What is the recommended treatment for a patient exposed to an animal that may be carrying the rabies virus?

Rabies Post-Exposure Management

For a patient exposed to an animal that may carry rabies, immediately provide thorough wound cleansing followed by both rabies immune globulin (RIG) and a 4-dose rabies vaccine series (days 0,3,7,14) if previously unvaccinated, or vaccine alone (2 doses on days 0 and 3) if previously vaccinated. 1, 2, 3

Immediate Wound Management (Critical First Step)

Thoroughly wash and flush the wound with soap and water for approximately 15 minutes immediately—this single intervention markedly reduces rabies transmission risk even without other prophylaxis. 1, 3

• Apply povidone-iodine solution or other virucidal agent to the wound after cleansing 1, 3
• Avoid suturing puncture wounds when possible to prevent trapping virus in deeper tissues 1, 3
• Administer tetanus prophylaxis based on vaccination history 1, 4
• Consider antibiotic prophylaxis given contamination risk, particularly for cat bites which have high infection rates 1, 5

Post-Exposure Prophylaxis Protocol

For Previously UNVACCINATED Patients

Both passive and active immunization are essential: rabies immune globulin (RIG) PLUS rabies vaccine. 1, 3

Rabies Immune Globulin (RIG)

• Administer 20 IU/kg body weight on day 0 1, 3
• Infiltrate the full dose thoroughly into and around the wound site—inadequate wound infiltration has been associated with rare prophylaxis failures 1, 3
• Any remaining volume after wound infiltration should be injected intramuscularly at a site distant from vaccine administration 1, 3
• RIG can be administered up to day 7 if not given initially, but should ideally be given immediately 1, 3
• Do NOT exceed the recommended 20 IU/kg dose, as this can suppress active antibody production 1, 3

Rabies Vaccine (Updated 4-Dose Schedule)

• Administer 4 doses of rabies vaccine (HDCV or PCECV) intramuscularly on days 0,3,7, and 14 2, 1
• Give vaccine in the deltoid area for adults (anterolateral thigh for children)—never use the gluteal area, which reduces immunogenicity 1, 4
• Administer vaccine at a different anatomical site than the RIG—never in the same syringe or anatomical location 1, 3

Important Note: The 4-dose schedule (days 0,3,7,14) replaced the older 5-dose regimen (days 0,3,7,14,28) based on strong evidence showing equivalent efficacy with reduced doses. 2

For Previously VACCINATED Patients

Administer ONLY vaccine—do NOT give RIG, as it can suppress the anamnestic antibody response. 5, 3

• Give 2 doses of rabies vaccine on days 0 and 3 5, 3
• Inject in the deltoid area (never gluteal) 5, 4
• Previously vaccinated persons have immunological memory and do not need passive immunization 5, 3

Exception: Immunocompromised patients require the full 5-dose schedule (days 0,3,7,14,28) even with prior vaccination history, plus serologic testing to confirm adequate antibody response. 5

Animal-Specific Management Decisions

Dogs, Cats, and Ferrets

• If the animal is healthy and available: confine and observe daily for 10 days from the time of exposure 2, 4
• Do NOT administer rabies vaccine to the animal during observation to prevent confusion between rabies signs and vaccine reactions 2
• If the animal develops signs suggestive of rabies during observation, immediately euthanize and submit the head for testing 2
• If the animal is a stray or unwanted and unavailable: begin immediate prophylaxis without delay 1, 4
• Rabies virus is excreted in saliva of infected dogs, cats, and ferrets only during illness and/or for a few days before illness or death 2

Wildlife (Bats, Raccoons, Skunks, Foxes, Coyotes)

• Regard as rabid unless proven negative by laboratory testing 4
• Begin immediate prophylaxis as soon as possible following exposure 2, 4
• For bat exposures specifically: consider prophylaxis for ANY physical contact when bite, scratch, or mucous membrane contact cannot be excluded, as bat bites may be minor and difficult to recognize 3, 4

Small Rodents and Lagomorphs

• Squirrels, hamsters, guinea pigs, gerbils, chipmunks, rats, mice, rabbits, and hares almost never require prophylaxis 4
• Consult state or local health department before initiating prophylaxis 2, 4

Critical Timing Considerations

Rabies post-exposure prophylaxis is a medical urgency—begin as soon as possible after exposure. 1, 3, 6

• Treatment can be discontinued if the animal is later proven negative by laboratory testing 1, 4
• Even delays of months do not preclude prophylaxis if clinical rabies signs are absent, as incubation periods exceeding 1 year have been documented 1, 3
• Once clinical manifestations develop, rabies is nearly 100% fatal with no effective treatment available 6, 7, 8
• Prompt prophylaxis combining wound care, RIG, and vaccine is nearly 100% effective in preventing human rabies 2, 6, 7

Common Pitfalls to Avoid

• Do NOT delay prophylaxis while attempting to locate an escaped animal—begin treatment immediately 1
• Do NOT rely on the animal's healthy appearance—rabid animals may appear normal early in infection 1, 3
• Do NOT fail to infiltrate RIG directly into the wound—this is associated with prophylaxis failures 1, 3
• Do NOT administer RIG to previously vaccinated patients—it suppresses their anamnestic response 5, 3
• Do NOT use the 5-dose schedule for previously vaccinated immunocompetent patients—only 2 doses are needed 5, 3
• Do NOT inject vaccine in the gluteal area—use deltoid only, as gluteal injection reduces immunogenicity 1, 5, 4

Regional Epidemiology Context

• In the United States, more rabies cases are reported annually in cats (281 in 2004) than dogs (94 in 2004), making cat exposures particularly concerning 2
• Stray cats represent a significant rabies risk, particularly in areas with wildlife rabies epizootics 1
• Bats are increasingly implicated as important wildlife reservoirs for rabies virus variants transmitted to humans 3, 4
• In most of Asia, Africa, and Latin America, dogs remain the major source of human rabies exposure 9