What should be done for a patient bitten by a stray cat with a puncture wound, redness, and mild bleeding, who is up to date with tetanus vaccine but has not received rabies vaccine?

Management of Stray Cat Bite in Previously Unvaccinated Patient

This patient requires immediate rabies post-exposure prophylaxis consisting of both rabies vaccine AND rabies immune globulin (RIG), making option B the correct answer. 1, 2

Immediate Wound Management

• Thoroughly wash and flush the puncture wound with soap and water for approximately 15 minutes immediately - this single intervention markedly reduces rabies transmission risk even without other prophylaxis 1, 2
• Apply a povidone-iodine solution or other virucidal agent to the wound after cleansing 1, 2
• Avoid suturing puncture wounds when possible to prevent trapping virus in deeper tissues 1
• Consider tetanus prophylaxis based on vaccination history (though patient is reportedly up to date) 1, 2
• Evaluate need for antibiotic prophylaxis given the puncture nature and contamination risk 1

Rabies Post-Exposure Prophylaxis Protocol

For previously unvaccinated persons exposed to stray cats, the essential components are BOTH passive and active immunization: 1, 2

Rabies Immune Globulin (RIG)

• Administer 20 IU/kg body weight on day 0 1, 2
• Infiltrate the full dose thoroughly into and around the puncture wound site - this is critical as inadequate wound infiltration has been associated with rare prophylaxis failures 1, 2
• Any remaining volume after wound infiltration should be injected intramuscularly at a site distant from vaccine administration 1, 2
• RIG can be administered up to day 7 if not given initially, but should ideally be given immediately 1

Rabies Vaccine

• Administer 5 doses intramuscularly on days 0,3,7,14, and 28 1, 2
• Give in the deltoid area for adults (anterolateral thigh for children) - never use the gluteal area 1
• Administer at a different anatomical site than the RIG 1

Why Other Options Are Incorrect

Option A (tetanus vaccine and immunoglobulin only): The patient is already up to date with tetanus, and this completely ignores the rabies risk, which is the primary life-threatening concern 1, 2

Option C (observe and reassess after 48 hours): This is dangerous and inappropriate - rabies prophylaxis should begin immediately for stray animal bites when the animal cannot be captured and observed 1, 3, 2

Option D (reassurance based on healthy appearance): This is the most dangerous option - stray or unwanted cats that bite should be considered high-risk regardless of appearance 1, 2. The 10-day observation period only applies when the animal can be captured and confined 1, 2

Critical Decision Points for Stray Cat Bites

Stray cats represent a significant rabies risk in the United States: 1

• More cats than dogs were reported rabid during most of the 1980s, particularly associated with wildlife rabies epizootics 1
• Fewer cat vaccination laws and roaming habits increase rabies exposure risk 1

The animal's availability determines the approach: 2

• If the stray cat can be captured: confine and observe for 10 days, or euthanize immediately and test the brain 1, 2
• If the stray cat escapes or is unavailable (as in this case): begin immediate prophylaxis 3, 2

Common Pitfalls to Avoid

• Do not delay prophylaxis while attempting to locate an escaped stray animal - begin treatment immediately 3, 2
• Do not rely on the animal's healthy appearance - rabid animals may appear normal early in infection 1, 2
• Do not fail to infiltrate RIG directly into the wound - this is associated with prophylaxis failures 1, 4
• Do not exceed the recommended RIG dose (20 IU/kg) as this can suppress active antibody production 1
• Do not administer RIG and vaccine in the same syringe or anatomical site 1

Timing Considerations

• Rabies post-exposure prophylaxis is a medical urgency - begin as soon as possible after the 2-hour exposure 1, 3
• Treatment can be discontinued if the animal is later proven negative by laboratory testing 1, 2
• Even delays of months do not preclude prophylaxis if clinical rabies signs are absent, as incubation periods exceeding 1 year have been documented 1