Rabies Post‑Exposure Prophylaxis Guidelines for Unvaccinated Adults

Wound Management

• Thorough wound cleansing with soap and water for approximately 15 minutes should be performed immediately after exposure. [CDC 2]
• If available, irrigate the wound with a virucidal agent such as povidone‑iodine solution. [CDC 1]
• Initial wound care is critical and must never be delayed, as it provides the first line of defense against viral entry. [CDC 2]

Rabies Immune Globulin (RIG) Administration

Dosing and Timing

• Administer RIG at a dose of 20 IU per kilogram of body weight on day 0 (the same day the first vaccine dose is given). [CDC 1]
• If RIG was not given on day 0, it may still be administered up to and including day 7 of the vaccine series. [CDC 4]
• RIG is not indicated after day 7 because an adequate antibody response to the vaccine is presumed to have occurred. [CDC 5]

Technique

• Infiltrate the full calculated RIG dose around and into all wounds, whenever anatomically feasible. [CDC 1]
• Any remaining RIG volume should be given intramuscularly at a site distant from the vaccine injection site. [CDC 1]
• RIG must never be administered in the same syringe or at the same anatomic site as the rabies vaccine. [CDC 1]
• Do not exceed the recommended RIG dose, as excess RIG can partially suppress the active antibody response. [CDC 1]

Rabies Vaccine Schedule for Previously Unvaccinated Persons

• Give four 1.0 mL doses of either human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV). [CDC 1]
• Schedule the doses on days 0, 3, 7, and 14 (day 0 is the first dose). [CDC 1]
• Administer each dose intramuscularly in the deltoid muscle for adults and older children. [CDC 1]
• The gluteal region must be avoided because it yields lower neutralizing antibody titers. [CDC 1]

Special Populations

• Immunosuppressed patients: Use a five‑dose schedule (days 0, 3, 7, 14, 28) to ensure an adequate antibody response. [CDC 6]
• Previously vaccinated persons: Administer only two vaccine doses (days 0 and 3) and omit RIG. [CDC 4]

Timing and General Recommendations

• Initiate prophylaxis as soon as possible after exposure, irrespective of the time elapsed between exposure and presentation. [CDC 8]
• The combination of RIG and vaccine is recommended for both bite and non‑bite exposures. [CDC 9]

Common Pitfalls to Avoid

• Do not delay treatment while awaiting animal testing results; begin prophylaxis immediately and discontinue only if the animal tests negative. [CDC 1]
• Ensure the full calculated RIG dose is infiltrated at wound sites; insufficient RIG has been linked to rare prophylaxis failures. [CDC 5]
• Avoid administering the vaccine in the gluteal region, as this significantly reduces the immunologic response. [CDC 4]
• Do not give RIG to individuals with documented prior complete vaccination, because it may inhibit the anamnestic antibody response. [CDC 4]