Rabies Post-Exposure Prophylaxis for Previously Vaccinated Patients
A patient who completed all 4 doses of intramuscular rabies vaccine plus immunoglobulin for a Category 3 bite is considered "previously vaccinated" and should receive only 2 doses of rabies vaccine (on days 0 and 3) for any subsequent exposure, with NO rabies immunoglobulin administered. 1
Critical Definition: Previously Vaccinated Status
Your patient qualifies as "previously vaccinated" because they completed the full 4-dose post-exposure prophylaxis series. 1 This status applies to anyone who has received one of the ACIP-recommended pre- or post-exposure prophylaxis regimens with cell-culture vaccines. 1
Simplified Re-Exposure Regimen
For this subsequent Category 3 exposure, administer:
- Two 1.0 mL intramuscular vaccine doses only - first dose immediately (day 0) and second dose on day 3 1, 2
- Inject in the deltoid muscle for adults and older children, or anterolateral thigh for young children 1
- Do NOT administer rabies immunoglobulin (RIG) - this is critical, as RIG will suppress the anamnestic immune response that previously vaccinated persons mount rapidly 1, 2
Why No Immunoglobulin?
The guideline explicitly states that RIG should not be administered to previously vaccinated persons to avoid inhibiting the relative strength or rapidity of the expected anamnestic (memory) response. 1 Previously vaccinated individuals have immunologic memory and will rapidly produce protective antibodies after just 2 booster doses. 1, 2
Essential Wound Care
- Immediately wash all wounds thoroughly with soap and water for 15 minutes - this single intervention is the most effective measure for preventing rabies infection 2, 3
- Follow with povidone-iodine irrigation if available 2, 3
Critical Pitfall to Avoid
Do not give the full 4-dose series plus RIG to a previously vaccinated person. 1, 2 This is a common error that wastes resources and, more importantly, the RIG will actually suppress the patient's robust memory immune response. 1
Exception: Immunocompromised Patients
If your patient is immunocompromised (on corticosteroids, other immunosuppressive agents, has HIV, or chronic lymphoproliferative disorders), upgrade to the full 5-dose regimen (days 0,3,7,14,28) plus RIG at 20 IU/kg, even though they were previously vaccinated. 2, 3 Obtain serologic testing 7-14 days after the final dose to confirm adequate antibody response. 2, 3
Timing Considerations
- Initiate treatment as soon as possible after the new exposure - ideally within 24 hours, though treatment should begin immediately upon recognition even if delayed 3
- Each new exposure must be treated independently - the fact that they completed prior vaccination does not mean they can skip treatment for new exposures 2, 4
No Routine Serologic Testing Needed
Routine post-vaccination antibody testing is unnecessary in healthy, immunocompetent patients who complete this 2-dose booster regimen. 1 All healthy persons demonstrate adequate antibody response after the recommended regimen. 1