Is rabies a high risk for a 59-year-old male patient with a history of Acquired Immune Deficiency Syndrome (AIDS) who was bitten/scratched by a stray cat with unknown vaccine status on the face, currently being treated with doxycycline due to an allergy to penicillin?

Rabies Risk Assessment and Management for Cat Bite/Scratch

For this stray cat bite/scratch with unknown vaccine status, rabies is NOT considered high risk in most of the United States, but you should attempt to confine and observe the cat for 10 days OR initiate rabies post-exposure prophylaxis (PEP) immediately if the cat cannot be captured. 1

Immediate Wound Management (Critical First Step)

• Thoroughly wash and flush the wound with soap and water for approximately 15 minutes immediately - this alone can markedly reduce rabies transmission risk 2, 1
• Irrigate with a virucidal agent such as povidone-iodine solution after washing 1, 3
• Your doxycycline for bacterial infection prophylaxis is appropriate given the penicillin allergy 3

Rabies Risk Assessment for Cats

• Cats actually have HIGHER rabies rates than dogs in the United States - during 2000-2006, more cats than dogs were reported rabid, primarily associated with raccoon rabies in the eastern US 1
• The high cat rabies rate is attributed to lower vaccination rates, fewer leash laws, and nocturnal roaming patterns that increase exposure to rabid wildlife (raccoons, skunks, foxes, bats) 1
• Regional epidemiology matters: rabies risk varies significantly by geographic location 1, 2

Decision Algorithm for This Stray Cat

Option 1 (Preferred if feasible):

• Attempt to capture/locate the stray cat and confine for 10-day observation 1
• Any illness during confinement should prompt immediate euthanasia and rabies testing 1
• If the cat remains healthy for 10 days, it was NOT shedding rabies virus at the time of the bite 1

Option 2 (If cat cannot be captured):

• Initiate rabies PEP immediately - this is the safer approach when the animal is unavailable for observation 1, 2
• The stray/unwanted status of this cat places it in higher risk category 1, 2

Rabies PEP Protocol (If Indicated)

• Rabies immune globulin (RIG) 20 IU/kg body weight on day 0 - infiltrate as much as possible into and around the wound site 2, 1
• Rabies vaccine series: days 0,3,7,14, and 28 1, 2, 3
• This is a medical urgency, not emergency, but should not be delayed once exposure is confirmed 1, 2

Special Considerations for AIDS Patient

• Your patient's immunocompromised status (AIDS) makes complete PEP even MORE critical 4
• A case report documented that T-cell immunosuppression in AIDS resulted in weak inflammatory response and unusually abundant viral multiplication in rabies encephalitis 4
• The patient should receive BOTH vaccine AND immunoglobulin (not just vaccine alone) given immunocompromised status 4
• Once clinical rabies develops, it is nearly 100% fatal even with treatment 5, 6

Urgent Care Plan

Immediate actions:

1. Contact local health department NOW to report the exposure and determine local rabies epidemiology 1
2. Attempt to locate/identify the cat through animal control 1
3. If cat cannot be located within hours, initiate RIG and first vaccine dose today 2
4. Ensure tetanus prophylaxis is current 3

Critical Pitfalls to Avoid

• Do NOT delay PEP initiation while attempting to locate an escaped stray cat - the immunocompromised status makes this especially dangerous 2, 4
• Failing to infiltrate RIG into the wound site reduces effectiveness 2
• The 10-day observation period is ONLY reliable for healthy domestic dogs, cats, and ferrets - not applicable if the cat appears ill 1, 2
• Inadequate wound cleansing increases transmission risk 2, 3

Bottom Line for Urgent Care

Given the stray status, unknown vaccine history, facial location (high-risk site with rich nerve supply), and patient's AIDS diagnosis, I would initiate rabies PEP immediately unless the cat can be captured and confined for observation within the next few hours. 1, 2, 4 Contact your local health department immediately for guidance and to coordinate animal control efforts. 1