Rabies Post-Exposure Prophylaxis After Puppy Bite Injury
If the puppy is healthy and available for observation, do not initiate rabies vaccination immediately—instead, confine and observe the puppy for 10 days, and only begin post-exposure prophylaxis if the animal develops signs of rabies during this period. 1, 2, 3
Immediate Assessment and Wound Management
Thoroughly wash the wound with soap and water for 15 minutes immediately, as this is the single most effective measure for preventing rabies infection and markedly reduces transmission risk in animal studies. 1, 3, 4
Any penetration of skin by teeth constitutes a bite exposure requiring evaluation, regardless of wound severity or location. 1, 3
Decision Algorithm for Rabies PEP
If the Puppy is Healthy and Available for 10-Day Observation:
Do NOT initiate rabies vaccine or immunoglobulin during the observation period. 1, 2, 3
The CDC recommends confining the puppy and observing it daily for 10 days without administering rabies biologics. 2, 3
A healthy domestic dog that remains alive and healthy for 10 days after biting would not have been shedding rabies virus in its saliva at the time of the bite. 1
Begin post-exposure prophylaxis only if the puppy develops signs suggestive of rabies during the 10-day observation period (behavioral changes, paralysis, excessive salivation, aggression, or other neurological signs). 1, 2, 3
If signs of rabies develop, the animal should be euthanized immediately and its head submitted for laboratory testing while simultaneously initiating PEP in the exposed person. 1, 2, 3
If the Puppy is Stray, Unwanted, or Cannot Be Observed:
Initiate rabies post-exposure prophylaxis immediately if the puppy cannot be confined for observation or if its vaccination status is unknown. 3
Consult local or state public health officials to determine regional rabies prevalence in dogs and guide decision-making. 1, 3
Complete PEP Regimen (If Indicated)
For Previously Unvaccinated Individuals:
Administer both human rabies immune globulin (HRIG) at 20 IU/kg body weight on day 0 AND a 4-dose vaccine series on days 0,3,7, and 14. 1, 5, 3
Infiltrate the full calculated dose of HRIG around and into the wound(s) if anatomically feasible, with any remaining volume injected intramuscularly at a site distant from vaccine administration. 1, 5
Administer 1.0 mL of rabies vaccine (HDCV or PCECV) intramuscularly in the deltoid muscle for adults. 1, 5
Never administer HRIG in the same syringe or at the same anatomical site as the vaccine. 1, 5
HRIG can be administered up to and including day 7 after the first vaccine dose if not given initially. 1, 3
For Previously Vaccinated Individuals:
- Administer only 2 doses of vaccine on days 0 and 3—do NOT give HRIG, as it will suppress the anamnestic antibody response. 1, 5
Additional Wound Management
Assess the need for tetanus prophylaxis if the patient has not received vaccination within the past 10 years, preferring Tdap over Td if not previously given. 2
Consider preemptive antimicrobial therapy (amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days) for moderate to severe injuries, immunocompromised patients, or wounds with high infection risk. 2
Schedule follow-up within 48-72 hours to assess for signs of infection and evaluate wound healing. 2
Critical Pitfalls to Avoid
Do not withhold PEP while waiting for the 10-day observation period to complete if the puppy is unavailable for observation or shows any signs of illness. 1, 3
The circumstance of the bite matters: bites during feeding attempts are generally considered provoked, but this should not influence the decision to observe the animal or initiate treatment if observation is impossible. 3
Even if the puppy appears healthy, if it cannot be confined and observed for the full 10 days, treat this as an unknown exposure requiring immediate PEP. 3
Regional rabies epidemiology varies significantly—in the United States, dog rabies is rare, but consultation with local health officials is essential for risk assessment. 1, 3