Postexposure Prophylaxis for Tetanus and Rabies

Human Tetanus Immunoglobulin (HTIG) Administration

The Centers for Disease Control and Prevention recommends HTIG for contaminated wounds in patients with incomplete tetanus vaccination (<3 doses or unknown status) 1, 2
For immunocompromised patients, HTIG must be given within 6 months of potential exposure 3

The Centers for Disease Control and Prevention recommends HRIG for all previously unvaccinated persons with rabies exposure, including bite exposures, non-bite exposures, and exposures from high-risk animals 1, 2, 4
HRIG is not indicated for previously vaccinated persons or those with documented rabies virus neutralizing antibody titer 1, 2, 3
The recommended dose of HRIG is 20 IU/kg body weight for all ages 1, 2, 4
HRIG should be administered as soon as possible, ideally within 24 hours of exposure, and can be given up to and including day 7 of the vaccine series 1, 2, 4
The American Academy of Pediatrics and the Centers for Disease Control and Prevention recommend infiltrating the full calculated dose of HRIG thoroughly around and into all wounds, if anatomically feasible, and injecting any remaining volume intramuscularly at a site distant from vaccine administration 1, 2, 5
Immunocompromised patients still require HRIG at the standard 20 IU/kg dose and should use an extended 5-dose vaccine schedule 3

The Centers for Disease Control and Prevention recommends immediately washing wounds thoroughly with soap and water for 15 minutes, applying povidone-iodine solution or other virucidal agent, and assessing the need for tetanus prophylaxis in all rabies exposures 1, 2, 5

The Centers for Disease Control and Prevention (CDC) recommends that previously vaccinated persons should receive only 2 vaccine doses after a subsequent bite, with no administration of Human Rabies Immunoglobulin (HRIG) 6, 7
The American College of Physicians and the CDC agree that HRIG is unnecessary and should not be administered to previously vaccinated persons, as it can inhibit the anamnestic antibody response 6, 7

The Advisory Committee on Immunization Practices (ACIP) considers individuals previously vaccinated if they have received any ACIP-recommended pre-exposure prophylaxis regimen with cell-culture vaccines 6, 7
The ACIP also considers individuals previously vaccinated if they have received any complete post-exposure prophylaxis regimen with cell-culture vaccines (HDCV, PCECV, or RVA) 6, 7

Immunocompromised patients may require HRIG even if previously vaccinated, along with an extended 5-dose vaccine schedule (days 0, 3, 7, 14, and 28) 6
The CDC recommends consulting with public health officials for immunocompromised patients with prior vaccination history 6

The CDC recommends that HRIG be given only once, ideally on day 0 with the first vaccine dose, for unvaccinated persons receiving their first post-exposure prophylaxis 6, 7
If not given on day 0, HRIG can still be administered up to and including day 7 of the vaccine series 6, 7
Beyond day 7, HRIG is not indicated because vaccine-induced antibodies are presumed to have developed 6, 8

The CDC/ACIP defines a previously vaccinated person as anyone who has completed an ACIP‑recommended pre‑exposure or post‑exposure prophylaxis regimen with cell‑culture rabies vaccines (HDCV, PCECV, or RVA) or who has documented rabies‑virus neutralizing antibody titers. Strong recommendation (expert consensus). 9

Administration of human rabies immune globulin (HRIG) to individuals with existing immune memory can partially suppress the active antibody production that follows booster vaccination, potentially interfering with the protective response. Strong recommendation (expert consensus). 9

The total HRIG dose must not exceed 20 IU/kg body weight; doses higher than this have been shown to suppress the active antibody response. Strong recommendation (expert consensus). 9

HRIG is not indicated after day 7 of the vaccine series because vaccine‑induced antibodies are presumed to have developed by that time. Strong recommendation (expert consensus). 9