Does a patient with scratches on the abdomen from a dog require rabies Immunoglobulin (IG) and rabies vaccine?

Dog Scratches and Rabies Post-Exposure Prophylaxis

For scratches on the abdomen from a dog, both rabies immune globulin (RIG) and rabies vaccine are indicated if the dog cannot be observed for 10 days, is unavailable, has unknown vaccination status, or shows any signs of illness. 1, 2

Immediate Wound Management

• Wash all scratches immediately and thoroughly with soap and water for approximately 15 minutes, as this is the single most important intervention for preventing rabies transmission. 3, 1, 4
• After soap and water cleansing, irrigate the scratches with povidone-iodine solution or another virucidal agent if available. 3, 1
• Administer tetanus prophylaxis as indicated based on the patient's immunization history. 3, 1

Risk Assessment: The 10-Day Observation Rule

The critical decision point is whether the dog can be confined and observed for 10 days:

• If the dog is healthy, domestic, and available for observation: Confine and observe the dog for 10 days without initiating rabies prophylaxis. 3, 1, 2

  • A dog that remains healthy for the full 10 days would not have been shedding rabies virus at the time of the scratch and therefore was not infectious. 3, 1
  • This observation must be prospective (not retrospective) to be valid. 2

• Initiate immediate rabies prophylaxis if any of the following apply:

  • The dog is stray, unwanted, or unavailable for observation 3, 1, 2
  • The dog's vaccination status is unknown or not current 3, 2
  • The dog shows any signs of illness during the observation period 3, 1
  • The dog dies or is euthanized before completing the 10-day observation 1, 2
  • The exposure occurred in a canine rabies-endemic area 2
  • The attack was unprovoked (more likely to indicate rabies) 3

Rabies Post-Exposure Prophylaxis Protocol

For previously unvaccinated persons requiring prophylaxis, administer BOTH rabies immune globulin and vaccine:

Rabies Immune Globulin (RIG)

• Dose: 20 IU/kg body weight, given once on day 0 3, 1, 5
• Administration: Infiltrate the full calculated dose into and around the scratch wounds if anatomically feasible; inject any remaining volume intramuscularly at a site distant from vaccine administration 3, 5
• Timing: Must be given within 7 days of the first vaccine dose; beyond day 7, RIG is not indicated as antibody response to vaccine is presumed to have occurred 3, 5
• Critical warning: Never exceed the recommended dose, as excess RIG can suppress active antibody production 3, 1
• Never administer RIG in the same syringe or anatomical site as the vaccine 3

Rabies Vaccine

• Regimen: Five 1-mL doses administered intramuscularly on days 0,3,7,14, and 28 3, 1, 6
• Site: Deltoid area for adults; anterolateral thigh is acceptable for children 3
• Never use the gluteal area for vaccine administration 3

For Previously Vaccinated Persons

• Administer only 2 doses of vaccine (days 0 and 3) without RIG if the person has previously received a complete rabies vaccination series with documented adequate antibody response. 2, 6

Critical Pitfalls to Avoid

• Do not delay wound cleansing – this is the first and most important intervention, even before deciding on prophylaxis. 1
• Do not initiate unnecessary prophylaxis for healthy domestic dogs that can be observed – this wastes resources and exposes patients to unnecessary treatment. 1
• Do not fail to infiltrate RIG into the scratch wounds – studies show that only 56% of eligible patients receive proper wound infiltration, yet this is critical for treatment efficacy. 7
• Do not assume scratches are lower risk than bites – CDC and WHO guidelines explicitly state that the combination of RIG and vaccine is recommended for both bite and nonbite exposures (including scratches). 3, 5
• Do not wait for laboratory confirmation if the dog is unavailable – treatment is a medical urgency and should begin immediately when indicated. 3

Special Considerations

• Scratches constitute nonbite exposures when contaminated with saliva or potentially infectious material; if the material is dry, the virus is considered noninfectious. 5
• The vaccination status of the dog matters: a dog with continuously current vaccination history is unlikely to become infected with rabies, though rare cases have been reported. 3, 1
• Post-exposure prophylaxis should be administered "regardless of the length of delay" after exposure, provided clinical signs of rabies are not present in the exposed person. 3, 2