What post‑exposure rabies prophylaxis is recommended for a 70‑year‑old woman who completed a full pre‑exposure rabies vaccination series one year ago and now presents with a Category III dog bite?

Post-Exposure Rabies Prophylaxis for Previously Vaccinated Individual with Category III Exposure

A 70-year-old woman who completed pre-exposure rabies vaccination one year ago and now presents with a Category III dog bite requires only two doses of rabies vaccine (1.0 mL intramuscularly) on days 0 and 3, with NO rabies immune globulin (RIG). 1, 2, 3, 4

Immediate Wound Management

• Thoroughly wash the wound with soap and water for at least 15 minutes immediately—this single intervention is the most effective measure for reducing rabies viral load and is more important than any pharmaceutical intervention. 1, 2
• Irrigate with a virucidal agent such as povidone-iodine solution if available. 2
• Assess and provide tetanus prophylaxis as indicated. 1
• Consider antibiotic prophylaxis to prevent secondary bacterial infection. 1

Simplified Two-Dose Vaccine Regimen

• Administer 1.0 mL of rabies vaccine (HDCV or PCECV) intramuscularly on day 0 (today) and day 3 only—no additional doses are needed. 1, 2, 3, 4
• Inject in the deltoid muscle (never use the gluteal area, which produces inadequate antibody response and has been associated with prophylaxis failures). 1, 2, 4
• Day 0 is defined as the day the first dose is administered, not necessarily the day of the bite. 2

Critical: NO Rabies Immune Globulin

• Do NOT administer RIG to this patient—giving RIG to previously vaccinated individuals will suppress the rapid anamnestic (memory) immune response and is contraindicated. 1, 2, 3, 4
• Previously vaccinated persons develop a rapid memory antibody response that makes passive immunization with RIG unnecessary and potentially harmful. 1, 3

Rationale for Simplified Regimen

• This patient meets the definition of "previously vaccinated" because she completed a full pre-exposure vaccination series with a cell culture vaccine one year ago. 3, 4
• Previously vaccinated individuals mount a rapid anamnestic immune response upon re-exposure, achieving protective antibody titers (>0.5 IU/mL) within days of the first booster dose. 1, 3
• Studies demonstrate that all previously vaccinated immunocompetent individuals achieve adequate antibody levels by day 14 after the two-dose booster regimen. 5
• This simplified protocol eliminates the need for RIG (which is expensive and often in short supply) and reduces the vaccine series from 4–5 doses to just 2 doses. 1, 2

Important Exception: Immunocompromised Status

If this patient is immunocompromised (taking corticosteroids, other immunosuppressive agents, has HIV, or other immunosuppressive illness), the protocol changes completely:

• Administer a 5-dose vaccine regimen on days 0,3,7,14, and 28. 1, 2
• Give RIG at 20 IU/kg on day 0, infiltrated around and into the wound. 1, 2
• Perform mandatory serologic testing (RFFIT) 1–2 weeks after the final dose to confirm adequate antibody response (≥1:5 titer). 1, 2
• Immunosuppression substantially reduces vaccine response, making the standard two-dose regimen inadequate even in previously vaccinated individuals. 1, 2

Common Pitfalls to Avoid

• Do not give RIG to previously vaccinated immunocompetent patients—this is the most common error and will inhibit the protective immune response. 1, 2, 3
• Do not use the gluteal area for vaccine injection—this route produces inadequate antibody titers and has been associated with prophylaxis failures. 1, 2, 4
• Do not delay treatment while waiting for animal observation results—initiate the two-dose series immediately; it can be discontinued if the dog remains healthy after 10 days of observation. 1
• Do not assume the patient needs the full 4-dose unvaccinated regimen—verify prior vaccination history to avoid unnecessary doses and costs. 3, 4

Timing Flexibility

• Small delays of a few days between the day 0 and day 3 doses are unimportant and do not compromise protection. 6, 1
• If the patient misses the day 3 appointment and presents on day 5, simply administer the second dose that day—do not restart the series. 6

Efficacy

• When administered properly, this two-dose regimen in previously vaccinated individuals is nearly 100% effective at preventing rabies. 1, 2, 7
• No cases of rabies have been documented in the United States in previously vaccinated individuals who received appropriate post-exposure boosters. 1, 8
• Rabies encephalomyelitis has never been reported in anyone who received both pre-exposure vaccination and a post-exposure booster. 8

No Routine Serologic Testing Required

• Routine post-vaccination antibody testing is not necessary in immunocompetent previously vaccinated individuals, as all achieve protective titers. 1, 4
• Serologic testing is indicated only if the patient is immunocompromised or if there are concerns about the adequacy of the prior vaccination series. 1, 4