What is the post-exposure prophylaxis (PEP) protocol for rabies after a dog bite?

Post-Exposure Prophylaxis for Rabies After Dog Bite

Immediately begin thorough wound washing with soap and water for 15 minutes, then initiate rabies post-exposure prophylaxis (PEP) consisting of rabies immune globulin (RIG) plus a 5-dose vaccine series (days 0,3,7,14,28) for previously unvaccinated individuals, unless the dog can be confined and observed for 10 days. 1, 2

Immediate Wound Management (First Priority)

Wound cleansing is the single most critical intervention and must never be delayed. 2, 3

• Wash all bite wounds and scratches immediately and thoroughly with soap and water for 15 minutes 1, 2, 3
• Irrigate with povidone-iodine solution after soap and water cleansing 4, 1, 2
• This local wound treatment alone has been shown to markedly reduce rabies transmission risk in animal studies 4, 5
• Administer tetanus prophylaxis as indicated based on immunization status 4, 1, 2
• Address bacterial infection control measures 4

Risk Assessment Algorithm

Geographic Considerations

• In the United States: Rabies in dogs is uncommon except along the US-Mexico border and areas with enzootic wildlife rabies 1
• Outside the United States (Asia, Africa, Latin America): Dogs remain the major rabies vector and represent high-risk exposures—over 50% of US human rabies cases result from dog exposures abroad 4, 5

Dog Observation Protocol (US and Low-Risk Areas)

• If the dog is healthy, domestic, and available: Confine and observe for 10 days 1, 2, 5
• If the dog remains healthy for the full 10 days: No rabies prophylaxis is needed 2
• Initiate PEP immediately if: The dog is stray/unwanted, cannot be confined, dies or develops illness during observation, or shows signs of rabies 2, 5

High-Risk Scenarios Requiring Immediate PEP

• Unprovoked attacks (more likely to indicate rabies than provoked bites) 4, 1, 5
• Exposures in canine rabies-enzootic areas outside the United States 4
• Dog cannot be observed for 10 days 2, 5
• Any bat exposure with physical contact where bite cannot be excluded 5

Rabies Post-Exposure Prophylaxis Protocol

For Previously Unvaccinated Persons

The standard regimen consists of both passive and active immunization administered together. 4, 1

Rabies Immune Globulin (RIG)

• Dose: 20 IU/kg body weight, given once on day 0 2
• Administration: Infiltrate as much as possible deep into and around all wounds; administer remainder intramuscularly at a site distant from vaccine 5
• Timing: Must be given at the beginning of PEP, can be administered through day 7 after first vaccine dose 4, 5
• Critical warning: Do not exceed the recommended dose, as excess RIG can suppress active antibody production 2
• Human rabies immune globulin (HRIG) is preferred over equine products due to lower risk of serum sickness 5, 6

Rabies Vaccine

• Regimen: 5 doses on days 0,3,7,14, and 28 4, 1, 2
• Route: Intramuscular (IM) in the deltoid for adults; anterolateral thigh acceptable for children 4
• Never use the gluteal area: Results in lower neutralizing antibody titers 4
• Available vaccines include HDCV (human diploid cell vaccine), RVA, and PCEC—all are equally effective 4
• Alternative: WHO-recommended intradermal 1-week regimen offers cost and dose savings with equivalent safety 3, 7

For Previously Vaccinated Persons

• Vaccine only (no RIG): 2 doses on days 0 and 3 for those with documented prior complete vaccination series or documented adequate rabies antibody titers 4, 5

Timing Considerations

• Begin treatment within 24 hours of exposure when possible 4
• However, PEP is indicated regardless of delay if clinical rabies signs are not present, as incubation periods exceeding 1 year have been documented 4
• Treatment can be discontinued if the observed dog remains healthy for 10 days 4

Critical Pitfalls to Avoid

• Never delay wound cleansing—this is the first and most important intervention 2, 3
• Do not initiate unnecessary PEP for healthy domestic dogs that can be observed for 10 days in non-enzootic areas 2
• Do not assume vaccination status eliminates risk—even vaccinated animals can rarely develop rabies, particularly if only single-dose vaccinated 4
• Do not use gluteal injection site for vaccine administration 4
• Do not exceed recommended RIG dose—this suppresses active antibody response 2
• Ensure patient compliance: Loss of wages, forgotten dates, and cost are major barriers to completing the full vaccine series 8

Additional Prophylaxis

Antibiotic Prophylaxis

• Amoxicillin-clavulanate is first-line for dog bite wounds, especially hand wounds, wounds over tendons/bones, and immunocompromised patients 2
• For penicillin allergy: doxycycline, fluoroquinolone plus anaerobic coverage, or clindamycin plus fluoroquinolone 2