Treatment of Fatal Rabies
Once clinical rabies develops, focus on comfort care and adequate sedation rather than curative treatment, as no proven effective medical therapy exists and the disease is virtually always fatal. 1, 2
Core Treatment Principle
The Advisory Committee on Immunization Practices (ACIP) explicitly states that no proven effective medical treatment is recognized after clinical signs develop, and rabies carries the highest case fatality rate of any infectious disease. 1, 2 The disease is not considered curable despite experimental attempts. 1, 2
Primary Management Approach: Palliative Care
When rabies is definitively diagnosed, prioritize comfort care and adequate sedation in an appropriate medical facility as the minimum standard of care. 1, 2
Specific Palliative Measures
Sedation is essential because patients become extremely agitated with stimuli including loud noises, air currents, and the sight or sound of running water during the acute neurologic phase. 1, 2
Use benzodiazepines (diazepam or midazolam) via intravenous or intrarectal routes to alleviate anxiety, agitation, and seizures. 3
Address thirst and dehydration with intravenous fluids, as hydrophobia prevents oral intake. 3, 4
Control fever with antipyretic medications. 3
Create calm, quiet conditions allowing family communication with the patient in safety and privacy during fluctuating periods of lucidity. 4
Manage pain, hypersecretion, and other distressing symptoms as they arise. 4
Important Caveat About Psychological Distress
Beyond the overt encephalitis, patient stress is compounded by psychological trauma from isolation and hopelessness during lucid periods. 1 Compassionate communication and family presence are critical components of care. 4
Experimental Therapies: Highly Selective Consideration Only
Experimental aggressive treatment should only be considered in young, healthy patients at early disease stages in specialized tertiary care centers, and only after extensive informed consent discussions. 1, 2
Survival Data Context
- Only 6 documented human survivors exist worldwide. 2, 5
- 5 of these 6 survivors had received rabies vaccination before symptom onset. 1, 2, 5
- Only 1 patient has ever recovered without prior vaccination. 1, 2
Factors That May Justify Experimental Treatment
Recovery is extremely rare and should only be considered when specific prognostic factors are present: 4, 6
- High rabies antibody titers in serum or CSF at diagnosis (the most important factor) 6
- Previous rabies vaccination with antibody development within the first week of illness 4
- Infection by American bat rabies virus variants 4
Critical Warnings About Experimental Treatment
Families must understand before consent: 1
- High probability of treatment failure despite aggressive measures 1
- Anticipated substantial expenses 1
- Severe neurological sequelae requiring lengthy rehabilitation in the rare event of survival 1
Experimental Agents Previously Attempted
Various experimental measures have been tried without consistent success, including vidarabine, multisite intradermal vaccination, interferon, intravenous/intrathecal rabies immune globulin, antithymocyte globulin, inosine pranobex, ribavirin, ketamine, and high-dose steroids. 1 Recent attempts with monoclonal antibodies have also failed to achieve adequate serum and CSF levels. 6
What NOT to Do
Do not initiate rabies vaccination after clinical symptoms appear in confirmed rabies cases—this is not recommended and may be detrimental. 1
Infection Control Precautions
Human rabies patients do not pose greater infection risk than common bacterial/viral infections. 1
- Use standard precautions with gowns, goggles, masks, and gloves, particularly during intubation and suctioning. 1
- Postexposure prophylaxis for healthcare workers is indicated only if the patient bites them or if saliva/neural tissue contaminates an open wound or mucous membrane. 1
The Bottom Line for Clinical Practice
In resource-limited settings where most rabies deaths occur, comprehensive palliative care using essential medications (benzodiazepines, antipyretics, IV fluids) can provide dignified end-of-life care at no risk to healthcare workers. 3 Healthcare staff should be trained and clinical guidelines updated to include palliative care protocols for rabies in endemic countries. 3