What is the appropriate treatment for a female patient with a history of non-compliance to her medication regimen for a pre-existing medical condition, who presents with a category 2 rabies exposure from a cat scratch, stable vital signs, elevated blood pressure, and an abrasion on her right arm?

Rabies Post-Exposure Prophylaxis for Category 2 Exposure

Primary Recommendation

Your proposed plan requires modification: HTIG (Human Tetanus Immune Globulin) is NOT indicated for rabies prophylaxis—you need HRIG (Human Rabies Immune Globulin) instead, and the stray cat status makes this a high-risk exposure requiring immediate full prophylaxis without waiting for observation. 1, 2

Correct Treatment Protocol

Immediate Wound Management

• The patient correctly washed with soap and water, but this should have been done for at least 15 minutes with thorough irrigation 1, 2
• Apply povidone-iodine solution after soap and water cleansing 1
• Avoid suturing the wound to prevent deeper contamination 2

Rabies Post-Exposure Prophylaxis (Category 2 Exposure)

For this stray cat with unknown vaccination status and unavailable for observation:

• HRIG (NOT HTIG): 20 IU/kg body weight on Day 0 1, 2

  • Infiltrate the full dose around and into the wound if anatomically feasible 1, 2
  • Any remaining volume should be injected intramuscularly at a site distant from the vaccine 2
  • Never administer HRIG in the same syringe or anatomical site as the rabies vaccine 2
  • Never administer HRIG after Day 7 of the vaccine series 1

• Human Rabies Vaccine: 1.0 mL IM (deltoid) on Days 0,3,7,14, and 28 1, 2

  • Administer simultaneously with HRIG on Day 0 at a different anatomical site 1, 2
  • Complete all 5 doses for previously unvaccinated persons 2

Tetanus Prophylaxis

• Tetanus Toxoid (TT) 0.5 mL IM now is appropriate 2
• Assess tetanus immunization status and administer booster if indicated 1

Critical Decision Algorithm

The key determinant is cat availability for observation:

• If cat is stray/unavailable (THIS CASE): Initiate immediate full rabies PEP (HRIG + vaccine series) without waiting 1, 3
• If cat is healthy and available: Confine and observe for 10 days without initiating prophylaxis; evaluate by veterinarian at first sign of illness 1, 3
• If cat develops signs of rabies during observation: Euthanize immediately, submit head for examination, and initiate full PEP 3

Risk Assessment Considerations

This exposure is high-risk because:

• Stray cats have unknown vaccination status and higher rabies risk than owned cats 1
• More cats than dogs are reported rabid in the United States 1
• The cat is unavailable for the required 10-day observation period 1, 3
• Category 2 exposure (scratch with abrasion) constitutes nonbite exposure requiring prophylaxis when the animal is high-risk 3

Common Pitfalls to Avoid

• Never confuse HTIG (tetanus) with HRIG (rabies)—these are completely different products 1, 2
• Never delay rabies prophylaxis waiting for animal testing results when the cat is unavailable 1
• Never exceed the recommended HRIG dose of 20 IU/kg 1, 2
• Never administer HRIG and vaccine in the same anatomical site 2
• Never give HRIG after Day 7 of the vaccine series, as antibody response has begun 2

Prophylaxis Discontinuation

Prophylaxis can only be discontinued if:

• Laboratory testing confirms the animal was not rabid, OR 1
• The cat remains healthy throughout the entire 10-day observation period 1, 3

Since this is a stray cat unavailable for observation, complete the full 5-dose vaccine series regardless of any subsequent information unless laboratory testing proves the cat was not rabid 1, 2

Management of Comorbidities

The patient's medication non-compliance and pre-existing medical condition do not contraindicate rabies prophylaxis—rabies PEP is a medical urgency and should proceed immediately 3, 2. The elevated blood pressure (180/90) should be monitored but does not delay treatment 3.