What is the treatment for rabies exposure?

Treatment for Rabies Exposure

Immediately wash all bite wounds and scratches thoroughly with soap and water for 15 minutes, then administer rabies immune globulin (20 IU/kg) infiltrated into and around the wound plus a 4-dose rabies vaccine series on days 0,3,7, and 14 for previously unvaccinated persons. 1

Immediate Wound Management (First Priority)

• Wash all bite wounds and scratches immediately and thoroughly with soap and water for approximately 15 minutes – this single intervention markedly reduces rabies transmission risk in animal studies 2, 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, 4

Post-Exposure Prophylaxis for Previously Unvaccinated Persons

Rabies Immune Globulin (RIG)

• Administer human rabies immune globulin (HRIG) at exactly 20 IU/kg body weight as a single dose on day 0 1, 4
• Infiltrate the full dose of HRIG thoroughly around and into all wounds if anatomically feasible – this is critical for effectiveness 2, 1
• Administer any remaining RIG intramuscularly at a site distant from vaccine administration 5
• HRIG can be given up to day 7 after the first vaccine dose, but beyond day 7 it is not indicated 5, 4

Rabies Vaccine

• Administer rabies vaccine (HDCV, PCECV, or RVA) as a 4-dose series on days 0,3,7, and 14 1
• Administer vaccine intramuscularly in the deltoid area only for adults – never use the gluteal area as this results in lower neutralizing antibody titers 1
• The combination of wound care, HRIG, and vaccine is nearly 100% effective when properly administered 1

Post-Exposure 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 post-exposure prophylaxis 5, 1
• Do not administer HRIG in previously vaccinated persons – it may blunt the rapid anamnestic antibody response 5, 1
• Previously vaccinated persons include those who received a complete pre-exposure series or documented adequate rabies antibody titer 5

Risk Assessment and Decision Algorithm

When to Initiate PEP

• Begin PEP immediately for stray dog bites when the animal cannot be observed or tested 2
• Unprovoked attacks are more likely to indicate rabies than provoked attacks 5, 2
• If the animal can be captured: either confine and observe for 10 days (dogs, cats, ferrets only) or euthanize immediately and submit the head for rabies testing 2, 4
• The 10-day observation period is reliable only for healthy domestic dogs, cats, and ferrets – not for other animals 2

Exposure Types Requiring Treatment

• Any penetration of skin by teeth constitutes a bite exposure requiring evaluation 5, 4
• Bat exposures require special consideration: rabies PEP should be considered for any physical contact with bats when bite or mucous membrane contact cannot be excluded because bat bites may be undetected 4
• Nonbite exposures: scratches, abrasions, open wounds, or mucous membranes contaminated with saliva or neural tissue from a rabid animal 5, 4
• Casual contact (petting a rabid animal, contact with blood, urine, or feces) does not constitute exposure and does not require prophylaxis 4

Critical Timing Considerations

• Postexposure prophylaxis is a medical urgency, not a medical emergency – decisions should be made promptly but need not be delayed for consultation 5, 1
• Begin treatment within 24 hours when possible 5
• Prophylaxis should be administered regardless of delay, even months after exposure, provided the person shows no clinical signs of rabies 5, 1

Common Pitfalls to Avoid

• Do not delay PEP initiation while attempting to locate an escaped animal 2
• Inadequate wound cleansing increases transmission risk – thorough 15-minute washing is essential, not optional 2, 3
• Failing to infiltrate RIG into the wound site reduces effectiveness – this step cannot be skipped 2
• Never administer vaccine and RIG in the same anatomical site or same syringe 5
• Do not exceed the recommended 20 IU/kg dose of HRIG as this may suppress active antibody production 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 disease is nearly 100% fatal once symptoms develop 6, 7, 8

Regional Epidemiology Considerations

• In the United States, rabies in dogs is most common along the US-Mexico border and in areas with enzootic wildlife rabies 2
• Wild carnivores (skunks, raccoons, foxes, coyotes) and bats are the primary rabies vectors in the US 5
• Stray or unwanted dogs carry higher risk than owned, vaccinated dogs 2
• In developing countries of Asia, Africa, and Central/South America, dogs are the major rabies vector and exposures represent a special threat 5