What is the recommended treatment for a patient with a history of rabies vaccination and HRIG administration who suffered a category 3 cat bite?

Rabies Post-Exposure Management for Previously Vaccinated Patient

This patient requires only a 2-dose rabies vaccine booster (days 0 and 3) without any rabies immunoglobulin (HRIG), along with proper wound care and tetanus prophylaxis. 1, 2, 3

Rationale for Simplified Treatment

Since this patient has a documented history of complete rabies vaccination and previous HRIG administration, she is considered previously immunized and requires only vaccine boosters—not passive immunization with HRIG. 1

The key principle: Previously vaccinated persons have immunological memory and do not need HRIG, which can actually suppress their anamnestic antibody response. 1

Specific Treatment Protocol

Immediate Wound Management

• Thoroughly wash and flush the wound for approximately 15 minutes with soap and copious water 1, 4, 3
• Apply povidone-iodine solution or similar virucidal agent to the wound site 1, 4
• Avoid suturing when possible to prevent deeper viral inoculation 4
• Administer tetanus toxoid booster if indicated 1
• Consider antibiotic prophylaxis based on wound characteristics (cat bites have high infection risk) 1

Vaccination Schedule

• Administer 1.0 mL rabies vaccine (HDCV or PCECV) intramuscularly on day 0 (today) 1, 2, 3
• Administer second 1.0 mL dose on day 3 1, 2, 3
• Inject in the deltoid area (never gluteal, which reduces immunogenicity) 1, 3

What NOT to Do

• Do NOT administer HRIG - this is contraindicated in previously vaccinated persons as it may suppress the anamnestic response 1, 3
• Do NOT use the 5-dose schedule intended for unvaccinated persons 1, 2

Evidence Supporting This Approach

The 2008 ACIP guidelines explicitly state that "persons who have ever previously received complete vaccination regimens (pre-exposure or post-exposure) with a cell culture vaccine...should receive only vaccine" without HRIG. 1 This recommendation is echoed in the FDA labeling for rabies vaccines. 3

The WHO updated recommendations further streamline this to a 2-dose schedule (days 0 and 3) for previously vaccinated immunocompetent persons, representing the most current evidence-based approach. 2, 4

Studies demonstrate that previously vaccinated individuals maintain immunological memory even decades after initial vaccination, with the majority (82%) showing anamnestic responses by day 7. 5 The 2-dose booster reliably produces protective antibody levels in all previously vaccinated persons. 1, 2

Important Caveats

If Immunosuppressed

• If this patient is immunocompromised, she would require the full 5-dose schedule (days 0,3,7,14,28) even with prior vaccination history 2, 4
• Serologic testing would be indicated to confirm adequate antibody response 1

If Vaccination History Uncertain

• If the patient's prior vaccination documentation cannot be verified or involved non-cell culture vaccines without documented antibody titers, treat as unvaccinated with full 5-dose series plus HRIG 3, 5

Timing Considerations

• Begin treatment immediately—this is a medical urgency, not emergency 1
• Even delayed treatment is indicated as rabies incubation periods exceeding 1 year have been documented 1

Animal Observation

• The cat should be observed for 10 days if healthy and available 1, 3
• If the cat develops signs of rabies during observation, continue the vaccine series 3
• If the cat remains healthy for 10 days or tests negative for rabies, prophylaxis can be discontinued 1, 3

No routine serologic testing is needed after this 2-dose booster series in immunocompetent patients. 1, 3