Complete Rabies Vaccination Series for Immunocompetent Patients
For an immunocompetent patient after a dog bite who has never been vaccinated against rabies, a complete series consists of 4 doses of rabies vaccine administered intramuscularly on days 0,3,7, and 14, plus rabies immune globulin (RIG) at 20 IU/kg given on day 0. 1, 2, 3
Components of a Complete Series
Vaccine Dosing Schedule
- 4 intramuscular doses of 1.0 mL each of HDCV (human diploid cell vaccine) or PCECV (purified chick embryo cell vaccine) 1, 2, 4
- Administered on days 0,3,7, and 14 (day 0 is the day the first dose is given, not necessarily the exposure date) 1, 2, 3
- Inject in the deltoid muscle for adults and older children 1, 2, 4
- Use the anterolateral thigh for young children 1, 2, 4
- Never use the gluteal area as this produces inadequate antibody response and has been associated with vaccine failures 1, 2, 4
Rabies Immune Globulin (RIG)
- 20 IU/kg body weight administered once on day 0 1, 2, 3
- Infiltrate the full calculated dose around and into the wound(s) if anatomically feasible 1, 2, 3
- Any remaining volume is injected intramuscularly at a site distant from vaccine administration 1, 2, 3
- Do not administer RIG in the same syringe or at the same anatomic site as the first vaccine dose 1, 2, 3
- RIG can be given up to and including day 7 if initially missed, but not after day 7 as it may suppress active antibody production 1, 5
Immediate Wound Care
- Thoroughly wash all wounds with soap and water for 15 minutes before administering biologicals 2, 3
- This single intervention is perhaps the most effective measure for preventing rabies infection 2, 3
Key Distinctions for Different Patient Populations
Previously Vaccinated Persons
- Require only 2 doses of vaccine on days 0 and 3 1, 2, 3
- Do NOT receive RIG as it will inhibit the anamnestic immune response 1, 2, 3
- This applies to anyone who completed a recommended pre-exposure or post-exposure vaccination series with cell culture vaccine 1, 2
Immunocompromised Patients
- Require a 5-dose regimen (days 0,3,7,14, and 28) plus RIG at 20 IU/kg, even if previously vaccinated 1, 2, 3
- Corticosteroids, immunosuppressive agents, antimalarials, and immunosuppressive illnesses substantially reduce vaccine response 1, 2
- Mandatory serologic testing 1-2 weeks after the final dose to confirm adequate antibody response (≥0.5 IU/mL or complete virus neutralization at 1:5 dilution by RFFIT) 1, 2
Evidence Supporting the 4-Dose Regimen
The reduction from the older 5-dose regimen to the current 4-dose schedule is supported by strong evidence:
- The Advisory Committee on Immunization Practices revised recommendations in 2010 to eliminate the day 28 dose for immunocompetent patients 1
- Research demonstrates that the 4-dose regimen is clinically safe and immunogenic, with 100% seroprotection rates from day 14 through day 180 6
- When administered with proper wound care and RIG, this protocol is nearly 100% effective when given promptly 2, 3
- Over 1,000 persons annually in the United States receive only 3-4 doses with no documented cases of rabies developing, even when exposed to confirmed rabid animals 2
Critical Timing Considerations
- Initiate PEP as soon as possible after exposure—delays of even hours matter significantly 2, 3
- There is no absolute cutoff beyond which PEP should be withheld; treatment should begin immediately upon recognition of exposure, even if weeks or months have elapsed 2, 3
- Rabies is nearly 100% fatal once clinical symptoms develop 2, 3
Common Pitfalls to Avoid
- Never administer vaccine in the gluteal area—this is associated with vaccine failure 1, 2, 4
- Never give RIG to previously vaccinated persons—this suppresses the memory immune response 1, 2, 3
- Do not exceed 20 IU/kg of RIG—higher doses suppress active antibody production 2, 3
- Do not routinely test antibody titers in healthy immunocompetent patients after completing PEP—all healthy persons demonstrate adequate response 1, 2