Rabies Post-exposure Prophylaxis Guidance

Post-exposure prophylaxis recommendations

The Advisory Committee on Immunization Practices (ACIP) rabies PEP recommendations consists of:

• Wound care
• A dose of human rabies immune globulin (HRIG)
• Rabies vaccine given at the time of the first medical visit, and a dose of vaccine given again on days 3, 7, and 14 after the first dose.

Wound care

Regardless of the risk for rabies, bite wounds can cause serious injury, including but not limited to nerve or tendon laceration and infection. For many types of bite wounds, immediate and gentle irrigation with water or a dilute water povidone-iodine solution has been shown to significantly decrease the risk of bacterial infection.

Wound cleansing is especially important in rabies prevention. In animal studies, thorough wound cleansing alone without other medical treatments (e.g., vaccine) has been shown to markedly reduce the likelihood of developing rabies.

Make decisions regarding the use of antibiotics and primary wound closure together with the patient.

Human rabies immune globulin

People who have been previously vaccinated or are receiving pre-exposure prophylaxis (PrEP) for rabies should not receive human rabies immune globulin (HRIG).

HRIG is administered only once at the beginning of the PEP course. HRIG provides immediate antibodies until rabies vaccination provides immunogenicity.

HRIG should never be administered in the same syringe or in the same anatomical site as the first vaccine dose. However, subsequent doses of vaccine in the four-dose series can be administered in the same anatomic location where the HRIG dose was administered.

Rabies vaccine

For people who have never been vaccinated against rabies, PEP should always include the administration of HRIG and rabies vaccine. The combination of HRIG and vaccine is recommended for both bite and non-bite exposures, regardless of the interval between exposure and initiation of treatment, so long as the patient is not showing signs consistent with rabies.

For people who have previously been vaccinated against rabies, PEP consists of two doses of vaccine three days apart.

PEP for individuals without previous rabies vaccination

PEP for individuals with previous rabies vaccination

Precautions and contraindications for rabies vaccination

There are no known contraindications for rabies vaccination. Pregnancy is not a contraindication for rabies PEP, and exposure to rabies or a rabies diagnosis in the mother does not require pregnancy termination.

PEP is suitable for all age groups including infants and children.

For immunosuppressed or immunocompromised individuals, rabies PEP should be administered using a 5-dose vaccine regimen, which includes one dose of vaccine on days 0, 3, 7, 14, and 28. Help patients understand that their immune response may be inadequate.

Avoid immunosuppressive agents during rabies PEP unless essential for treating other conditions. Patients on immunosuppressive medications should consult with their healthcare providers about the possibility of delaying these treatments during PEP.

After completing the vaccine series, test the patient for rabies virus neutralizing antibody. The patient's physician and public health officials should guide further management.

Care received outside of the U.S.

If a patient received rabies PEP outside the United States, the regimen may have included medications not used in the United States. Therefore, additional therapy might be necessary. Contact your public health department for specific advice in such cases.

Generally, if they received a PEP regimen recognized by the World Health Organization (WHO), then no further medical care is necessary. If the regimen is not recognized by WHO, or if the PEP regimen was not completed outside of the United States, confirming adequate vaccine response and administering additional doses may be necessary. If you check for specimens collected two to four weeks after PrEP or PEP and they meet or exceed 0.5 international units per milliliter, they are considered sufficient; in this case, no additional doses are necessary.

Purified equine rabies immune globulin (ERIG) has been used effectively in developing countries where HRIG might not have been available. Adverse reactions have been rare and generally minor.

Unpurified anti-rabies serum might still be used in some countries where neither HRIG nor ERIG are available. Anti-rabies serum is associated with higher rates of serious adverse reactions, including anaphylaxis. Health authorities have proposed monoclonal antibodies as an alternative to rabies immune globulin. This product is only advised if it is licensed in the country where it was administered.

Since cell culture vaccines have been routinely used in the United States, there have been no PEP failures in immunocompetent patients. Overseas, failures have occurred when the recommended PEP protocol was not followed closely or when RIG was not appropriately administered.

For more information about PEP, also see the international WHO guidelines for rabies post-exposure treatment.