Emergency Treatment of Rabies
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Rabies, a viral disease of the central nervous system (CNS), is widespread throughout the world. (See the image below.)
Treatment of rabies should be based on history and exposure. One should not withhold treatment while waiting for diagnostic tests.
Go Rabies for complete information on this topic.
Treatment discussed here focuses on animal exposures where rabies transmission is a possibility. This is the primary concern of the emergency physician. Treatment of human rabies is supportive and often involves therapy for other possible etiologies before specific diagnosis is made, usually postmortem or well into an intensive care unit (ICU) hospitalization.
Eliciting a history of recent animal or bite exposures is of utmost importance, as many patients described in the literature were initially sent home by the emergency department.
Postexposure prophylaxis (PEP) consists of wound cleaning, vaccination, and administration of rabies immunoglobulin.
Immediate therapy, provided prior to the administration of vaccine and immunoglobulin, consists of the thorough cleaning of all bite and scratch wounds with soap and water, 2% benzalkonium chloride, and/or a virucidal agent (ie, povidone-iodine solution). Wound cleaning alone has been shown to reduce the likelihood of rabies transmission in animal studies. Provide wound care as needed; tetanus prophylaxis is usually indicated, as are measures to prevent bacterial infection. When appropriate, wound closure should be avoided. [1]
The 2 rabies vaccines currently available in the United States are the human diploid cell vaccine (HDCV, Imovax) and the purified chick embryo cell vaccine (PCECV, RabAvert). Both are made for intramuscular administration and are equal in efficacy and safety. The vaccine takes 7-10 days to induce an active immune response, with immunity lasting approximately 2 years.
Once a vaccination series is initiated, it is usually completed with the same vaccine product, although no trials have been done to study the effects (beneficial or adverse) of beginning with one and ending with another. [1]
Slight erythema may be expected with both vaccines, but any further skin changes should be reported to the health department to determine actual necessity of vaccine.
No postexposure vaccine failures in the United States have been reported since HDCV was licensed in 1980. Of 13 cases of postexposure treatment failure that occurred outside the United States, all were from not cleaning wounds, not giving rabies vaccine, or giving rabies vaccine into the gluteal region rather than the deltoid region.
Passive immunization with human rabies immunoglobulin (HRIG, HyperRab S/D, KedRab, Imogam Rabies-HT) provides immediate protection.
The immunoglobulin elicits neutralizing antibodies and has a half-life of 21 days.
Products are from hyperimmunized human donor plasma and could potentially contain infectious agents, although this risk is small secondary to initial screening of donors. Currently, no documented transmission of adventitious agents exists. [1]
Neural tissue rabies vaccines should no longer be used, although they may still be used in some developing countries.
In countries that cannot afford the 5-dose regimen, the World Health Organization (WHO) states that 2 regimens are available that fulfill their requirements. These have been used in developing countries as replacements for the more expensive injections. These injections should be administered in consultation with the Centers for Disease Control and Prevention (CDC).
Administer one dose (20 IU/kg) to produce virus-neutralizing antibodies. Administer on day 0 at the same time as the vaccine. If not immediately available, the HRIG should be administered as soon as it becomes available up until and including day 7 of treatment. Concentrate as much of the dose as possible in and around the wound (if wound location allows). The remaining HRIG should be administered intramuscularly at a site distance from the vaccine administration. [2]
Case reports have documented safe administration of HRIG and HDCV during pregnancy.
Four doses (1 mL each) of either HDCV or PCECV vaccine should be administered on days 0, 3, 7, and 14. The first dose should be administered as soon as possible after exposure. It should be given intramuscularly into the deltoid muscle of adults. In children, it should be administered into either the deltoid muscle or the anterolateral aspect of the thigh. Do not use the gluteal region, because this could result in a decreased immunologic response. It is important to give all 4 doses. [2]
Immunocompromised persons should receive HRIG and the vaccine as described above but should, in addition, receive a fifth dose, on day 28. Any immunosuppressive agents should be stopped during rabies PEP unless necessary and essential for management of another condition.
Additionally, serum should be tested to document seroconversion 1-2 weeks after completing PEP. The rapid fluorescent focus inhibition test (RFFIT) should be used to determine that an appropriate antibody response has developed. If the patient does not seroconvert, the patient should continue management with both the physician and public health officials. [2]
Previously vaccinated persons include those who have received the 3-dose preexposure series of HDCV, rabies adsorbed virus (RVA), or PCECV; a full PEP; or a previous vaccination with any rabies vaccine with a documented history of seroconversion.
HRIG should not be administered.
For the vaccine, administer 2 doses (1 mL each) into the deltoid muscle on day 0 and day 3.
Manning SE, Rupprecht CE, Fishbein D, Hanlon CA, Lumlertdacha B, Guerra M, et al. Human rabies prevention–United States, 2008: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2008 May 23. 57:1-28. [Medline].
Rupprecht CE, Briggs D, Brown CM, Franka R, Katz SL, Kerr HD, et al. Use of a reduced (4-dose) vaccine schedule for postexposure prophylaxis to prevent human rabies: recommendations of the advisory committee on immunization practices. MMWR Recomm Rep. 2010 Mar 19. 59:1-9. [Medline].
Raffi Kapitanyan, MD Assistant Professor of Emergency Medicine, Rutgers Robert Wood Johnson Medical School
Raffi Kapitanyan, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Peter W Pryor, II, MD, MPH Fellow in Emergency Medical Services/Disaster Medicine, Attending Physician, Department of Emergency Medicine, Robert Wood Johnson University Hospital, University of Medicine and Dentistry of New Jersey
Disclosure: Nothing to disclose.
John Bertolini, MD, FACEP Regional Vice President, Emergency Medical Associates
John Bertolini, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.
Erin C Beaumont, MD Rutgers Robert Wood Johnson Medical School
Disclosure: Nothing to disclose.
Mark A Merlin, DO, EMT-P, FACEP Assistant Professor, EMS Medical Director, Department of Emergency Medicine, University of Medicine and Dentistry-Robert Wood Johnson Medical School; Medical Director, New Jersey EMS/Disaster Medicine Fellowship, New Jersey EMS Physician Response Program, New Jersey EMS Task Force; Chair of New Jersey Mobile Intensive Care Unit Advisory Council, New Jersey Department of Health and Senior Services
Mark A Merlin, DO, EMT-P, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Medical Association, American Osteopathic Association
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Eric L Weiss, MD, DTM&H Medical Director, Office of Service Continuity and Disaster Planning, Fellowship Director, Stanford University Medical Center Disaster Medicine Fellowship, Chairman, SUMC and LPCH Bioterrorism and Emergency Preparedness Task Force, Clinical Associate Professor, Department of Surgery (Emergency Medicine), Stanford University Medical Center
Eric L Weiss, MD, DTM&H is a member of the following medical societies: American College of Emergency Physicians, American College of Occupational and Environmental Medicine, American Medical Association, American Society of Tropical Medicine and Hygiene, Physicians for Social Responsibility, Southeastern Surgical Congress, Southern Oncology Association of Practices, Southern Clinical Neurological Society, Wilderness Medical Society
Disclosure: Nothing to disclose.
Robert E O’Connor, MD, MPH Professor and Chair, Department of Emergency Medicine, University of Virginia Health System
Robert E O’Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Heart Association, American Medical Association, National Association of EMS Physicians, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Robert L Norris, MD Professor Emeritus, Department of Emergency Medicine, Stanford University Medical Center
Robert L Norris, MD is a member of the following medical societies: American College of Emergency Physicians, Wilderness Medical Society
Disclosure: Nothing to disclose.
Emergency Treatment of Rabies
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