Post-Exposure Prophylaxis for Rabies

Wound Management

Irrigate wounds with a virucidal agent (e.g., povidine-iodine solution) if available, as recommended by the Centers for Disease Control and Prevention (CDC) 1
Infected wounds should not be closed, and thorough wound irrigation with a large volume of warm or room temperature potable water is recommended by the American Heart Association and the CDC to remove any foreign matter, and remove any superficial debris but avoid deeper debridement unless absolutely necessary 2, 3, 4, 5, 6, 7, 8
Elevate the injured area, especially if swollen, to accelerate healing, as recommended by the Infectious Diseases Society of America (IDSA) and the Clinical Infectious Diseases guideline, with a strength of evidence level of moderate, and consider passive immobilization methods as needed, according to the IDSA 8, 9
Prompt washing of sites of animal scratches or bites is advised to prevent infection, as recommended by the American College of Physicians and the CDC, and thorough wound cleansing with sterile normal saline and copious irrigation is recommended to prevent infection, as suggested by the IDSA 10, 11, 8

Assess the need for rabies prophylaxis based on the vaccination status of the animal, circumstances of the bite, and whether the animal can be observed for 10 days, as recommended by the CDC, and the combination of Rabies Immune Globulin (RIG) and vaccine is recommended for both bite and nonbite exposures, regardless of the interval between exposure and treatment initiation, as suggested by the Advisory Committee on Immunization Practices (ACIP) and the CDC 12, 13
If vaccination cannot be verified, consideration of observation of the animal for 10 days is recommended by the CDC, with a moderate strength of evidence 3
Post-exposure prophylaxis may be indicated if observation is not possible or the animal shows signs of rabies, according to the CDC, with a moderate strength of evidence 3

Administer 20 IU/kg body weight of RIG, infiltrating the full dose around and into the wound if anatomically feasible, as suggested by the ACIP and the CDC, and previously vaccinated individuals should receive vaccine alone without RIG, as recommended by the CDC 13, 3
Exceeding the recommended RIG dose is advised against, as excessive RIG may suppress active antibody production, as recommended by the CDC 1

The CDC recommends a standard regimen of 1.0 mL IM (deltoid area) of Human Diploid Cell Vaccine (HDCV) or Purified Chick Embryo Cell Vaccine (PCECV) on days 0, 3, 7, and 14, with an additional dose on day 28 for immunosuppressed patients 1
Administering rabies vaccine in the gluteal area is advised against, as this can result in diminished immune response and vaccine failure, as recommended by the CDC 1, 3
For previously unvaccinated individuals, 5 doses of rabies vaccine should be administered on days 0, 3, 7, 14, and 28, as recommended by the CDC and the World Health Organization (WHO) 13, 4

Broad-spectrum antibiotic coverage is necessary for animal bite wounds, which typically contain multiple bacterial species including Pasteurella (in 50%), Staphylococci, Streptococci, and anaerobes, as stated by the IDSA, and the preferred antibiotic regimen is Amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days, as it covers Pasteurella multocida, Staphylococci, Streptococci, and anaerobes commonly found in animal bite wounds, according to the IDSA 8
Alternative antibiotic regimens for patients allergic to penicillin include doxycycline (100 mg twice daily), fluoroquinolone plus metronidazole, or clindamycin plus TMP-SMZ, as recommended by the IDSA 9, 8
The American College of Physicians recommends considering prophylactic antibiotics for high-risk wounds, such as hand wounds and puncture wounds, as well as for immunosuppressed patients 8

Administer tetanus toxoid (0.5 mL intramuscularly) if vaccination is outdated (>5 years) or status is unknown, as recommended by the IDSA, the American College of Physicians, and the CDC, and Tetanus, diphtheria, and pertussis (Tdap) is preferred over Tetanus and diphtheria (Td) if the former has not been previously given, as suggested by the American College of Physicians 9, 3, 8

Schedule follow-up within 24-48 hours to assess for signs of infection, with a strength of evidence level of high, as recommended by the IDSA, and monitor for increasing redness, swelling, pain, warmth, or drainage, and consider hospitalization if infection progresses despite appropriate therapy, as recommended by the IDSA 8
Potential complications of wounds include osteomyelitis, synovitis, nerve or tendon injury, compartment syndromes, post-infectious arthritis, fracture, and bleeding, as reported by the American Academy of Orthopaedic Surgeons (AAOS) and the Clinical Infectious Diseases guidelines, and hand bites, particularly over joints or tendons, are at higher risk of infection and complications, and consultation with a hand specialist may be considered if joint spaces or tendons are involved, as reported by the IDSA 4, 8