A 26-year-old man comes to the emergency department after returning from a cave diving trip. Yesterday, the patient spent time in a cave chamber that had a large number of bats. Several bats flew around his face, causing 2 facial scratches. The patient has never received rabies vaccination. He has no significant medical history. The patient does not use tobacco, alcohol, or recreational drugs. He does not take medications and has no known allergies. What is the best next step in management of this patient?
Rabies prophylaxis guidelines | |
Status | Recommendation |
Preexposure prophylaxis |
|
Postexposure prophylaxis, previously unvaccinated |
AND
|
Postexposure prophylaxis, previously vaccinated |
|
Rabies is a fatal viral disease primarily acquired from exposure to saliva from a rabid animal via a bite or scratch. Postexposure prophylaxis can prevent the development of rabies infection. This patient's history of bat contact places him at risk for rabies infection; therefore, postexposure prophylaxis should be considered.
There are 2 forms of prophylaxis available:
Most patients are diagnosed following exposure (postexposure prophylaxis). However, individuals whose work/travel involves likely exposure to rabies (eg, laboratory work with live rabies virus) should receive a preexposure prophylaxis course.
In the unvaccinated patient, postexposure prophylaxis consists of active immunization with 4 doses of the rabies vaccine, which generates virus-neutralizing antibodies within 10 days, AND passive immunization with rabies immunoglobulin, which provides immediate virus-neutralizing antibodies. The wound should also be thoroughly cleaned with a viricidal agent such as providone-iodine.
(Choices A and E) Given that the patient experienced wounds due to bat contact, his chance of developing rabies is too high to observe or reassure; he requires postexposure prophylaxis to reduce his risk of developing rabies.
(Choice C) Passive immunization with rabies immunoglobulin blunts the immune response to the vaccine. Immunoglobulin should be avoided in previously vaccinated individuals because some amount of antibody is still circulating.
(Choice D) Unvaccinated patients require rabies immunoglobulin to provide coverage against rabies for the first 7-10 days after rabies vaccination. For previously vaccinated patients, postexposure prophylaxis consists of a rabies vaccination booster (2 doses) alone (ie, no rabies immunoglobulin); this is because immunoglobulin may interfere with the immune response to revaccination and circulating antibodies are already present.
Educational objective:
Patients exposed to rabies require postexposure prophylaxis with 4 doses of the rabies vaccine in addition to rabies immunoglobulin. In contrast, previously vaccinated individuals who are potentially reexposed to rabies should receive only a booster course of rabies vaccine (2 doses).