HWN Suggests

Urgent Care Management of Possible Rabies Exposure

PEP is a medical urgency, not an emergency, but should not be delayed. PEP is highly effective in preventing rabies when the regimen is correctly followed. For previously unvaccinated individuals, PEP consists of active immunization with rabies vaccine combined with passive immunization with HRIG. Rabies vaccination induces an immune response by triggering the recipient to produce neutralizing antibodies; these natively produced antibodies take 7 to 10 days to develop. Passive immunization with HRIG, administered concurrently with the first dose of vaccine, provides antibodies and covers the gap period until active immunity is achieved.

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  Rabies postexposure prophylaxis (PEP) schedule

A person who is exposed and has never been vaccinated against rabies should get 4 doses of rabies vaccine—one dose right away, and additional doses on the 3rd, 7th, and 14th days. They should also get another shot called Rabies Immune Globulin at the same time as the first dose.

  Tips for Treatment Following Possible Rabies Exposure

Initially, it’s most important to thoroughly irrigate and clean the wound. Since incubation periods of more than one year have been reported in humans, when a likely exposure has occurred, RPEP should be given regardless of the length of the delay.

 Post-Exposure Rabies Prophylaxis — Shorter, Simpler, and Less Costly

After bites by animals potentially infected with rabies, three-visit (over one week) intradermal rabies vaccination was compared to standard four-visit (over two weeks) intramuscular rabies vaccination. Both vaccine regimens prompted similarly protective neutralizing antibody and T-cell responses. While still off-label, the shorter, simpler regimen could protect patients at lower cost than the current standard regimen.

Articles of Interest

Taking a Bite Out of Rabies

Infection with rabies virus in humans is almost universally fatal. Transmitted through the bites of infected animals, rabies prevention through postexposure prophylaxis (PEP) is critical to saving patient lives. Unfortunately, rabies PEP is quite expensive and requires multiple follow-up visits to the doctor. For these reasons, compliance isn’t 100%. In addition, because rabies is rare, in the US PEP is usually only available in emergency departments (ED) and in limited quantity. And not everyone is trained properly in its administration. That, combined with less than full compliance, results in reduced efficacy for rabies PEP.

EM@3AM: Rabies

PEP: 20/kg IU IM with rabies vaccination on days 0,3,7,14 with an additional dose on day 28 if immunosuppressed.

Rabies Post-Exposure Prophylaxis

If in doubt, treat as non-immune.

Rabies: Which Patients Need Post-Exposure Prophylaxis?

The highest risk species for rabies in California are bats, skunks, and foxes. Risk is also high for raccoon and coyote bites. Bites from birds, reptiles, and small rodents (including squirrels) present a negligible risk of rabies. Most other wildlife that are not rabies reservoirs (including opossums) fall into a middle level of risk.

Resources

KedRab

Trust KEDRAB–a Human Rabies Immune Globulin (HRIG) for all ages and sizes, all exposures and wound types, and all healthcare professionals involved in the treatment of potential rabies exposures. Administer a human rabies immune globulin (HRIG), such as KEDRAB, as soon as possible after exposure, but no later than 7 days after the first dose of the vaccine2,3