Rabies Vaccination After Cat Scratch
Rabies post-exposure prophylaxis (PEP) is necessary for a cat scratch only if the cat cannot be confined and observed for 10 days, is stray/unwanted, shows signs of rabies, or dies/becomes ill during the observation period. 1
Immediate Wound Management
- Thoroughly wash and flush the scratch wound immediately with soap and water for approximately 15 minutes to reduce infection risk and potential rabies transmission. 1
- Irrigate with povidone-iodine solution after soap and water cleansing, as this virucidal agent further reduces rabies risk. 1
- Examine the wound carefully for depth, tendon involvement, bone involvement, or joint penetration. 1
Decision Algorithm for Rabies PEP
If the cat is healthy, available, and can be observed:
- Confine and observe the cat for 10 days without initiating rabies prophylaxis. 2, 1
- If the cat remains healthy for the full 10 days, no rabies prophylaxis is needed, as the cat would not have been shedding rabies virus at the time of the scratch. 3, 1
- The cat should be evaluated by a veterinarian at the first sign of illness during confinement. 2
Initiate immediate rabies PEP if:
- The cat is stray or unwanted and cannot be confined for observation 2, 1
- The cat dies or develops illness before completing the 10-day observation period 2, 1
- The cat shows signs suggestive of rabies during observation 2, 1
- The cat is unavailable for testing after showing suspicious signs 2
Rabies PEP Regimen (for previously unvaccinated persons)
If PEP is indicated, administer both Human Rabies Immune Globulin (HRIG) and rabies vaccine: 3, 4
- HRIG: 20 IU/kg body weight given once on day 0 (as much as possible infiltrated around the wound, with remainder given intramuscularly at a site distant from vaccine administration) 3, 4
- Rabies vaccine series: 5 doses on days 0,3,7,14, and 28 3, 4
Risk Assessment Factors
- Unprovoked attacks are more likely to indicate rabies than provoked attacks. 2, 1
- More cats than dogs are reported rabid in the United States, with the majority associated with raccoon rabies epizootics in the eastern US. 2, 1
- Cats are important vectors of lyssaviruses and are at risk from interactions with infected prey such as bats or transmission from other rabid animals. 5
Tetanus Prophylaxis
- Assess tetanus immunization status and administer tetanus prophylaxis as indicated. 1
- Administer tetanus toxoid to patients with unknown or incomplete tetanus immunization. 1
Critical Pitfalls to Avoid
- Never delay wound cleansing, as thorough wound cleansing alone has been shown to markedly reduce rabies likelihood in animal studies. 1
- Do not exceed the recommended HRIG dose, as excess can suppress active antibody production. 3, 1
- Do not initiate unnecessary post-exposure prophylaxis for healthy domestic cats that can be observed for 10 days. 1
- Do not confuse cat-scratch disease (caused by Bartonella henselae) with rabies exposure—cat-scratch disease presents with lymphadenitis and does not require rabies vaccination. 6
Important Clinical Context
- A case report documented fatal paralytic rabies following a category III cat scratch on the face, despite receiving intradermal anti-rabies vaccine (though without HRIG). 7 This underscores the importance of proper wound management, complete PEP regimen including HRIG for severe exposures, and not underestimating scratches to high-risk areas like the face.
- Rabies virus is shed in saliva some days before the onset of clinical signs and can be transmitted through a scratch to the skin or mucous membranes. 8