How to manage a patient with a dog bite and unknown rabies status of the dog?

Management of Dog Bite with Unknown Rabies Status

A patient bitten by a dog of unknown rabies status requires immediate wound care followed by simultaneous administration of both rabies immune globulin (RIG) and rabies vaccine, unless the dog can be confined and observed for 10 days. 1

Immediate Wound Management (First Priority)

• Wash the wound thoroughly with soap and water for 15 minutes immediately - this is the single most effective measure for preventing rabies 1, 2
• Gently irrigate with water or dilute povidone-iodine solution without damaging tissues 1
• Avoid suturing wounds when possible to allow drainage 1
• Administer tetanus prophylaxis as indicated 3, 1
• Consider antibiotic prophylaxis based on wound characteristics 1

Critical Decision Point: Can the Dog Be Observed?

If the Dog is Available and Healthy-Appearing:

• Confine the dog and observe it daily for 10 days 3, 1
• Do NOT administer rabies vaccine to the animal during observation 3
• Have a veterinarian evaluate the dog at the first sign of illness 3
• Initiate postexposure prophylaxis (PEP) in the patient immediately while awaiting observation results - this is critical because rabies is nearly 100% fatal once symptoms develop 1, 4
• PEP can be discontinued if the dog remains healthy for the full 10 days 1
• If the dog develops signs of rabies during observation, euthanize immediately and submit the head under refrigeration (not frozen) for laboratory examination 3

If the Dog is Unavailable, Stray, or Unwanted:

• Begin full postexposure prophylaxis immediately without waiting 3, 1
• The dog may be euthanized immediately and the head submitted for rabies testing if captured 3
• Never delay prophylaxis waiting for test results when the animal is unavailable or high-risk 1

Postexposure Prophylaxis Protocol

For Previously Unvaccinated Patients:

• Administer both RIG and rabies vaccine simultaneously at the first presentation 1, 4
• RIG dosing: Infiltrate as much as anatomically feasible deep into and around all wounds; administer any remaining volume intramuscularly at a site distant from vaccine administration 1
• Give RIG only once, and only at the beginning of prophylaxis (up to and including day 7 after first vaccine dose) 1
• Never administer RIG after day 7 as it may interfere with active immunity 1
• Do not exceed recommended RIG dosage as excess can suppress vaccine response 1

Vaccine Regimen:

• Initiate rabies vaccine as soon as possible, ideally within 24 hours 1
• Administer a 5-dose regimen on days 0,3,7,14, and 28 3, 1
• Give intramuscularly in the deltoid area for adults; anterolateral thigh is acceptable for children 3
• Never use the gluteal area 3

For Previously Vaccinated Patients:

• Administer vaccine only (no RIG) if the patient has documented prior complete rabies vaccination 1
• Give 2 doses on days 0 and 3 1

Critical Timing Considerations

• This is a medical urgency, not an emergency, but decisions must not be delayed 1
• Administer prophylaxis regardless of time elapsed since exposure, provided clinical signs of rabies are not present 1
• Incubation periods exceeding 1 year have been documented, emphasizing the importance of prophylaxis even with delayed presentation 1
• Once clinical rabies develops, postexposure prophylaxis is consistently ineffective - rabies is nearly 100% fatal at that point 1, 4

Common Pitfalls to Avoid

• Do not wait for animal testing results before initiating PEP when the dog is unavailable or cannot be observed 1
• Do not delay wound washing - this must be done immediately 1, 2
• Do not administer RIG and vaccine in the same anatomical site 1
• Do not give RIG after day 7 of the vaccine series 1
• Do not withhold prophylaxis based on time elapsed since exposure unless clinical rabies is present 1
• Remember that prophylaxis can be discontinued if laboratory testing confirms the animal was not rabid 1

Risk Assessment Context

• Dogs are the major vector of rabies in most developing countries, and exposures to dogs in these areas represent a special threat 3
• In the United States, dog rabies is well-controlled, but the unknown status of this particular dog necessitates the cautious approach outlined above 3
• An unprovoked attack is more likely to indicate rabies than a provoked attack 3

Human rabies is preventable with proper postexposure prophylaxis, which is nearly 100% effective when administered correctly and promptly 1, 4. The key is not to delay treatment while attempting to locate or observe the dog if this is not immediately feasible.