Rabies Post-Exposure Prophylaxis Protocol

Immediate Wound Management

The Centers for Disease Control and Prevention recommends thorough wound cleansing for 15 minutes using soap and water, followed by irrigation with a virucidal agent, to reduce rabies transmission risk 1, 2
Avoid aggressive scrubbing that damages tissue, but ensure complete removal of saliva and debris from all wound surfaces 1
Do not suture wounds when possible, as closure may trap virus in the tissue 1
Administer tetanus prophylaxis and antibiotic prophylaxis as clinically indicated 1, 3

The Centers for Disease Control and Prevention recommends administering human rabies immunoglobulin (HRIG) at exactly 20 IU/kg body weight on day 0, infiltrating the full calculated dose around and into all wounds if anatomically feasible 1, 2
HRIG must be given only once, ideally simultaneously with the first vaccine dose 1, 2
If HRIG was not given on day 0, it can still be administered up to and including day 7 of the vaccine series 1, 2
The World Health Organization recommends administering 1.0 mL of human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) intramuscularly on days 0, 3, 7, and 14 using a 4-dose regimen for immunocompetent individuals 1, 2

The Centers for Disease Control and Prevention recommends that immunocompromised individuals receive a 5-dose vaccine regimen (days 0, 3, 7, 14, and 28) plus HRIG at 20 IU/kg, even if they were previously vaccinated 4, 5
Individuals who have completed a full pre-exposure or post-exposure vaccination series with a cell culture vaccine require only 2 doses of vaccine (days 0 and 3) and should NOT receive HRIG 1, 2, 4, 5

The World Health Organization recommends initiating PEP as soon as possible after exposure, ideally within 24 hours, though treatment remains indicated regardless of time elapsed since exposure 6, 4
There is no absolute cutoff beyond which PEP should be withheld 4
Successful treatment has been documented even when initiated many months after exposure due to delayed recognition 6, 4

Never use the gluteal area for vaccine injection, as this produces inadequate antibody titers and has been associated with vaccine failure 1, 2, 3, 5
Never give HRIG to previously vaccinated persons, as it will inhibit the anamnestic antibody response 4, 5
Never administer HRIG and vaccine in the same syringe or anatomical site, as this may interfere with vaccine immunogenicity 1, 2, 5
Never exceed 20 IU/kg dose of HRIG, as higher doses can suppress active antibody production 1, 2, 3

The World Health Organization recommends that RIG should be administered immediately for a new Category III exposure, even if the patient is already receiving vaccine for an initial Category II exposure, as the combination of RIG and vaccine is essential for severe exposures, providing immediate passive immunity while vaccine-induced active immunity develops over 7-14 days 7
The Centers for Disease Control and Prevention guidelines, as reported in MMWR Recommendations and Reports, specify that RIG indication is based on the current exposure category, not the vaccination status during an ongoing series, and a new Category III exposure requires passive immunization regardless of active vaccination already in progress 7

The World Health Organization recommends administering 20 IU/kg body weight of human RIG (HRIG) or equine RIG (ERIG), infiltrating the full calculated dose into and around all wounds from the new Category III exposure if anatomically feasible, with any remaining volume given intramuscularly at a site distant from vaccine administration 7
The Indian National Rabies Control Programme aligns with WHO guidelines, specifying RIG for Category III exposures regardless of vaccine regimen, with identical RIG protocols for both intradermal and intramuscular regimens 7

The World Health Organization guidelines, as reported in MMWR Recommendations and Reports, state that RIG can be administered up to and including Day 7 of the vaccine series if it was not given initially, and the patient's existing vaccine-induced immunity should provide protection against the new exposure, as rabies virus neutralizing antibodies are typically detectable by Day 7-14 of the vaccine series 7, 8, 9
The Annals of Emergency Medicine reports that exceeding the recommended 20 IU/kg dose of RIG can suppress active antibody production from the vaccine, and administering a second dose of RIG would effectively double the passive antibody load and interfere with the ongoing immune response 8