What is the recommended rabies (Rabies virus) post-exposure prophylaxis for a healthy individual with no significant medical history after a cat bite?

Rabies Post-Exposure Prophylaxis for Cat Bite

For a healthy individual bitten by a cat, immediately confine and observe the cat for 10 days if it is healthy and available; do not start rabies post-exposure prophylaxis during this observation period unless the animal develops signs of rabies. 1, 2, 3

Initial Wound Management (Perform Immediately)

• Thoroughly wash and flush the bite wound with soap and water for 15 minutes, as this is the single most effective measure for preventing rabies transmission 2, 3
• Apply povidone-iodine solution after soap and water cleansing 2
• Administer tetanus prophylaxis as indicated 2, 3, 4
• Address bacterial infection risk, particularly Pasteurella multocida which is isolated in over half of cat bite wounds; consider amoxicillin-clavulanate for outpatient treatment 4

Decision Algorithm for Rabies PEP

If the Cat is Healthy and Available for Observation:

• Confine the cat and observe for 10 days 1, 2, 3
• Do NOT initiate rabies vaccine or immune globulin during the observation period 1, 3
• Have a veterinarian evaluate the cat at the first sign of illness during confinement 1
• Begin PEP immediately at the first sign of rabies in the cat 3
• If the cat remains healthy for the full 10 days, it was not shedding rabies virus at the time of the bite and PEP is not needed 2, 3

If the Cat is Stray, Unwanted, or Cannot be Confined:

• Immediately initiate rabies PEP without waiting 5, 2, 3
• The cat may be euthanized immediately and its brain submitted for rabies testing 1, 3
• If laboratory testing confirms the cat is negative for rabies, discontinue PEP immediately 2

If the Cat Dies or is Killed Before Completing 10-Day Observation:

• Immediately initiate rabies PEP because the observation period cannot be completed 6
• The observation period is prospective, not retrospective—the animal must remain alive and healthy throughout the full 10 days 6

Complete PEP Regimen (For Previously Unvaccinated Individuals)

When PEP is indicated, administer both passive and active immunization:

Rabies Immune Globulin (RIG):

• Administer 20 IU/kg body weight on day 0 only 5, 2, 3
• Infiltrate as much as anatomically feasible around and into the wound(s) 5, 3
• Inject any remaining volume intramuscularly at a site distant from the vaccine injection 3
• Do NOT exceed the recommended dose, as excess RIG can suppress active antibody production 2
• Do NOT administer RIG and vaccine at the same anatomical site 2

Rabies Vaccine:

• Administer 4 doses on days 0,3,7, and 14 using either human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV), 1.0 mL intramuscularly 5
• The 4-dose schedule is the current CDC recommendation and saves approximately $16.6 million annually compared to the previous 5-dose regimen 5

For Previously Vaccinated Individuals:

• Administer vaccine only (no RIG)—2 doses on days 0 and 3 2, 3
• This applies to individuals with documented prior complete rabies vaccination series 2, 3

Geographic and Epidemiologic Context

• In the United States, more cats than dogs were reported rabid between 2000-2006, primarily due to lower vaccination rates in cats and their exposure to wildlife reservoirs like raccoons 2
• The median risk of rabies transmission from a cat bite without PEP is estimated at 0.001 (1 in 1,000) 7
• Cat bites in developing countries of Asia, Africa, and Latin America warrant heightened concern due to higher regional rabies prevalence 2
• Unprovoked attacks are more likely to indicate rabies than provoked attacks 2

Critical Pitfalls to Avoid

• Never delay wound cleansing—this is your first and most important intervention 2
• Do not initiate unnecessary PEP for healthy domestic cats that can be observed, as this wastes resources (approximately $2.9 million per life saved) and exposes patients to unnecessary treatment 5, 2
• Do not assume vaccination status alone eliminates risk, as even vaccinated cats can rarely develop rabies, though this is extremely uncommon 2
• Do not withhold PEP if the animal cannot be tested or observed, regardless of apparent health at time of bite 5
• Consult local or state health departments for region-specific rabies epidemiology and guidance 2, 3

Timing Considerations

• PEP should be administered regardless of the length of delay, as long as the exposed person shows no clinical signs of rabies 5, 6
• Rabies incubation periods exceeding 1 year have been documented in humans, making delayed treatment still effective 6
• PEP is considered a "medical urgency, not a medical emergency"—it should be done as soon as possible but is not too late to administer even after delays 6