What is the appropriate workup and treatment for a patient suspected of being exposed to rabies?

Rabies Workup and Management After Suspected Exposure

For any patient with suspected rabies exposure, immediately wash the wound thoroughly with soap and water for 15 minutes, then determine if postexposure prophylaxis (PEP) is indicated based on exposure type, animal species, and availability for observation. 1

Immediate Wound Management

• Thoroughly irrigate all bite wounds and scratches with soap and copious water for at least 15 minutes as this single intervention markedly reduces rabies transmission risk in animal studies. 1, 2, 3
• Apply a povidone-iodine solution or other virucidal agent to the wound after washing. 1, 3
• Assess for tetanus prophylaxis needs and administer if the patient has not been vaccinated within 10 years. 2, 3
• Consider antibiotic prophylaxis with amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days if the patient is immunocompromised, has advanced liver disease, or has deep wounds near joints or bones. 2

Exposure Risk Assessment

Define the Exposure Type

Bite exposures: Any penetration of skin by teeth, regardless of severity or location, constitutes a potential rabies risk. 1, 3

Nonbite exposures: Scratches, abrasions, open wounds, or mucous membranes contaminated with saliva or neural tissue from a potentially rabid animal warrant consideration for PEP. 1, 3

Non-exposures: Petting an animal, contact with blood/urine/feces, or saliva contact with intact skin do NOT require PEP. 3

Animal Species and Observation Protocol

Domestic dogs, cats, and ferrets:

• If the animal is healthy and available, confine and observe for 10 days without initiating PEP. 1, 2, 3
• A healthy animal that remains asymptomatic for 10 days could not have been shedding rabies virus at the time of the bite. 2
• Begin PEP immediately only if the animal develops signs of rabies during observation (behavioral changes, paralysis, excessive salivation, aggression, neurological signs). 2, 3
• If the animal is stray, unwanted, or cannot be observed, euthanize immediately and submit the head for rabies testing while initiating PEP. 1, 3

Bats:

• Consider any physical contact with a bat as a potential exposure when bite, scratch, or mucous membrane contact cannot be excluded, as bat bites may be minor and unrecognized. 3
• Initiate PEP immediately unless the bat is available for testing and tests negative. 3

Wild carnivores (raccoons, skunks, foxes):

• Regard as rabid unless proven negative by laboratory testing. 3
• Initiate PEP immediately unless the animal is available for expeditious testing or has already tested negative. 3

Small rodents and lagomorphs:

• Bites from squirrels, hamsters, guinea pigs, gerbils, chipmunks, rats, mice, rabbits, and hares almost never require PEP. 3
• Consult local public health officials before deciding on prophylaxis. 3

Postexposure Prophylaxis Regimen

For Previously UNVACCINATED Persons

Administer both rabies immune globulin (RIG) AND vaccine on day 0 at different anatomical sites: 1, 3

• RIG dose: 20 IU/kg body weight administered once on day 0. 4, 3
• Infiltrate the full calculated RIG dose around and into the wound(s) if anatomically feasible, with any remaining volume injected intramuscularly at a site distant from vaccine administration. 2, 3
• Never administer RIG in the same syringe or at the same anatomical site as the vaccine. 2
• If RIG was not given on day 0, it can still be administered up to and including day 7 of the vaccine series, but NOT after day 7. 3

Vaccine schedule: Administer 1.0 mL intramuscularly on days 0,3,7, and 14 (4-dose series). 1, 2

For Previously VACCINATED Persons

Administer ONLY vaccine (two doses on days 0 and 3) without RIG: 1, 5

• Previously vaccinated persons are those who completed a recommended preexposure or postexposure regimen with a cell culture vaccine (HDCV, RVA, or PCEC) or have documented rabies antibody titers. 1
• Do NOT give RIG to previously vaccinated persons as it will suppress the anamnestic antibody response. 1, 5

Critical Timing Considerations

• Rabies PEP is a medical urgency, not a medical emergency. 1
• Consult local or state public health officials immediately to determine the need for prophylaxis based on regional rabies epidemiology. 1, 3
• Incubation periods exceeding 1 year have been documented, so PEP remains indicated regardless of delay, provided clinical rabies symptoms are not present. 1, 2
• Do not delay PEP while waiting for animal testing results if the animal is confirmed rabid, high-risk, or unavailable for observation. 4, 3

Follow-Up and Monitoring

• Evaluate all patients within 48-72 hours to assess for signs of wound infection and healing progress. 2
• For immunocompromised patients, consider serologic testing after completing the vaccine series to confirm adequate antibody response. 1
• Report all suspected rabies exposures to the local health department. 4

Common Pitfalls to Avoid

• Never withhold PEP in previously unvaccinated persons while waiting for the 10-day animal observation period if the animal is unavailable, shows signs of illness, or is a high-risk species (bat, wild carnivore). 2, 3
• Never administer RIG after day 7 of the vaccine series. 4, 3
• Never give RIG to previously vaccinated persons. 1, 5
• Do not assume intact skin exposure (e.g., lick without visible break) requires PEP unless careful examination reveals microscopic breaks, abrasions, or compromised skin integrity. 2

Management of Clinical Rabies

If clinical rabies develops (extremely rare with appropriate PEP), rabies is not considered curable and treatment focuses on comfort care and adequate sedation in an appropriate medical facility. 1

• Rapid antemortem diagnosis is a priority using saliva, serum, skin biopsy, and cerebrospinal fluid testing. 1
• Experimental therapies may be considered in young healthy persons at early stages after informed consent, but treatment failure is highly probable and survivors often have significant neurologic deficits. 1
• Healthcare workers caring for rabies patients should use standard precautions (gowns, goggles, masks, gloves), particularly during intubation and suctioning. 1
• PEP for healthcare workers is indicated only if the patient bites them or their mucous membranes/nonintact skin contacts the patient's saliva or neural tissue. 1