What is the post-exposure prophylaxis treatment for rabies?

Rabies Post-Exposure Prophylaxis

For previously unvaccinated individuals exposed to rabies, immediately initiate wound cleansing followed by both rabies immune globulin (RIG) at 20 IU/kg and a 5-dose vaccine series (days 0,3,7,14,28); previously vaccinated individuals require only 2 vaccine doses (days 0,3) without RIG. 1

Immediate Wound Management

Thorough wound cleansing is the single most critical first step and can markedly reduce rabies transmission risk even without other prophylaxis. 1

• Immediately wash all bite wounds and scratches with soap and water for approximately 15 minutes 1, 2
• Use dilute povidone-iodine solution if available for additional virucidal effect 1, 3
• Animal studies demonstrate that wound cleansing alone significantly reduces rabies likelihood 1
• Avoid suturing wounds when possible to prevent trapping virus in tissue 1
• Administer tetanus prophylaxis as indicated 1

For Previously Unvaccinated Persons

Rabies Immune Globulin (RIG) Administration

RIG must be given at the time of first vaccine dose (day 0) or up to day 7 maximum—never beyond day 7. 1, 3

• Dose: 20 IU/kg (0.133 mL/kg) body weight for all ages including children 1, 3
• Infiltrate the full dose thoroughly into and around all wounds if anatomically feasible 1, 3
• Any remaining volume should be injected intramuscularly at a site distant from vaccine administration 1
• Never administer RIG in the same syringe or anatomical site as the vaccine 1, 3
• Do not exceed the recommended dose as RIG can partially suppress active antibody production 1
• After day 7, RIG is contraindicated because vaccine-induced antibody response has begun 1, 3

Common Pitfall: Failure to infiltrate RIG directly into wound sites has been associated with rare prophylaxis failures 1

Vaccine Administration

Administer 5 doses of rabies vaccine (HDCV or PCECV) intramuscularly on days 0,3,7,14, and 28. 1, 3

• Day 0 is the day the first vaccine dose is given—initiate as soon as possible after exposure 1
• Adults: inject in the deltoid muscle only 1, 3
• Children: use anterolateral thigh 1
• Never use the gluteal region due to risk of sciatic nerve injury and reduced immunogenicity 3
• Subsequent vaccine doses can be given in the same anatomic location where RIG was administered 1

For Previously Vaccinated Persons

Previously vaccinated individuals require only 2 doses of vaccine on days 0 and 3, with no RIG. 4

• This modified regimen applies to anyone who has completed a pre-exposure or post-exposure vaccination series with cell culture vaccine 1, 4
• Also applies to those with documented rabies virus neutralizing antibody titer 1
• Previously vaccinated persons develop rapid anamnestic immune response upon re-exposure 4
• Studies show protective antibody titers (>0.5 IU/mL) persist at 1 year post-vaccination 4

Exception: Immunosuppressed patients require the full 5-dose regimen with RIG regardless of prior vaccination status 4

Timing Considerations

Rabies post-exposure prophylaxis is a medical urgency, not an emergency, but decisions must not be delayed. 1, 5

• Begin treatment within 24 hours when possible 1, 3
• However, initiate prophylaxis regardless of delay, even months after exposure, provided the patient shows no clinical signs of rabies 1, 5
• Incubation periods exceeding 1 year have been documented in humans 1, 5
• Once clinical rabies symptoms develop, prophylaxis is ineffective and the disease is invariably fatal 1, 5, 6

Common Pitfall: Delaying treatment while awaiting animal testing results when high-risk exposure has occurred 5

When to Discontinue Prophylaxis

• If the biting dog or cat remains healthy during a 10-day observation period, prophylaxis can be discontinued 1
• If laboratory testing (direct fluorescent antibody test) confirms the animal was not rabid, discontinue prophylaxis 1

Evidence Quality

The recommendations are based on consistent guidance from the CDC Advisory Committee on Immunization Practices (ACIP) across multiple iterations (1991,2008) 1 and FDA-approved drug labeling 3. The 5-dose vaccine regimen over 28 days has been proven safe and effective with adequate antibody response in all recipients in U.S. studies 1. No prophylaxis failures have been documented in the United States when current biologics are properly administered 1.