What is the recommended treatment for a patient who has received post-exposure rabies prophylaxis (Post-Exposure Prophylaxis, PEP) in the last year and suffers a catastrophic scratch?

Rabies Post-Exposure Prophylaxis for Previously Vaccinated Patients

For a patient who received complete rabies post-exposure prophylaxis within the last year and sustains a catastrophic scratch from a potentially rabid animal, administer only 2 doses of rabies vaccine on days 0 and 3—do NOT administer rabies immune globulin (HRIG). 1, 2

Immediate Wound Management

• Thoroughly cleanse all wounds with soap and water for 15 minutes immediately, as this is the single most effective measure for preventing rabies infection 1, 2
• Apply a virucidal agent such as povidone-iodine solution to the wound after cleansing 3
• Avoid suturing the wound when possible, as this may drive virus deeper into tissues 3
• Administer tetanus prophylaxis if vaccination status is not current 1

Simplified Vaccination Schedule for Previously Vaccinated Persons

Previously vaccinated individuals require only 2 doses of vaccine (HDCV or PCECV), administered on days 0 and 3, with NO rabies immune globulin. 1, 2, 3

• Day 0 is defined as the day the first dose is administered, not necessarily the day of exposure 2
• Administer 1.0 mL intramuscularly in the deltoid area (or anterolateral thigh in young children) 2, 3
• Never use the gluteal area for vaccine administration, as this produces inadequate antibody response 2, 3

Critical Distinction: Why No HRIG?

HRIG should NOT be administered to previously vaccinated persons because it will suppress the anamnestic antibody response. 2

• Previously vaccinated individuals mount a rapid secondary immune response that makes passive immunization unnecessary 1
• The simplified 2-dose regimen applies to anyone who has ever received a complete vaccination series (either pre-exposure or post-exposure) with a cell culture vaccine 1, 4

Important Exception: Immunocompromised Patients

If the patient is immunocompromised, upgrade to the full 5-dose regimen (days 0,3,7,14, and 28) PLUS HRIG at 20 IU/kg, even though they were previously vaccinated. 2, 3

• Immunosuppressed patients cannot mount adequate anamnestic responses 1
• Consider serologic testing 7-14 days after the final dose to confirm seroconversion 2

Timing Considerations

Initiate prophylaxis as soon as possible after exposure—this is a medical urgency, not an emergency, but delays of even hours matter. 2

• Treatment should begin immediately upon recognition of exposure, even if weeks or months have elapsed since the actual exposure 2
• There is no absolute cutoff beyond which post-exposure prophylaxis should be withheld, provided clinical signs of rabies are not present 3

Common Pitfalls to Avoid

• Do not administer HRIG to previously vaccinated persons—this is the most critical error, as it inhibits the protective anamnestic response 2
• Do not use the gluteal area for vaccine administration—this is associated with vaccine failure 2, 3
• Do not forget to upgrade immunocompromised patients to the 5-dose regimen with HRIG—the standard 2-dose schedule is inadequate for this population 2
• Do not delay wound cleansing—immediate thorough cleansing is perhaps the most effective single preventive measure 2, 3

When to Discontinue Prophylaxis

If the exposing animal is proven not to be rabid through appropriate laboratory testing (direct fluorescent antibody test), post-exposure prophylaxis can be discontinued 4