What treatment should be given to a fully vaccinated individual who has been scratched by a stray cat?

Management of Cat Scratch in a Fully Vaccinated Individual

For a fully vaccinated person scratched by a stray cat, immediately wash the wound thoroughly with soap and water for 15 minutes, assess tetanus status, and do NOT initiate rabies post-exposure prophylaxis unless the cat develops signs of rabies during a 10-day observation period or cannot be confined for observation. 1

Immediate Wound Management

• Thoroughly wash the scratch with soap and water for 15 minutes immediately - this is the single most effective measure for preventing rabies and markedly reduces infection risk. 1
• Apply povidone-iodine solution or similar virucidal agent to the wound site after soap and water cleansing to further reduce viral transmission risk. 1
• Examine the wound for depth and assess whether deeper structures are involved. 1

Tetanus Prophylaxis Assessment

• Assess the patient's tetanus immunization status and administer tetanus toxoid if the vaccination history is unknown, incomplete, or the last dose was more than 5-10 years ago (depending on wound characteristics). 1, 2

Rabies Risk Assessment and Decision Algorithm

The critical decision point is whether the cat can be confined and observed:

If the cat is available and can be confined:

• Confine and observe the cat for 10 days without initiating rabies prophylaxis. 2
• If the cat remains healthy for the full 10-day observation period, no rabies prophylaxis is needed. 3
• If the cat dies, develops illness, or shows signs suggestive of rabies during observation, immediately initiate rabies post-exposure prophylaxis. 2

If the cat is stray/unwanted and cannot be confined:

• Immediately initiate rabies post-exposure prophylaxis. 1, 2

Rabies Post-Exposure Prophylaxis for Previously Vaccinated Persons

Since the patient is fully vaccinated against rabies, they should receive ONLY rabies vaccine booster doses - NOT rabies immune globulin (RIG). 4

The key distinction here is critical: previously vaccinated persons have a fundamentally different prophylaxis regimen:

• Administer rabies vaccine on days 0 and 3 only (2-dose schedule). 1
• Do NOT administer rabies immune globulin (RIG/HRIG) - RIG is only for previously unvaccinated persons. 4
• Administer vaccine intramuscularly in the deltoid area (adults) or anterolateral thigh (children) - never in the gluteal area as this results in lower antibody titers. 1

For Previously Unvaccinated Persons (for comparison):

If the patient were NOT previously vaccinated, they would require both HRIG (20 IU/kg body weight) and a 4-5 dose vaccine series on days 0,3,7, and 14 (or 28). 1

Antibiotic Prophylaxis Considerations

• Consider antibiotic prophylaxis with amoxicillin-clavulanate only if the scratch is deep or shows signs of infection, as cat scratches carry risk of Bartonella henselae (cat-scratch disease) and bacterial infection. 1
• For penicillin-allergic patients, alternatives include doxycycline, a fluoroquinolone plus an agent active against anaerobes, or clindamycin plus a fluoroquinolone. 3

Critical Timing Considerations

• Begin treatment immediately after exposure (within 24 hours ideally), though even delayed treatment is indicated as rabies incubation periods exceeding 1 year have been documented. 1
• If rabies prophylaxis is indicated but not initiated immediately, it should still be given regardless of delay, provided clinical signs of rabies are not present. 4

Common Pitfalls to Avoid

• Never administer RIG to previously vaccinated persons - this is unnecessary and can suppress active antibody production. 4
• Do not inject rabies vaccine in the gluteal area, as this results in lower neutralizing antibody titers. 1
• Never delay wound cleansing, as thorough wound cleansing alone has been shown to markedly reduce rabies likelihood in animal studies. 2
• Do not initiate unnecessary post-exposure prophylaxis for healthy cats that can be observed for 10 days. 2

Risk Assessment Factors

• Unprovoked attacks are more likely to indicate rabies than provoked attacks (scratches during feeding or handling an apparently healthy animal are generally considered provoked). 2, 4
• A fully vaccinated cat is unlikely to become infected with rabies, though rare cases have been reported. 4
• More cats than dogs are reported rabid in the United States, with the majority associated with raccoon rabies epizootics in the eastern US. 2