What is the recommended antibiotic prophylaxis for a patient who has taken post-exposure rabies prophylaxis (PERP) within the last year and presents with a cat scratch?

Management of Cat Scratch in Previously Vaccinated Rabies Patient

For a patient who received post-exposure rabies prophylaxis within the past year, a new cat scratch requires only wound care and antibiotic prophylaxis—no additional rabies vaccination is needed. 1

Rabies Management

Previously vaccinated individuals (within the last year) do NOT require rabies immunoglobulin (HRIG) or the full 5-dose vaccine series. 1 The 2008 ACIP guidelines are explicit that persons who have previously received complete rabies vaccination regimens should receive only vaccine (not HRIG) for subsequent exposures, and those with documented immunity within the past year typically require only 2 booster doses on days 0 and 3. 1

Key Points on Rabies Risk Assessment:

• Cat scratches alone (without bite) carry minimal rabies transmission risk, as rabies virus is primarily transmitted through saliva entering deep wounds or mucous membranes. 1
• Evaluate the cat's vaccination status and behavior—a healthy, vaccinated cat observed for 10 days poses negligible risk. 1
• If the cat is unavailable for observation or shows signs of illness, consult local health authorities immediately. 1

Wound Management and Infection Prevention

Immediate thorough wound cleansing with sterile normal saline is essential, as this alone significantly reduces infection risk from both bacteria and potential rabies virus. 1, 2

Antibiotic Prophylaxis:

Amoxicillin-clavulanate 875/125 mg twice daily is the first-line prophylactic antibiotic for cat scratches, particularly for: 2

• Deep wounds
• Wounds on hands, feet, face, or near joints
• Immunocompromised patients
• Any scratch with significant tissue trauma

Duration: 3-5 days for prophylaxis; extend to 7-14 days if infection develops. 2

Alternative Antibiotics (for penicillin allergy):

• Doxycycline 100 mg twice daily (excellent Pasteurella multocida coverage) 2
• Ciprofloxacin 500-750 mg twice daily or levofloxacin 750 mg daily 2
• Trimethoprim-sulfamethoxazole plus metronidazole (requires dual coverage) 2

Critical caveat: Clindamycin should NOT be used as monotherapy for cat scratches due to poor Pasteurella coverage. 2

Cat Scratch Disease Surveillance

Monitor for development of cat scratch disease (CSD) caused by Bartonella henselae, which typically presents 3-30 days post-exposure with: 3

• Papule or pustule at scratch site
• Regional lymphadenopathy appearing ~3 weeks later
• Constitutional symptoms (fever, malaise)

Treatment if CSD Develops:

Azithromycin is the treatment of choice: 3, 2

• Adults >45 kg: 500 mg day 1, then 250 mg daily for 4 days
• Children <45 kg: 10 mg/kg day 1, then 5 mg/kg daily for 4 days

Most CSD cases in immunocompetent patients are self-limited and resolve without antibiotics, but azithromycin accelerates lymph node resolution. 4, 5

Additional Considerations

• Update tetanus prophylaxis if not current within 5 years (or 10 years for clean wounds). 2
• Elevate the affected limb if swelling develops to accelerate healing. 2
• Return precautions: Instruct patient to return immediately for increasing pain, redness, swelling, purulent drainage, fever, or lymph node enlargement. 2

Special Populations:

• Diabetic patients require more aggressive treatment (1-2 weeks minimum, potentially 3-4 weeks) due to impaired immune response and delayed healing. 2
• Immunocompromised patients are at risk for atypical presentations including bacillary angiomatosis and require vigilant monitoring. 2, 6