In a 4-year-old girl bitten by a newly adopted cat that is febrile and lethargic with no local erythema, what is the most appropriate next step in management?

Management of Cat Bite in a 4-Year-Old with Febrile, Lethargic Cat

Given that the newly adopted cat is febrile and lethargic—clinical signs highly suggestive of rabies—the most appropriate next step is to immediately initiate rabies post-exposure prophylaxis with both rabies immunoglobulin and vaccine (Option D), while simultaneously attempting to capture the cat for testing or 10-day observation. 1, 2

Immediate Wound Management

Before addressing rabies prophylaxis, the wound requires proper care:

• Thoroughly wash and flush the wound with soap and water for approximately 15 minutes, which can markedly reduce rabies transmission risk 1, 2
• Apply a virucidal agent such as povidone-iodine solution after washing 1
• Administer tetanus prophylaxis and antibiotics as indicated for bacterial infection control 2

Why Rabies PEP is Critical in This Case

The cat's clinical presentation is the key decision point here:

• A febrile and lethargic cat represents a high-risk scenario for rabies, as these are potential prodromal signs of the disease 3
• Cats have higher rabies rates than dogs in the United States, with 274-281 rabid cats reported annually compared to fewer than 100 dogs 3, 1
• The cat is "newly adopted," meaning its vaccination status and exposure history are likely unknown 3
• The CDC guidelines emphasize that any animal showing signs of illness after biting should be immediately evaluated for rabies 3, 2

The 10-Day Observation Rule Does NOT Apply Here

A critical pitfall to avoid:

• The standard recommendation to confine and observe a healthy dog, cat, or ferret for 10 days applies only to animals that appear healthy at the time of the bite 3, 2
• This cat is NOT healthy—it is febrile and lethargic 3
• For sick animals, the guideline states: "At the first sign of illness during confinement, if signs suggestive of rabies develop, the animal should be euthanized immediately and tested" 3, 2
• Delaying post-exposure prophylaxis while attempting to locate or observe a potentially rabid animal is dangerous, especially in children 1

Rabies Post-Exposure Prophylaxis Protocol

For this previously unvaccinated child:

Day 0 (Immediately):

• Rabies immunoglobulin (RIG) 20 IU/kg body weight, infiltrating as much as possible into and around the wound site 1, 2
• First dose of rabies vaccine at a site anatomically distant from the RIG injection 2, 4

Subsequent vaccine doses:

• Days 3,7,14, and 28 (traditional 5-dose regimen) 2, 4
• Alternatively, the 1-week intradermal regimen may be considered as it is safe, immunogenic, and cost-effective 5, 6

Concurrent Actions

• Immediately contact the local health department to report the exposure and determine local rabies epidemiology 1, 2
• Attempt to capture and confine the cat for immediate euthanasia and rabies testing 3, 2
• If the cat tests negative for rabies, the vaccine series can be discontinued 2
• If the cat cannot be located, continue the full PEP series 1, 2

Why Other Options Are Inadequate

Option A (Reassure): Completely inappropriate given the sick cat's presentation and high rabies risk in cats 3, 1

Option B (Prophylactic antibiotics alone): While antibiotics are important for preventing bacterial infection from cat bites (which have high infection rates), they do nothing to prevent rabies, which is nearly 100% fatal once symptoms develop 7, 4, 8

Option C (Irrigate wound alone): While wound irrigation is essential and should be done first, it is insufficient as sole management when rabies exposure is suspected 1, 2, 5

Critical Clinical Pitfalls

• Never delay rabies PEP initiation while waiting for animal testing results when the animal shows signs of illness 1, 2
• Failing to infiltrate RIG into the wound site reduces effectiveness—as much as anatomically feasible should be infiltrated around the wound 1, 2
• Do not assume a "newly adopted" cat from a shelter is vaccinated—verify vaccination status and consider that recent vaccination may not provide immediate protection 3
• Rabies is nearly 100% fatal once clinical symptoms appear, making prevention the only viable strategy 7, 4, 8