Does a patient who received a rabies booster series require Equine Rabies Immune Globulin (ERIG) and a restarted vaccination series after a category 2 bite on the wrist?

Rabies Post-Exposure Prophylaxis for Previously Vaccinated Patient with Category 2 Bite

No, do not give ERIG and do not restart the full series—this patient needs only 2 doses of vaccine (days 0 and 3) without any rabies immunoglobulin. 1, 2

Immediate Wound Management

• Thoroughly wash and flush the wound for 15 minutes with soap and copious water 3, 2
• Apply povidone-iodine solution or similar virucidal agent to the wound site 3, 2
• Avoid suturing when possible to prevent deeper viral inoculation 2
• Administer tetanus toxoid booster if indicated 2
• Consider antibiotic prophylaxis based on wound characteristics 2

Vaccination Protocol for Previously Vaccinated Persons

Administer only 2 doses of rabies vaccine (HDCV or PCECV): 1, 2

• Day 0: 1.0 mL intramuscularly in the deltoid (immediately)
• Day 3: 1.0 mL intramuscularly in the deltoid

Never use the gluteal area—this reduces immunogenicity 3, 2

Why No ERIG?

ERIG (or HRIG) is contraindicated in previously vaccinated persons because it suppresses the anamnestic antibody response. 1, 2 The ACIP explicitly states that persons who have ever previously received complete vaccination regimens should receive only vaccine without any rabies immunoglobulin 1. Previously vaccinated individuals maintain immunological memory even decades after initial vaccination, with the majority showing anamnestic responses by day 7 2.

Rationale for Simplified 2-Dose Schedule

The patient has immunological memory from their previous booster series and does not need the full 5-dose regimen used for unvaccinated persons 1, 2. The 2-dose schedule (days 0 and 3) is sufficient to trigger a rapid anamnestic response 1, 2. This updated recommendation streamlines treatment for previously vaccinated immunocompetent persons 2.

Critical Exception: Immunocompromised Patients

If this patient is immunocompromised, they would require the full 5-dose schedule (days 0,3,7,14,28) even with prior vaccination history, and serologic testing should be performed to confirm adequate antibody response. 2 However, ERIG is still not indicated even in immunocompromised previously vaccinated persons 1.

Animal Observation

• If the biting animal is healthy and available, observe for 10 days 2
• If the animal develops signs of rabies during observation, continue the vaccine series 2
• If the animal remains healthy for 10 days or tests negative for rabies, prophylaxis can be discontinued 2

Common Pitfalls to Avoid

• Do not administer ERIG or HRIG—this is the most critical error, as immunoglobulin will suppress the patient's anamnestic response 1, 2
• Do not use the 5-dose schedule intended for unvaccinated persons—this wastes vaccine and delays completion of prophylaxis 2
• Do not inject vaccine in the gluteal area—this results in diminished immune response 3, 2
• Do not delay treatment—begin immediately, as this is a medical urgency 2