eMedicine Specialties > Infectious Diseases > Viral Infections

Rabies: Treatment & Medication

Author: Sandra G Gompf, MD, FACP, FIDSA, Associate Professor of Infectious Diseases and International Medicine, University of South Florida College of Medicine; Chief, Infectious Diseases Section, Director, Occupational Health and Infection Control Programs, James A Haley Veterans Hospital
Coauthor(s): Charurut Somboonwit, MD, Assistant Professor of Medicine, Division of Infectious Disease and International Medicine, University of South Florida College of Medicine; Senior Physician, Polk County Health Department; Tri M Pham, MD, Fellow, Division of Infectious Diseases and International Medicine, University of South Florida College of Medicine; Albert L Vincent, PhD, Associate Professor, Division of Infectious Diseases and International Health, Department of Internal Medicine, University of South Florida College of Medicine; Scientific and Research Advisor to the Division of Epidemiology, Hillsborough County Health Department
Contributor Information and Disclosures

Updated: Oct 3, 2008

Treatment

Medical Care

  • Before the onset of rabies symptoms, both passive and active immunizations are effective for preventing progression to full-blown rabies.
  • Vaccines commonly available in the United States are discussed further in Deterrence/Prevention.
    • Human diploid cell vaccine (HDCV, Pasteur Merièux)12
    • Rabies vaccine, adsorbed (RVA, Michigan State Department of Health)
  • Optimal results require the following:
    • Immediate vigorous wound cleansing with a solution of 1 part soap and 4 parts water
    • Passive immunization
      • No prior vaccination with HDCV or RVA - Human rabies immunoglobulin (HRIG)
      • Prior vaccination - No HRIG
    • Active immunization
      • No prior vaccination with HDCV or RVA - Primary series HDCV or RVA
      • Prior vaccination - Booster series HDCV or RVA
  • A neutralizing antibody (NAb) titer greater than or equal to 0.5 IU/mL (or complete neutralization at a serum dilution of 1:5) is considered an acceptable antibody response for protection against rabies. Of 7 patients infected with HIV who had CD4 counts less than 200 cells/µL, 3 had a poor or even undetectable NAb response to vaccination. Patients infected with HIV who had higher CD4 lymphocyte counts had a good antibody response to postexposure rabies vaccination.13 If an acceptable antibody response is not achieved, a second double-dose series of rabies vaccine should be administered in an attempt to successfully mount an adequate antibody response.
  • Elderly patients (>50 y) produce antibody titer levels 52% lower than younger patients. Whether this equates to reduced protective efficacy remains unclear.
  • Do not administer immunoglobulin and vaccine with the same syringe or in the same site.
  • Passive antibody provides protection for 1-2 weeks until the vaccine elicits protective antibody.
  • In exposures to high-risk species, initiate treatment immediately pending laboratory examination of the animal, if it is caught.
  • Therapy can be stopped if results from the animal's brain examination are negative.
  • The median duration of rabies illness in dogs, cats, and ferrets is less than 10 days, and viral shedding in saliva occurs within a few days of onset of illness and death. Because of the exceedingly low prevalence of rabies in domestic animals in the United States, healthy unvaccinated domestic dogs, cats, and ferrets may be observed for 10 days for signs of illness. If the animal remains healthy, administer no treatment; otherwise, begin treatment on the exposed individual pending necropsy results of the animal. Treatment can be discontinued if examination of the animal's brain is negative for rabies. Vaccinated animals in the United States have not transmitted rabies; outside the United States, rare instances of transmission occur. Species other than the above should be managed in conjunction with the local health department, taking into account whether viral shedding periods are known for the species, the animal's history and risk for rabies exposure, and local epidemiology.
  • Consult the local health department because the risk of rabies differs geographically based on local endemicity and immunization practices. Some countries and limited areas in US territories are considered rabies-free, and no prophylaxis is administered.
  • Note that an assessment of whether a bite was provoked is subjective and does not significantly affect the chances that the animal is rabid. Therefore, this is probably not helpful in determining the need for prophylactic treatment.
  • Intensive cardiopulmonary supportive care is the only treatment available for patients with symptomatic rabies.
  • Regardless of treatment, symptomatic rabies is invariably fatal, resulting from autonomic dysfunction that leads to cardiac arrhythmia and hypotension. Only 6 recorded cases of survivors exist, 5 of whom received some level of preexposure or postexposure prophylaxis in the asymptomatic phase and subsequently developed rabies. The use of ribavirin and induced coma has yet to be reproduced or validated in the one survivor who did not receive preexposure or postexposure prophylaxis; however, some role for combination therapies including ribavirin, interferon, ketamine, and immunomodulatory therapies has been proposed and may be considered in future cases under investigational protocols. The rarity of human rabies hinders timely testing for effective therapies. Immunomodulatory therapies such as rabies immunoglobulin, rabies vaccine, and interferon have not altered outcomes in trials.
  • Pregnancy is not a contraindication to postexposure prophylaxis against rabies, which is warranted to protect the life of the fetus and mother. No adverse pregnancy outcomes have been documented with postexposure prophylaxis. No mother-to-fetus transmission has been described; thus, neither rabies exposure nor diagnosis of rabies in the mother is an indication for pregnancy termination.
  • Steroids, which are usually indicated in the treatment of local vaccine reactions or cerebral edema, are contraindicated because of increased mortality noted in animal studies and because they reduce the response to the vaccine.

Consultations

  • Local health department personnel
  • Infectious diseases specialist
  • Neurologist

Medication

Before the onset of rabies symptoms, both passive and active immunizations are effective in preventing progression to full-blown rabies. Optimal results require immediate vigorous wound cleansing, passive immunization, and active immunization.

In developing countries, nerve tissue vaccines are still the most widely used type for prophylaxis of rabies worldwide. They are dangerous in terms of induction of autoimmune CNS disease, require multiple injections, and are not always effective. Two types exist, the Semple type (STV) and the suckling mouse brain vaccine (SMBV).

STV is obtained from inactivated virus prepared on adult animal nerve tissue. It is inexpensive and relatively easy to produce. In India, 3 million people receive postexposure courses of STV each year. STV may produce neurological reactions, including postvaccination encephalomyelitis, in up to 1 in 220 courses, with a 3% mortality rate.

SMBV is cultured on immature mouse brain tissue, which contains little myelin. It is the most widely used rabies postexposure vaccine in Vietnam. Rare neurologic reactions occur, with complications in 1 in 27,000 treated people, with a 22% mortality rate.

Both SMBV and STV are widely used throughout the developing world and are the vaccines administered to US travelers exposed to animal bites in such countries.

Immunizing agents (passive)

Rabies immunoglobulin is recommended as part of the rabies postexposure regimen for persons not previously immunized against rabies.

In the United States, passive immunization consists of administration of HRIG pooled from the sera of immunized human donors. Two products are available in the United States, BayRab and Imogam.

In developing countries, equine rabies immunoglobulin (ERIG) is sometimes used but has a higher incidence of adverse effects. ERIG is no longer produced by large pharmaceutical companies. When produced by smaller pharmaceutical firms, quality cannot be ensured.

A US Investigational New Drug Application has been submitted for a new-generation purified ERIG.

A human rabies virus–specific monoclonal antibody is in development, theoretically to decrease the possibility of anaphylaxis.14

Because of cost, ERIG and HRIG are not readily available throughout much of the developing world, areas in which rabies is more common than in the United States.

If HRIG is available only after more than a week after vaccination has started, then it is probably unnecessary because an active antibody response has already begun.

Vaccine and antiserum should never be mixed or injected in the same limb.


Rabies immune globulin-Human (BayRab, Imogam)

Has been licensed since 1975, and, unlike its predecessor, ERIG, is not associated with significant adverse reactions, anaphylaxis, or serum sickness. Purified ERIG is still used in some developing nations because of cost or availability and is associated with an adverse effect rate of 0.8-6%, which usually involves minor reactions. HRIG is not associated with transmission of viral hepatitis or HIV. Experimentally, infiltration of HRIG at site of exposure is more protective than IM administration. Previously, half the dose was administered at the site and half IM; however, current recommendation is that the entire dose be infiltrated, if possible, in and around the site, with any remaining solution administered IM in the gluteus.

Adult

20 IU/kg; most or all of solution is infiltrated around the wound; any remaining solution should be administered IM in the gluteus; not to exceed 20 IU/kg

Pediatric

Administer as in adults, except inject into anterolateral thigh

Through an antigen-antibody antagonism, RIG may diminish antibody response to MMR vaccine; should administer live virus vaccines 14-30 d before or 6-12 wk after immune globulin administration; antibody response to rabies vaccine may be delayed if administered simultaneously with RIG

Documented hypersensitivity; to prevent interference with a maximum active immunity from rabies vaccine, do not administer in repeated doses once rabies vaccine treatment initiated; >20 IU/kg is associated with reduced antibody response to HDCV and should not be used

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in thrombocytopenia or bleeding disorders; do not administer immunoglobulin and vaccine using same syringe or in same site

Rabies vaccines (United States)

These agents promote immunity by inducing an active immune response.

Advantages of HDCV include freedom from heterologous protein, a high level of immunogenicity that permits a rational dosing schedule, and efficacy demonstrated in trials. The disadvantage of these vaccines is the cost of production.

The CDC only recommends postexposure prophylaxis with IM injections.

The WHO released guidelines for ID use of HDCV, purified chick embryo cell vaccine, and purified duck embryo cell vaccine in 1998.15 In areas where cost and vaccine supply are limiting factors, this may be the most feasible treatment option. IM regimens based on US Food and Drug Administration (FDA) approval and manufacturer's recommendations are included below, with WHO regimens listed as alternatives.

Booster immunization is for individuals at continuous or frequent risk of rabies, who should undergo periodic rabies antibody testing and who have serum rabies titer <1:5 dilution based on RFFIT results.


Human diploid cell vaccine (Imovax Rabies Vaccine, Imovax Rabies ID)

Inactivated forms of virus that promote immunity by inducing an active immune response.
Imovax Rabies ID indicated for preexposure use only by the ID route. Because of poorer response rates, ID use not approved by FDA for postexposure prophylaxis.

Adult

Preexposure
Primary immunization: 1 mL IM deltoid on days 0, 7, and 21 or 28
Booster immunization: 1 mL IM deltoid
Postexposure
No prior vaccination with HDCV or RVA: 1 mL IM deltoid on days 0, 3, 7, 14, and 28
Prior vaccination: 1 mL IM deltoid on days 0 and 3
Alternatives
2-1-1 IM regimen: 1 mL IM bid (1 dose in each deltoid) on day 0, then 1 mL IM deltoid on days 7 and 21
8-site ID regimen (WHO regimen, 1998; may be considered for use in resource-poor areas, but not FDA approved for this use in United States): 0.1 mL ID in each of 8 sites (each deltoid, each lateral thigh, each suprascapular region, and right and left lower quadrants of abdomen) on day 0, 0.1 mL ID in each of 4 sites (each deltoid, each lateral thigh) on day 7, 0.1 mL ID deltoid (1 site only) on days 28 and 90

Pediatric

Administer as in adults, except inject into anterolateral thigh

High-dose corticosteroids, antimalarials, and radiation therapy may inhibit immunization, and patients may remain susceptible despite vaccination; use of immunosuppressants should be avoided during postexposure therapy; persons receiving immunosuppressive therapy should receive RIG (3 doses/mL each IM)

Life-threatening hypersensitivity reactions; if reaction occurs, carefully consider patient risk of developing rabies before deciding to discontinue immunization

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Administer IM only in deltoid area; vaccination may fail if injected into gluteal area (because of higher likelihood of injecting into fat rather than muscle)
To prevent failure with Imovax Rabies ID, inject ID and not IM; use IM route for Imovax Rabies Vaccine; in documented hypersensitivity, may pretreat with antihistamines; epinephrine injection (1:1000), volume replacement, oxygen, and corticosteroids must be immediately available to counteract anaphylactic reactions that may occur
Pregnancy is not a contraindication to postexposure use of this vaccine because risks of inadequately treated rabies exposure clearly outweigh risks of fetal abnormalities based on limited data; preexposure prophylaxis may also be indicated in pregnancy; however, if risk of rabies is substantial and removal of pregnant woman from high-risk area is feasible, this may be preferred


Rabies vaccine, adsorbed (produced by the Michigan State Department of Health)

Inactivated virus vaccine that promotes immunity by inducing active immune response. Administered IM only, never ID.

Adult

Preexposure
Primary immunization: 1 mL IM deltoid on days 0, 7, and 21 or 28
Booster immunization: 1 mL IM deltoid
Postexposure
No prior vaccination with HDCV or RVA: 1 mL IM deltoid on days 0, 3, 7, 14, and 28
Prior vaccination with HDCV or RVA: 1 mL IM deltoid on days 0 and 3

Pediatric

Administer as in adults, except inject into anterolateral thigh

High-dose corticosteroids, antimalarials, and radiation therapy may inhibit immunization, and patients may remain susceptible despite vaccination; use of immunosuppressants should be avoided during postexposure therapy; persons receiving immunosuppressive therapy should receive RIG (3 doses/mL each IM)

None reported for postexposure immunization; if alternative products are not available, exercise caution in persons known to be sensitive to neomycin, amphotericin B, chlortetracycline, processed bovine gelatin, and chicken protein because trace amounts of these products may be present in vaccine

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Administer IM only in deltoid area; vaccination may fail if injected into gluteal area (because of higher likelihood of injecting into fat rather than muscle); epinephrine injection (1:1000), volume replacement, oxygen, and corticosteroids must be immediately available to counteract anaphylactic reactions that may occur; pregnancy is not a contraindication to postexposure use of this vaccine because risks of inadequately treated rabies exposure clearly outweigh risks of fetal abnormalities based on limited data; preexposure prophylaxis may also be indicated in pregnancy; however, if risk of rabies is substantial and removal of the pregnant woman from the high-risk area is feasible, this may be preferred


Purified chick embryo cell vaccine (RabAvert)

Inactivated virus vaccine that promotes immunity by inducing active immune response. Indicated for IM use only. Not FDA approved for ID use.

Adult

Preexposure
Primary immunization: 1 mL IM deltoid on days 0, 7, and 21 or 28
Booster immunization: 1 mL IM deltoid
Postexposure
No prior vaccination with HDCV or RVA: 1 mL IM deltoid on days 0, 3, 7, 14, and 28
Prior vaccination with HDCV or RVA: 1 mL IM deltoid on days 0 and 3
Alternative
2-1-1 IM regimen: 1 mL IM bid (1 dose in each deltoid) on day 0, then 1 mL IM deltoid on days 7 and 21
8-site ID regimen (WHO regimen, 1998; may be considered for use in resource-poor areas, but not FDA approved for this use in United States): 0.1 mL ID in each of 8 sites (each deltoid, each lateral thigh, each suprascapular region, and right and left lower quadrants of abdomen) on day 0, 0.1 mL ID in each of 4 sites (each deltoid, each lateral thigh) on day 7, 0.1 mL ID deltoid (1 site only) on days 28 and 90

Pediatric

Administer as in adults, except inject into anterolateral thigh

High-dose corticosteroids, antimalarials, and radiation therapy may inhibit immunization, and patients may remain susceptible despite vaccination; avoid immunosuppressants during postexposure therapy; persons receiving immunosuppressive therapy should receive RIG (3 doses/mL each IM)

None reported for postexposure immunization; if alternative products are not available, exercise caution in persons known to be sensitive to neomycin, amphotericin B, chlortetracycline, processed bovine gelatin, and chicken protein because trace amounts of these products may be present in vaccine

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Administer IM only in deltoid area; vaccination may fail if injected into gluteal area (because of higher likelihood of injecting into fat rather than muscle); epinephrine injection (1:1000), volume replacement, oxygen, and corticosteroids must be immediately available to counteract anaphylactic reactions that may occur; pregnancy is not a contraindication to postexposure use of this vaccine because risks of inadequately treated rabies exposure clearly outweigh risks of fetal abnormalities based on limited data; preexposure prophylaxis also may be indicated in pregnancy; however, if risk of rabies is substantial and removal of the pregnant woman from the high-risk area is feasible, this may be preferred

More on Rabies

Overview: Rabies
Differential Diagnoses & Workup: Rabies
Treatment & Medication: Rabies
Follow-up: Rabies
Multimedia: Rabies
References
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Further Reading

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Keywords

rabies, rabies virus, Lyssavirus, lyssaviruses, classic rabies, bat rabies virus, human rabies, zoonosis, rabies encephalitis, furious rabies, paralytic rabies, rabieslike illness, rabid canines, hydrophobia, rabid animal bite, wild animal bite, cat bite, dog bite, bat bite, mad dog, dumb rabies, apathetic rabies, RABV, Rhabdoviridae, rhabdoviruses, Mokola virus, Duvenhage virus, Obodhiang virus, Kotonkan virus, Rochambeau virus, European bat Lyssavirus type 1, European bat Lyssavirus type 2, Australian bat Lyssavirus

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Contributor Information and Disclosures

Author

Sandra G Gompf, MD, FACP, FIDSA, Associate Professor of Infectious Diseases and International Medicine, University of South Florida College of Medicine; Chief, Infectious Diseases Section, Director, Occupational Health and Infection Control Programs, James A Haley Veterans Hospital
Sandra G Gompf, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Coauthor(s)

Charurut Somboonwit, MD, Assistant Professor of Medicine, Division of Infectious Disease and International Medicine, University of South Florida College of Medicine; Senior Physician, Polk County Health Department
Charurut Somboonwit, MD is a member of the following medical societies: American College of Physicians, American Medical Association, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Tri M Pham, MD, Fellow, Division of Infectious Diseases and International Medicine, University of South Florida College of Medicine
Tri M Pham, MD is a member of the following medical societies: American College of Physicians, Florida Medical Association, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Albert L Vincent, PhD, Associate Professor, Division of Infectious Diseases and International Health, Department of Internal Medicine, University of South Florida College of Medicine; Scientific and Research Advisor to the Division of Epidemiology, Hillsborough County Health Department
Disclosure: none None None

Medical Editor

Daniel R Lucey, MD, MPH, Chief, Fellowship Program Director, Department of Internal Medicine, Division of Infectious Diseases, Washington Hospital Center; Professor, Department of Internal Medicine, Uniformed Services University of the Health Sciences
Daniel R Lucey, MD, MPH is a member of the following medical societies: Alpha Omega Alpha and American College of Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Richard B Brown, MD, FACP, Chief, Division of Infectious Diseases, Baystate Medical Center; Professor, Department of Internal Medicine, Tufts University School of Medicine
Richard B Brown, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians, American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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