Action
Patient presents with mammal bite, exposure to a bat, or contact to an open wound or mucous membrane with mammal saliva or brain tissue.
Decision
What type of animal bite or exposure?
Background
Vaccination against rabies comes in 2 forms: PrEP, given prior to potential rabies exposure; and PEP, given after potential rabies exposure.
Pre-exposure Prophylaxis for Rabies
Although UC clinicians are unlikely to administer PrEP themselves, it’s helpful to know what it entails so that is patients receive accurate advice and counseling. PrEP consists of three 1-mL injections of human diploid cell culture vaccine or purified chick embryo cell vaccine intramuscularly in the deltoid on days 0, 7, and 21 or 28, with the day of the first dose considered day 0. Individuals who receive PrEP vaccine must be made aware that it simplifies the PEP regimen if an exposure occurs, but it does not eliminate the need for PEP. Depending on the exposure risk, booster doses and antibody assays may be required.
Post-exposure Prophylaxis for Rabies
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.
Wound Care
The first priorities after an animal bite are: to ensure hemostasis, address injuries to nerves, tendons, or vasculature, and prevent infection. Vigorous, copious irrigation with use of an iodine-based antiseptic should be performed immediately for a minimum of 15 minutes to all bites, scratches, and open skin or mucosal exposures. Ethanol can be used if iodine is unavailable. In animal studies, thorough wound cleansing alone significantly reduced the likelihood of contracting rabies. Unless absolutely necessary, suturing a bite wound should be avoided. If gaping or poor hemostasis mandate primary wound closure, delay suturing for several hours after infiltration of human rabies immune globulin (HRIG) to allow diffusion into the tissues. If indicated, administer tetanus prophylaxis and antibiotics.
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