100% effective when properly administered 1, 5, 6
• No failures have been documented in the United States since current cell culture biologics were licensed, despite occasional improper administration 4, 1
• Worldwide experience with millions of treated persons annually confirms the effectiveness of this regimen 4

Treatment of Clinical Rabies

• Rabies is not considered curable once clinical symptoms appear – only 6 documented human survivors exist, and 5 had received pre-symptom vaccination 1
• Focus on comfort care and adequate sedation in an appropriate medical facility 1
• The Milwaukee Protocol (therapeutic coma plus antivirals) has shown inconsistent outcomes and is not routinely recommended 5

Common Pitfalls to Avoid

• Never administer vaccine in the gluteal region – this is associated with treatment failures 1
• Never give HRIG and vaccine in the same anatomical site – this may interfere with vaccine immunogenicity 4
• Never exceed the recommended HRIG dose – excess immunoglobulin can suppress active antibody production 4
• Never give HRIG to previously vaccinated persons – this is unnecessary and counterproductive 4, 1
• Never delay prophylaxis because of elapsed time since exposure – treatment remains effective even after prolonged delays 4, 1