Treatment of Wounds
Regardless of the risk of rabies, anyone who treats bite wounds must recognize and treat serious injury (e.g., nerve or tendon laceration), avoid infection (both local and systemic), and strive for the best possible cosmetic results. For many types of bite wounds, immediate gentle irrigation with water or a dilute water povidone-iodine solution has been shown to markedly decrease the risk of bacterial infection.
Wound cleansing is especially important in rabies prevention since, in animal studies, thorough wound cleansing alone without other postexposure prophylaxis has been shown to markedly reduce the likelihood of rabies. Tetanus prophylaxis should be administered if you have not been immunized in ten years. Decisions regarding the use of antibiotics, and primary wound closure should be decided in advisement with your physician or health care provider.
What Will I Be Given for Rabies Postexposure Prophylaxis?
For persons who have never been vaccinated against rabies previously, postexposure anti-rabies vaccination should always include administration of both passive antibody and vaccine. Persons who have been previously vaccinated or are receiving preexposure vaccination for rabies should receive only vaccine. The combination of human rabies immune globulin (HRIG) and vaccine is recommended for both bite and nonbite exposures, regardless of the interval between exposure and initiation of treatment.
| Type | Name | Route | Indications |
|---|---|---|---|
| Human Diploid Cell Vaccine (HDCV) | Imovax® Rabies | Intramuscular | Preexposure or Postexposure |
| Purified Chick Embryo Cell Vaccine (PCEC) | RabAvert® | Intramuscular | Preexposure or Postexposure |
| Human Rabies Immune Globulin | Imogam® Rabies-HT | Local infusion at wound site, with additional amount intramuscular at site distant from vaccine | Postexposure |
| Human Rabies Immune Globulin | HyperRab TM S/D | Local infusion at wound site, with additional amount intramuscular at site distant from vaccine | Postexposure |
What Will Rabies Postexposure Prophylaxis Involve?
The essential components of rabies postexposure prophylaxis are wound treatment and, for previously unvaccinated persons, the administration of both HRIG and vaccine. Administration of rabies postexposure prophylaxis is a medical urgency, not a medical emergency, but decisions must not be delayed. Incubation periods of greater than one year have been reported in humans. Thus, when a documented or likely exposure has occurred, postexposure prophylaxis is indicated regardless of the length of the delay, provided the clinical signs of rabies are not present in the person.
Postexposure Prophylaxis for Non-immunized Individuals
| Treatment | Regimen |
|---|---|
| Wound cleansing | All postexposure prophylaxis should begin with immediate thorough cleansing of all wounds with soap and water. If available, a virucidal agent such as povidine-iodine solution should be used to irrigate the wounds. |
| RIG | If possible, the full dose should be infiltrated around any wound(s) and any remaining volume should be administered IM at an anatomical site distant from vaccine administration. Also, RIG should not be administered in the same syringe as vaccine. Because RIG might partially suppress active production of antibody, no more than the recommended dose should be given. |
| Vaccine | HDCV or PCECV 1.0 mL, IM (deltoid area †), one each on days 0 §, 3, 7, 14, and 28. |
Rabies Immune Globulin
Human rabies immune globulin (HRIG) is administered only once, at the beginning of anti-rabies prophylaxis, to previously unvaccinated persons to provide immediate antibodies until they responds to the vaccine by actively producing antibodies of their own. If anatomically feasible, the full dose of HRIG should be thoroughly infiltrated in the area around and into the wounds. Any remaining volume should be injected intramuscularly at a site distant from vaccine administration.
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 five-dose series can be administered in the same anatomic location where the HRIG dose was administered.
If HRIG was not administered when vaccination was begun, it can be administered up to seven days after the administration of the first dose of vaccine. Beyond the seventh day, HRIG is not recommended since an antibody response to the vaccine is presumed to have occurred.
Because HRIG can partially suppress active production of antibody, no more than the recommended dose should be administered. The recommended dose of HRIG is 20 IU/kg body weight. This formula is applicable to all age groups, including children.
Rabies Vaccine
A regimen of five 1-mL doses of HDCV or PCEC vaccines should be administered intramuscularly to previously unvaccinated persons.
The first dose of the five-dose course should be administered as soon as possible after exposure. Additional doses should be administered on days 3, 7, 14, and 28 after the first vaccination. For adults, the vaccination should always be administered intramuscularly in the deltoid area (arm). For children, the anterolateral aspect of the thigh is also acceptable. The gluteal area should never be used for rabies vaccine injections because observations suggest administration in this area results in lower neutralizing antibody titers.
Postexposure Prophylaxis for Previously Immunized Individuals
| Treatment | Regimen |
|---|---|
| Wound cleansing | All postexposure prophylaxis should begin with immediate thorough cleansing of all wounds with soap and water. If available, a virucidal agent such as povidine-iodine solution should be used to irrigate the wounds. |
| RIG | RIG should not be administered. |
| Vaccine | HDCV or PCECV 1.0 mL, IM (deltoid area), one each on days 0 and 3. |
If exposed to rabies, previously vaccinated persons should receive two IM doses (1.0 mL each) of vaccine, one immediately and one three days later. Previously vaccinated persons are those who have received one of the recommended preexposure or postexposure regimens of HDCV, RVA, or PCECV, or those who received another vaccine and had a documented rabies antibody titer. RIG is unnecessary and should not be administered to these persons because an anamnestic response will follow the administration of a booster regardless of the pre-booster antibody titer.
Content Source: National Center for Zoonotic, Vector-Borne, & Enteric Diseases (ZVED)
