Cat Scratch Management Guidelines for Unvaccinated Adults

Immediate Wound Care

Thoroughly wash the scratch with soap and water for about 15 minutes; this is the single most effective measure to prevent both rabies transmission and bacterial infection (CDC) 1.
After cleansing, apply a virucidal agent such as povidone‑iodine to further reduce viral and bacterial load (CDC) 1.

Administer a 0.5 mL dose of tetanus‑diphtheria (Td) vaccine intramuscularly in the deltoid as the first dose of a primary series for any adult with no prior tetanus vaccination (IDSA) 2.
Schedule the second Td dose 4–8 weeks after the first and the third dose 6–12 months after the second to complete the primary immunization schedule (IDSA) 2.
For a clean, minor scratch, Td alone is sufficient; both Td and tetanus immune globulin (TIG) are reserved for more severe or contaminated wounds in unvaccinated patients (IDSA) 2.
Tetanus prophylaxis should be given as soon as possible during the initial encounter and must not be delayed (IDSA) 2.

If the cat is a healthy domestic pet that can be confined and observed for 10 days, rabies PEP is not initiated immediately; observation is sufficient (CDC) 1.
Initiate rabies PEP immediately when any of the following apply: the cat is stray, unavailable for observation, dies or shows illness suggestive of rabies before the 10‑day period, has an unknown or inadequate vaccination status with no feasible observation, or local epidemiology indicates a high rabies risk in cats (CDC) 1.
For unvaccinated persons requiring PEP, give both human rabies immune globulin (HRIG) 20 IU/kg on day 0 (infiltrate up to half the dose around the wound and give the remainder intramuscularly in the gluteal region) and a rabies vaccine series (HDCV, RVA, or PCEC) intramuscularly in the deltoid on days 0, 3, 7, and 14 (four‑dose regimen) (CDC) 1.
HRIG may be administered up to day 7 after the first vaccine dose if not given on day 0; beyond day 7 it is unnecessary because vaccine‑induced antibodies are presumed present (CDC) 1.
Do not exceed 20 IU/kg of HRIG, as higher doses can suppress the active antibody response (CDC) 1.

Routine prophylactic antibiotics are not indicated for a simple, superficial scratch without signs of infection (IDSA) 3.
Consider amoxicillin‑clavulanate (875/125 mg twice daily for 3–5 days) if the wound is deep, shows early infection signs (redness, warmth, swelling, purulent drainage), the patient is immunocompromised, the injury involves the hand, face, or a joint/tendon area, or there is marked edema (IDSA) 3.
For patients allergic to penicillins, use doxycycline (100 mg twice daily) or a fluoroquinolone combined with clindamycin as alternative regimens (IDSA) 3.

Advise the patient to monitor for CSD manifestations for 3–30 days after exposure, including a papule or pustule at the scratch site, regional lymphadenopathy (typically ~3 weeks), and fever or systemic symptoms (IDSA) 4.
If regional lymphadenopathy develops, treat with azithromycin 500 mg on day 1 followed by 250 mg daily for 4 additional days in patients weighing >45 kg (IDSA) 4.

Confirm the cat’s health status at day 10 of observation; if the cat remains healthy, no rabies PEP is required (CDC) 1.
Document the cat’s vaccination status, health condition, and ability to be observed, as well as whether the scratch was provoked or unprovoked (CDC) 1.
If rabies risk remains uncertain, consult local public health authorities and record the consultation (CDC) 1.

The Centers for Disease Control and Prevention recommends thoroughly washing the scratch with soap and water for 15 minutes immediately, as this is the single most effective measure for preventing rabies and reduces infection risk markedly 5, 6, 7
Apply povidone-iodine solution or similar virucidal agent to the wound site if available, to reduce the risk of infection 7, 8
Assess for tetanus prophylaxis needs based on immunization status, to prevent tetanus infection 6, 7
Consider antibiotic prophylaxis (amoxicillin-clavulanate) only if the scratch is deep or shows signs of infection, as cat scratches carry risk of Bartonella henselae (cat-scratch disease) and bacterial infection 7, 8

The American Academy of Pediatrics and the Centers for Disease Control and Prevention recommend that if the cat is rabid or suspected rabid, immediately administer both HRIG and rabies vaccine, as this is the standard postexposure prophylaxis for category III exposures (scratches with broken skin) 5, 9
Give HRIG at 20 IU/kg body weight: infiltrate up to half the dose around and into the wound if anatomically feasible, inject remainder intramuscularly in the gluteal area, to provide immediate passive antibody protection 6
Administer rabies vaccine (HDCV or PCECV) on days 0, 3, 7, and 14 (4-dose schedule for immunocompetent patients), to induce active immunity against rabies 10
The World Health Organization recommends that HRIG can be administered up to day 7 after the first vaccine dose if not given initially, as beyond day 7, HRIG is not indicated as vaccine-induced antibody response is presumed to have occurred 6

The Centers for Disease Control and Prevention recommends beginning treatment immediately after exposure (within 24 hours ideally), though even delayed treatment is indicated as rabies incubation periods exceeding 1 year have been documented 5, 8

The American Academy of Pediatrics recommends never administering more than the recommended 20 IU/kg dose of HRIG, as excess may partially suppress active antibody production 6
Do not inject rabies vaccine in the gluteal area (use deltoid in adults, anterolateral thigh in children), as this results in lower neutralizing antibody titers, according to the Centers for Disease Control and Prevention 6, 10

The Centers for Disease Control and Prevention recommends that previously vaccinated persons receive only rabies vaccine booster doses, and not rabies immune globulin, in the event of a cat scratch exposure, with a 2-dose schedule on days 0 and 3 11
The guideline society suggests that previously vaccinated individuals should not be administered rabies immune globulin, as it is only necessary for previously unvaccinated persons, and vaccine should be given intramuscularly in the deltoid area 11

The Centers for Disease Control and Prevention notes that unprovoked attacks are more likely to indicate rabies than provoked attacks, and this distinction is crucial in determining the need for post-exposure prophylaxis 11
A fully vaccinated cat is unlikely to become infected with rabies, though rare cases have been reported, according to the Centers for Disease Control and Prevention 12