Rabies Post-Exposure Prophylaxis Guidelines

Components of Rabies Post-Exposure Prophylaxis

The World Health Organization recommends a 4-dose vaccine schedule administered on days 0, 3, 7, and 14, along with rabies immunoglobulin infiltrated around the wound for previously unvaccinated individuals 1
Immediate and thorough cleansing of all bite wounds and scratches with soap and water for 15 minutes is the first critical step in rabies prevention, and if available, a virucidal agent such as povidone-iodine solution should be used to irrigate the wounds 1, 2
Wound cleansing alone has been shown to markedly reduce the likelihood of rabies in animal studies, and suturing should be avoided when possible to prevent deeper inoculation of the virus 3

Human Rabies Immunoglobulin (HRIG) is administered only once at the beginning of PEP to previously unvaccinated persons, with a recommended dose of 20 IU/kg body weight 1
If anatomically feasible, the full dose should be infiltrated around and into all wounds, and any remaining volume should be administered intramuscularly at a site distant from vaccine administration 1
HRIG can be administered up to day 7 after the first vaccine dose if not given initially, and should never be administered in the same syringe or at the same anatomical site as the first vaccine dose 3

For previously unvaccinated individuals, 4 doses of vaccine (HDCV or PCECV) administered intramuscularly (1.0 mL each) on days 0, 3, 7, and 14 are recommended, and for immunocompromised patients, a 5-dose schedule is still recommended (days 0, 3, 7, 14, and 28) 1
For previously vaccinated individuals, only 2 doses of vaccine are required (days 0 and 3), and HRIG is not necessary 1

Vaccine should be administered in the deltoid area for adults and older children, and for younger children, the anterolateral aspect of the thigh may be used 1
The gluteal area should never be used for vaccine administration due to risk of reduced immunogenicity 1
All PEP should begin as soon as possible after exposure, regardless of the time interval between exposure and initiation of treatment 1

Clinical trials with PCECV have demonstrated immunogenicity equivalent to HDCV 3

Postexposure prophylaxis should be initiated regardless of the length of delay since exposure, provided clinical signs of rabies are not present, and if the exposing animal is proven not to be rabid through appropriate laboratory testing, PEP can be discontinued 3

Administering vaccine in the gluteal area, which can result in diminished immune response 1
Inadequate wound cleansing, which is a critical first step in preventing rabies 3