Sunday, April 18, 2010

Rabies : Post-exposure Prophylaxis

# cleanse the wound with a solution of soap and water + povidone iodine solution
# evaluate the need to institute rabies post-exposure prophylaxis - you can use the
algorithm prn

# scratches, abrasions, open wounds or mucous membranes exposed to saliva or other potentially infectious material constitute significant non-bite exposures
# simple contact (eg. petting) with a rabid animal, or its urine or feces, does not constitute a non-bite exposure
# bites of squirrels, hamsters, guinea pigs, gerbils, chipmunks, rats, mice and other small rodents, rabbits and hares almost never require post-exposure prophylaxis
# theoretically, human bites that penetrate skin could represent a significant exposure, but there have been no reported cases in the USA
# direct exposure to bats, even in the absence of a definite bite or scratch, may represent a significant exposure eg. child, intoxicated or mentally retarded adult, sleeping in the same room as a bat; household contacts of those exposed patients do not require post-exposure prophylaxis
# post-exposure prophylaxis consists of 1 dose of rabies immunoglobulin (20IU/kg) and 5 doses of rabies vaccine over 28 days (days 0, 3, 7, 14 and 28)

# a larger dose of rabies immunglobulin (40 - 50 IU/kg) is recommended for significant bites about the face and neck
# if anatomically feasible, the full dose of RIG should be given at the bite site or in a muscle as anatomically near the bite site as practical
# the rabies vaccine should be given in the deltoid muscle (not buttocks); or antero-lateral thigh in very small children
# side-effects of vaccination include mild erythema, pain and swelling at the site of injection; systemic effects such as headache, nausea, muscle aches and dizziness; and serum sickness-like reaction (arthalgia, arthritis, angiedema, generalised urticaria, nausea, vomiting, fever and malaise)
# rabies vaccination should not be discontinued because of mild reactions
# patients with a history of prior rabies vaccination only require 2x IM doses of rabies vaccine, one immediately and the second dose on day 3
# the same post-exposure rabies protocol should be used for immuno-compromised and pregnant patients
# children should receive HRIG based on body weight (20IU/kg), but should receive the same adult dose of rabies vaccine