What is the immediate management for Category 3 (severe) rabies exposure?

Category 3 Rabies Exposure Management

Immediate Wound Management

Category 3 rabies exposure requires immediate and thorough wound cleansing with soap and water for at least 15 minutes, followed by infiltration of rabies immunoglobulin (RIG) into and around the wound, plus a 4-dose vaccine series on days 0,3,7, and 14. 1

Wound Cleansing Protocol

• Begin immediately with thorough washing of all wounds with soap and water for approximately 15 minutes—this single intervention markedly reduces rabies transmission risk in animal studies 2, 3
• Irrigate the wound with a virucidal agent such as povidone-iodine solution if available 1, 2
• This step is critical and should never be delayed, as local wound cleansing alone has been shown to significantly reduce the likelihood of rabies 3

Rabies Immunoglobulin (RIG) Administration

Administer 20 IU/kg body weight of human rabies immunoglobulin (HRIG) as soon as possible after exposure, ideally on day 0. 1, 2

RIG Infiltration Technique

• Infiltrate the full dose thoroughly into and around the wound if anatomically feasible 1, 2
• Any remaining volume after wound infiltration should be administered intramuscularly at an anatomical site distant from vaccine administration 1
• RIG should never be administered in the same syringe as vaccine, as this can suppress active antibody production 1, 2
• RIG can be administered up to 7 days after the first vaccine dose, but should ideally be given on day 0 2
• Do not exceed the recommended dose of 20 IU/kg, as excessive RIG might partially suppress active production of rabies virus antibody 1

Rabies Vaccine Administration

Administer a 4-dose vaccine regimen (HDCV or PCECV) intramuscularly on days 0,3,7, and 14. 1, 2

Vaccine Injection Sites

• Adults and older children: Deltoid area only 1
• Younger children: Outer aspect of the thigh may be used 1
• Never use the gluteal area for vaccine administration, as this may result in diminished immunologic response and increased risk of sciatic nerve injury 1

Special Populations

• Immunosuppressed persons should receive all 5 doses of vaccine on days 0,3,7,14, and 28 (not the standard 4-dose regimen) 1

Timing Considerations

Begin post-exposure prophylaxis as soon as possible after exposure (within 24 hours), regardless of the time interval between exposure and initiation. 1, 3

• The combination of RIG and vaccine is recommended for both bite and nonbite exposures 1
• Substantial delays between exposure and initiation of prophylaxis are of particular concern with severe wounds to the face and head, which provide rapid access to the central nervous system 1
• Treatment should begin immediately without waiting to locate or observe the animal, as delays can be fatal 2

Tetanus Prophylaxis

• Verify tetanus vaccination status and administer tetanus toxoid 0.5 mL intramuscularly if status is not current or unknown 2, 3

Critical Pitfalls to Avoid

• Failure to infiltrate RIG around the wound site: Patients who contracted rabies after post-exposure prophylaxis often did not receive appropriate infiltration of RIG around the wound 1
• Administering vaccine in the gluteal area: This has been associated with prophylaxis failures 1
• Inadequate wound cleansing: Insufficient local wound care has been linked to prophylaxis failures 1
• Administering RIG and vaccine in the same syringe or same anatomical site: This suppresses antibody production 1, 2
• Exceeding the recommended RIG dose: More than 20 IU/kg can suppress active antibody production 1
• Delaying treatment: Rabies is 100% fatal once clinical symptoms develop, making immediate prophylaxis the only viable strategy 2