Rabies Post-Exposure Prophylaxis Guidelines

Introduction to Rabies PEP

The Centers for Disease Control and Prevention (CDC) recommends that previously unvaccinated persons receive 4 doses of rabies vaccine on days 0, 3, 7, and 14, combined with rabies immune globulin (RIG) at 20 IU/kg on day 0, for post-exposure prophylaxis 1, 2, 3

The Advisory Committee on Immunization Practices (ACIP) recommends a 4-dose schedule for previously unvaccinated persons, which is a reduction from the historical 5-dose schedule, as evidence demonstrates that 4 doses in combination with RIG elicit adequate immune responses without the need for a fifth dose 1
The vaccine type should be either Human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) 1, 2
The dose volume should be 1.0 mL per dose, administered intramuscularly in the deltoid area for adults and older children, and in the anterolateral thigh for young children 2, 3

RIG should be administered at 20 IU/kg body weight on day 0, with the first vaccine dose, and infiltrated around and into the wound(s) if anatomically feasible 2, 3
RIG should not be administered in the same syringe or at the same anatomical site as the vaccine, and the recommended dose should not be exceeded, as it may partially suppress active antibody production 2, 3

Previously vaccinated individuals require only 2 doses of vaccine (days 0 and 3) and do not need RIG 2, 4
Immunocompromised individuals must receive the full 5-dose regimen (days 0, 3, 7, 14, and 28) plus RIG at 20 IU/kg, as their immune response may be inadequate with the standard 4-dose regimen 2, 3, 4

Immediate thorough washing of all wounds with soap and water for 15 minutes is recommended, and if available, irrigate wounds with a virucidal agent such as povidone-iodine solution 2, 3
Post-exposure prophylaxis should be initiated as soon as possible after exposure, with no absolute cutoff beyond which PEP should be withheld 3

When administered promptly and appropriately, rabies PEP combining wound care, RIG infiltration, and the vaccine series is nearly 100% effective in preventing human rabies 3
The reduction from 5 to 4 doses was estimated to save approximately $16.6 million annually in the U.S. healthcare system without compromising efficacy 2