What is the management protocol for a patient suspected of having been exposed to rabies, considering their vaccination status and medical history?

Rabies Infection Management

Immediate Wound Care is Critical

The most important initial step is immediate and thorough wound cleansing with soap and water for at least 15 minutes, as this single intervention markedly reduces rabies transmission risk even before any immunologic intervention. 1, 2

• Gently irrigate with water or dilute povidone-iodine solution, taking care not to damage skin or tissues 1, 2
• Avoid suturing wounds when possible to allow drainage, particularly for puncture wounds, hand wounds, and high-risk bites 2, 3
• Explore wounds for nerve or tendon laceration and foreign bodies 2
• Administer tetanus prophylaxis as indicated 1, 3
• Consider antibiotic prophylaxis, particularly if presentation is delayed >8-12 hours 2, 4

Risk Assessment Determines Prophylaxis Strategy

High-Risk Exposures Requiring Immediate Prophylaxis

Wild carnivores (raccoons, skunks, foxes), bats, primates, and unvaccinated/stray domestic animals require immediate rabies prophylaxis without waiting for observation or testing results. 2, 3, 5

• Any bat contact where bite or scratch cannot be excluded warrants prophylaxis, as bat bites may be minor and undetected 1, 5
• Unprovoked attacks are more likely to indicate rabid animals than provoked attacks 1

Lower-Risk Exposures

• Healthy dogs, cats, or ferrets with current vaccination history can be observed for 10 days; if the animal remains healthy, prophylaxis is unnecessary 1, 5
• Small rodents (squirrels, rats, mice, hamsters) and lagomorphs (rabbits, hares) rarely transmit rabies; consult local health department before initiating prophylaxis 5

Exposure Types

• Bite exposures: Any penetration of skin by teeth constitutes potential rabies exposure 1
• Nonbite exposures: Contamination of open wounds, abrasions, or mucous membranes with saliva or neural tissue from rabid animals warrants prophylaxis 1
• No exposure: Petting a rabid animal or contact with blood, urine, or feces does not constitute exposure and does not require prophylaxis 1

Postexposure Prophylaxis Protocol

For Previously Unvaccinated Persons

Administer both human rabies immune globulin (HRIG) 20 IU/kg and rabies vaccine simultaneously on day 0 at different anatomical sites. 1, 2, 6, 5

HRIG Administration

• Dose: 20 IU/kg body weight for all ages, including children 1, 6
• Infiltrate the full HRIG dose around and into the wound if anatomically feasible; inject any remaining volume intramuscularly at a distant site from vaccine administration 1, 2, 6
• Never exceed the recommended dose, as excess HRIG suppresses active antibody production 1, 6
• HRIG is administered only once at the beginning of prophylaxis 1
• If HRIG was not given on day 0, it can be administered up to and including day 7 of the vaccine series 1, 2, 6
• Never administer HRIG after day 7, as it interferes with active immunity 1, 2, 3
• Never administer HRIG in the same syringe or anatomical site as vaccine 1, 6

Rabies Vaccine Regimen

• Five 1.0-mL doses administered intramuscularly on days 0,3,7,14, and 28 1, 2, 6
• Administer in the deltoid area for adults; anterolateral thigh is acceptable for children 1
• Never use the gluteal area for vaccine administration 1
• Available vaccines: HDCV (human diploid cell vaccine), PCECV (purified chick embryo cell vaccine), or RVA (rabies vaccine adsorbed) 1

For Previously Vaccinated Persons

Previously vaccinated persons require only 2 doses of vaccine (1.0 mL each) on days 0 and 3; HRIG is unnecessary and should not be administered. 1

• Previously vaccinated persons are those who completed a recommended preexposure or postexposure regimen with cell culture vaccine or have documented rabies antibody titer 1
• RIG is contraindicated because it may inhibit the anamnestic antibody response 1

Critical Timing Considerations

Rabies postexposure prophylaxis is a medical urgency, not a medical emergency, but decisions must not be delayed. 1

• Initiate prophylaxis as soon as possible, ideally within 24 hours of exposure 3
• Postexposure prophylaxis should be administered regardless of time elapsed since exposure, provided clinical signs of rabies are not present 1, 2
• Incubation periods exceeding 1 year have been documented in humans 1
• Once clinical rabies develops, postexposure prophylaxis is consistently ineffective and mortality is nearly 100% 3, 7, 8

Special Populations

Immunosuppressed Patients

• Immunosuppressed persons should postpone preexposure vaccination when possible 1
• If postexposure prophylaxis is required, administer full regimen and check antibody titers 1
• Consult public health officials for management of failures to seroconvert 1

Preexposure Prophylaxis

• Indicated for high-risk groups: laboratory workers handling rabies virus, veterinarians, animal control officers, spelunkers, and international travelers to enzootic areas 1, 6
• Regimen: Three 1.0-mL doses on days 0,7, and 21 or 28 1, 6
• Routine serologic testing after vaccination is unnecessary for immunocompetent persons 1

Common Pitfalls to Avoid

• Never delay prophylaxis waiting for animal testing results if the animal is high-risk, unavailable, or cannot be observed 2, 3, 4
• Never administer HRIG after day 7 of the vaccine series 1, 2, 3
• Never exceed the recommended HRIG dose (20 IU/kg), as excess suppresses vaccine response 1, 6
• Do not withhold prophylaxis based on time elapsed since exposure unless clinical rabies is present 1, 2
• Do not suture high-risk wounds (puncture wounds, hand bites, cat bites), as this increases infection risk 2
• Do not administer HRIG to previously vaccinated persons, as it inhibits anamnestic response 1
• Prophylaxis can be discontinued only if laboratory testing (direct fluorescent antibody test) confirms the animal was not rabid 2, 3

Reporting and Consultation

• Report all suspected rabies exposures to local or state health departments immediately 1, 3, 4
• Consult public health officials when questions arise about need for prophylaxis 1
• Wild animals suspected of rabies should be euthanized and submitted for laboratory examination when possible 1, 5