Rabies

Background

Indication for Prophylaxis

• Bite or salivary exposure from bat, or mammalian carnivore
• Inhalation counts (e.g. dead bat in room)

Not needed if non-salivary exposure, or if bird, reptile, or rodent (rare cases)

Differential Diagnosis

Jaw Spasms

• Dystonic reaction
• Acute tetanus
• Conversion disorder
• Mandibular dislocation
• Electrolyte abnormality
  • Hypocalcemic tetany
  • Magnesium
• Meningitis
• Seizure disorder
• Strychnine poisoning
• Akathisia
• Stroke
• Drug toxicity (anticholinergic, phenytoin, valproate, carbamazepine)
• Torticollis
• PTA
• Rabies
• TMJ

Evaluation

Algorithm for Prophylaxis

Animal was captured

Is animal dog or cat?

• Yes: Observe 10 days, if abnormal, sacrifice and treat patient with the vacc and RIG. Then patient treatment can be discontinued if the animal pathology is negative for rabies
• No: Sacrifice animal and begin RIG and vaccine. Discontinue if animal negative path for rabies

Animal was not captured

Is Animal dog or cat?

• Yes: Give vacc and RIG only if rabies risk for species in area
• No: Treat with full course vacc and RIG

Management

Immunocompetent + NOT Vaccinated

• Clean wound
• Rabies vaccine (human diploid cell vaccine)
  • 1mL IM on days: 0, 3, 7, 14
  • Give in deltoid (not buttock), since Ab not created in fat cells
• AND, Rabies immune globulin
  • 20 IU/kg subcutaneous
  • Infiltrate around wound if possible
  • place remainder opposite arm of vaccine
  • can administer up to 7 days after the first vaccine dose

Immunocompetent + Vaccinated

• Clean wound
• Rabies vaccine (human diploid cell vaccine)
  • 1mL IM on days: 0 and 3
  • Give in deltoid (not buttock), since Ab not created in fat cells
• NO rabies immune globulin

Immuno-compromised

• Clean wound
• Rabies vaccine (human diploid cell vaccine)
  • 1mL IM on days: 0, 3, 7, 14, and 28
  • Give in deltoid (not buttock), since Ab not created in fat cells
• AND, Rabies immune globulin
  • 20 IU/kg subcutaneous
  • Infiltrate around wound if possible
  • place remainder opposite arm of vaccine
  • can administer up to 7 days after the first vaccine dose

References

Authors

Ross Donaldson, Daniel Ostermayer, Neil Young