What should be done for a patient bitten by a stray cat, with a puncture wound and up-to-date tetanus vaccine, but no prior rabies vaccination?

Management of Stray Cat Bite in Previously Unvaccinated Patient

For a patient bitten by a stray cat 2 hours ago with no prior rabies vaccination, you must immediately initiate both rabies immune globulin (RIG) and rabies vaccine (Option B), along with thorough wound care. 1, 2, 3, 4

Immediate Wound Management (First Priority)

• 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 2, 3, 4
• Apply povidone-iodine solution or other virucidal agent to the wound after cleansing 2, 3, 4
• Avoid suturing puncture wounds when possible to prevent trapping virus in deeper tissues 2
• The patient's tetanus status is already up-to-date, so additional tetanus vaccine is NOT needed 1

Rabies Post-Exposure Prophylaxis (Mandatory for Stray Cats)

Stray cats represent a significant rabies risk and require immediate prophylaxis because the animal is unavailable for observation or testing. 1, 2, 3

Rabies Immune Globulin (RIG) - Day 0

• Administer 20 IU/kg body weight of RIG immediately (day 0) 1, 2, 3, 4
• 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 2, 4, 5
• Any remaining volume after wound infiltration should be injected intramuscularly at a site distant from vaccine administration 2, 4
• RIG can be administered up to day 7 if not given initially, but should ideally be given immediately 2, 3
• Never exceed the 20 IU/kg dose as this can suppress active antibody production 2, 4

Rabies Vaccine Series

• Administer 4 doses of rabies vaccine intramuscularly on days 0,3,7, and 14 (the updated 2010 ACIP recommendation for immunocompetent patients) 1, 6
• Give the vaccine in the deltoid area for adults (anterolateral thigh for children) - never use the gluteal area 3, 4
• Administer the vaccine at a different anatomical site than the RIG and never in the same syringe 2, 3, 4

Why Other Options Are Incorrect

• Option A is wrong because the patient is already up-to-date with tetanus and does not need additional tetanus vaccine or immunoglobulin 1
• Option C (observe 48 hours) is dangerous because stray cats cannot be observed for the standard 10-day period, and rabies prophylaxis is a medical urgency that must begin immediately 1, 2, 3
• Option D (reassurance) is completely inappropriate because the cat is a stray (not available for observation), and rabid animals may appear healthy early in infection 1, 2, 3

Critical Decision Points for Stray Cat Bites

• If the stray cat escapes or is unavailable (as in this case), begin immediate prophylaxis without delay 2, 3
• Stray cats represent significant rabies risk, with more cats than dogs reported rabid during most of the 1980s in the United States 2
• The animal's healthy appearance is irrelevant - rabid animals may appear normal early in infection 2
• Do not delay prophylaxis while attempting to locate an escaped stray animal 2

Common Pitfalls to Avoid

• Failing to infiltrate RIG directly into the wound - this is associated with prophylaxis failures and occurs in 44% of cases based on recent data 2, 5
• Administering RIG and vaccine in the same syringe or anatomical site 2, 3, 4
• Delaying treatment to search for the animal - begin immediately 2, 3
• Using the gluteal region for vaccine administration due to risk of sciatic nerve injury 3, 4

Timing and Follow-up

• Rabies post-exposure prophylaxis is a medical urgency - begin as soon as possible after exposure 1, 2, 3
• Treatment can be discontinued if the animal is later captured and proven negative by laboratory testing 1, 3
• Even delays of months do not preclude prophylaxis if clinical rabies signs are absent, as incubation periods exceeding 1 year have been documented 1, 2
• When used appropriately with timely wound care and RIG administration, the 4-dose vaccine regimen is nearly 100% effective 6, 7