Rabies - post-exposure prophylaxis
Clinical facts and clinical management
- cleanse the wound with a solution of soap and water + povidone iodine solution
- evaluate the need to institute rabies post-exposure prophylaxis - you can use the algorithm prn
- scratches, abrasions, open wounds or mucous membranes exposed to saliva or other potentially infectious material constitute significant non-bite exposures
- simple contact (eg. petting) with a rabid animal, or its urine or feces, does not constitute a non-bite exposure
- bites of squirrels, hamsters, guinea pigs, gerbils, chipmunks, rats, mice and other small rodents, rabbits and hares almost never require post-exposure prophylaxis
- theoretically, human bites that penetrate skin could represent a significant exposure, but there have been no reported cases in the USA
- direct exposure to bats, even in the absence of a definite bite or scratch, may represent a significant exposure eg. child, intoxicated or mentally retarded adult, sleeping in the same room as a bat; household contacts of those exposed patients do not require post-exposure prophylaxis
- post-exposure prophylaxis consists of 1 dose of rabies immunoglobulin (20IU/kg) and 5 doses of rabies vaccine over 28 days (days 0, 3, 7, 14 and 28)
- a larger dose of rabies immunglobulin (40 - 50 IU/kg) is recommended for significant bites about the face and neck
- if anatomically feasible, the full dose of RIG should be given at the bite site or in a muscle as anatomically near the bite site as practical
- the rabies vaccine should be given in the deltoid muscle (not buttocks); or antero-lateral thigh in very small children
- side-effects of vaccination include mild erythema, pain and swelling at the site of injection; systemic effects such as headache, nausea, muscle aches and dizziness; and serum sickness-like reaction (arthalgia, arthritis, angiedema, generalised urticaria, nausea, vomiting, fever and malaise)
- rabies vaccination should not be discontinued because of mild reactions
- patients with a history of prior rabies vaccination only require 2x IM doses of rabies vaccine, one immediately and the second dose on day 3
- the same post-exposure rabies protocol should be used for immuno-compromised and pregnant patients
- children should receive HRIG based on body weight (20IU/kg), but should receive the same adult dose of rabies vaccine
- see the "New Jersey guide to post-exposure rabies treatment for the health care professional" for much more detail
Hyperlinks to internet-based educational resources.
What you should know about rabies - New Jersey Department of Health
New Jersey guide to post-exposure rabies treatment for the health care professional
Textbooks, journal articles and guidelines.
Human rabies prevention--United States, 1999. Recommendations of the
Advisory Committee on Immunization Practices1999 Jan 15;48(1):16] MMWR Morb Mortal Wkly Rep - 1999 Jan 8; 48(RR-1): 1-21
