Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

asymptomatic with recent vector exposure

1st line – reassurance

Back
INITIAL
|
asymptomatic with recent vector exposure
|
unimmunized: nonbite exposure with no infection risk
1st line – 

reassurance

There is no risk of infection if the exposure involves touching or feeding of animals, or licks on intact skin. If the history is reliable, no treatment is required.

1st line – wound cleansing

Back
INITIAL
|
asymptomatic with recent vector exposure
|
unimmunized: nonbite exposure with low infection risk
1st line – 

wound cleansing

Nibbling of uncovered skin or minor scratches or abrasions without bleeding carry a low risk of infection, and postexposure prophylaxis is required.

The wound should be thoroughly washed and flushed with soap and water (or water alone) for 15 minutes, and disinfected immediately with detergent, iodine, or ethanol.

Plus – multiple-dose immunization protocol

Back
INITIAL
|
asymptomatic with recent vector exposure
|
unimmunized: nonbite exposure with low infection risk
Plus – 

multiple-dose immunization protocol

Treatment recommended for ALL patients in selected patient group

There are 2 vaccines available in the US: human diploid cell vaccine and purified chick embryo cell vaccine. Purified vero cell vaccine and purified duck embryo vaccine are other vaccines that are available internationally and prequalified by the World Health Organization (WHO).

The US protocol (recommended by the Advisory Committee on Immunization Practices [ACIP]) involves intramuscular injection into the deltoid area (in adults) or anterolateral aspect of the thigh (in children). The first dose is given as soon as possible after the exposure (day 0). Further doses are given 3, 7, and 14 days after the initial dose (an additional dose at 28 days is recommended if the patient is immunocompromised).[44]

The WHO recommends either an intradermal (3-dose) or intramuscular (4-dose or 2-1-1 dose) regimen. The intradermal regimen is preferred as it is the most cost-, dose-, and time-sparing regimen.[33]

Primary options

ACIP protocol

rabies vaccine: 1 mL intramuscularly on days 0, 3, 7, and 14 (and 28 in immunocompromised patients)

OR

WHO protocols

rabies vaccine: 0.1 mL intradermally (divided between 2 sites) on days 0, 3, and 7; 1 dose intramuscularly (1-site) on days 0, 3, 7, and between days 14-28; 2 doses intramuscularly (2-sites) on day 0, followed by an additional dose (1-site) on days 7 and 21

Consider – rabies immune globulin

Back
INITIAL
|
asymptomatic with recent vector exposure
|
unimmunized: nonbite exposure with low infection risk
Consider – 

rabies immune globulin

Treatment recommended for SOME patients in selected patient group

ACIP recommends use in all patients with nonbite exposure.[44] The World Health Organization (WHO) recommends use in these types of exposures if the patient is immunosuppressed. Individuals with immunodeficiency should be evaluated on a case-by-case basis.[33]

Human rabies immune globulin (hRIG) is infiltrated into the wound(s) without primary closure. The full dose should be given into the wound(s) and surrounding area if anatomically feasible (loose suturing should be performed if necessary only after infiltration).

If this is not possible, US guidelines recommend any remaining hRIG should be given intramuscularly, although WHO guidance no longer supports this.[33][44] The site used to give intramuscular hRIG must be remote from the site used to give the vaccine. The total dose should not be exceeded; if the calculated dose is insufficient to infiltrate all wounds, sterile saline may be used to dilute the hRIG to allow thorough infiltration.

Use of rabies immune globulin may be delayed by up to 7 days from the first vaccine dose if necessary (e.g., it is not available).

Equine rabies immune globulin (eRIG) may be used in developing countries if hRIG is not available (note: the dose differs to hRIG). Both have shown similar clinical outcomes in the prevention of rabies. eRIG is less costly than hRIG and can now be administered without initial skin testing.[33]

In areas where RIG is limited, allocation should be prioritized for patients with high-risk exposures (e.g., multiple bites, deep wounds).[33]

Primary options

rabies immune globulin (human): 20 units/kg (maximum) as a single dose infiltrated into the wound and surrounding tissue

More

1st line – wound cleansing

Back
INITIAL
|
asymptomatic with recent vector exposure
|
unimmunized: bite exposure, licks on broken skin or mucous membrane, or exposure to bat bites or scratches
1st line – 

wound cleansing

Single or multiple transdermal bites or scratches, licks on broken skin, contamination of mucous membrane with saliva from licks, or exposure to bat bites or scratches carry a high risk of infection, and postexposure prophylaxis is required.

The wound should be thoroughly washed and flushed with soap and water (or water alone) for 15 minutes, and disinfected immediately with detergent, iodine, or ethanol.

Plus – multiple-dose immunization protocol

Back
INITIAL
|
asymptomatic with recent vector exposure
|
unimmunized: bite exposure, licks on broken skin or mucous membrane, or exposure to bat bites or scratches
Plus – 

multiple-dose immunization protocol

Treatment recommended for ALL patients in selected patient group

There are 2 vaccines available in the US: human diploid cell vaccine and purified chick embryo cell vaccine. Purified vero cell vaccine and purified duck embryo vaccine are other vaccines that are available internationally and prequalified by the World Health Organization (WHO).

The US protocol (recommended by the Advisory Committee on Immunization Practices [ACIP]) involves intramuscular injection into the deltoid area (in adults) or anterolateral aspect of the thigh (in children). The first dose is given as soon as possible after the exposure (day 0). Further doses are given 3, 7, and 14 days after the initial dose (an additional dose at 28 days is recommended if the patient is immunocompromised).[44] 

The WHO recommends either an intradermal (3-dose) or intramuscular (4-dose or 2-1-1 dose) regimen. The intradermal regimen is preferred as it is the most cost-, dose-, and time-sparing regimen.[33]

Primary options

ACIP protocol

rabies vaccine: 1 mL intramuscularly on days 0, 3, 7, and 14 (and 28 in immunocompromised patients)

OR

WHO protocols

rabies vaccine: 0.1 mL intradermally (divided between 2 sites) on days 0, 3, and 7; 1 dose intramuscularly (1-site) on days 0, 3, 7, and between days 14-28; 2 doses intramuscularly (2-sites) on day 0, followed by an additional dose (1-site) on days 7 and 21

Plus – rabies immune globulin

Back
INITIAL
|
asymptomatic with recent vector exposure
|
unimmunized: bite exposure, licks on broken skin or mucous membrane, or exposure to bat bites or scratches
Plus – 

rabies immune globulin

Treatment recommended for ALL patients in selected patient group

Human rabies immune globulin (hRIG) is infiltrated into the wound(s) without primary closure. The full dose should be given into the wound(s) and surrounding area if anatomically feasible (loose suturing should be performed if necessary only after infiltration).

If this is not possible, US guidelines recommend any remaining hRIG should be given intramuscularly, although WHO guidance no longer supports this.[33][44] The site used to give intramuscular hRIG must be remote from the site used to give the vaccine. The total dose should not be exceeded; if the calculated dose is insufficient to infiltrate all wounds, sterile saline may be used to dilute the hRIG to allow thorough infiltration.

Use of rabies immune globulin may be delayed by up to 7 days from the first vaccine dose if necessary (e.g., it is not available).

Equine rabies immune globulin (eRIG) may be used in developing countries if hRIG is not available (note: the dose differs to hRIG). Both have shown similar clinical outcomes in the prevention of rabies. eRIG is less costly than hRIG and can now be administered without initial skin testing.[33]

In areas where RIG is limited, allocation should be prioritized for patients with high-risk exposures (e.g., multiple bites, deep wounds).[33]

Primary options

rabies immune globulin (human): 20 units/kg (maximum) as a single dose infiltrated into the wound and surrounding tissue

More

1st line – wound cleansing

Back
INITIAL
|
asymptomatic with recent vector exposure
|
immunized: any exposure with infection risk
1st line – 

wound cleansing

The wound should be thoroughly washed and flushed with soap and water (or water alone) for 15 minutes, and disinfected immediately with detergent, iodine, or ethanol.

Rabies immune globulin is not required in these patients.

Plus – multiple-dose immunization protocol

Back
INITIAL
|
asymptomatic with recent vector exposure
|
immunized: any exposure with infection risk
Plus – 

multiple-dose immunization protocol

Treatment recommended for ALL patients in selected patient group

The US protocol, recommended by the Advisory Committee on Immunization Practices (ACIP), involves intramuscular injection into the deltoid area (in adults) or anterolateral aspect of the thigh (in children). The first dose is given as soon as possible after the exposure (day 0), with a second dose on day 3.[44] There are 2 vaccines available in the US: human diploid cell vaccine and purified chick embryo cell vaccine. Purified vero cell vaccine and purified duck embryo vaccine are other vaccines that are available internationally and prequalified by the World Health Organization (WHO).

The WHO recommends either intradermal or intramuscular administration on days 0 and 3, or a 4-site intradermal regimen (four 0.1 mL injections equally distributed over left and right deltoids, thigh, or suprascapular areas during a single visit). The intradermal regimens are preferred as they are the most cost-, dose-, and time-sparing regimens.[33]

Primary options

ACIP protocol

rabies vaccine: 1 mL intramuscularly on days 0 and 3

OR

WHO protocols

rabies vaccine: one dose intradermally/intramuscularly on days 0 and 3; 0.1 mL intradermally injected four times (equally distributed over left and right deltoids, thigh, or suprascapular areas)

ACUTE

symptomatic rabies

1st line – palliative care

Back
ACUTE
|
symptomatic rabies
1st line – 

palliative care

Occasional rabies survivors are noted, but there is no recognized curative medical therapy.

The patient should be isolated to minimize the number of medical staff who might need later prophylaxis. Standard precautions are recommended (e.g., masks, gloves, eye/face protection, gowns).

Rabies immunization or immune globulin is contraindicated during active disease, as it confers no benefit and may be harmful.

Many experts recommend palliation. Given that spasms in rabies (hydrophobia and aerophobia) are stimulus driven, recommendations include seclusion, room darkening, and restraint.

The only study of palliation in rabies recommends haloperidol.[45][46]

Other agents that may be used to relieve symptoms include opioid analgesics, anticonvulsants (for seizures), and neuromuscular blockers.[47]

Primary options

haloperidol: 0.5 to 10 mg orally every 1-4 hours initially, titrate according to response, maximum 100 mg/day

back arrow

Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer