treatment

Last reviewed 01/2018

If exposure is suspected, post exposure prophylaxis (PEP) should be started without any delay.

• is highly effective in preventing the virus from reaching the nervous system.
• several WHO approved post exposure regimens can be followed: includes wound cleaning, followed by PEP - active immunisation with rabies vaccine, with or without passive immunization with human rabies immune globulin (HRIG).   
• ineffective when administered after the onset of clinical symptoms (1)

Treatment after exposure:

• step 1 - wound management:

• risk of developing rabies can be greatly decreased by immediate wound cleaning
• should be carefully cleaned and adequately debrided
• thorough flushing with soap and water, detergent, povidone iodine, or other virucidal substances is recommended
• should avoid contamination or enlargement of the wound
• the risk of infection is high if the wound is bleeding
• rabies immunoglobulin must be infiltrated into the wound.
• wound should be left open since there have been reports of post-exposure prophylaxis failures associated with primary repair.

• step 2 – PEP (rabies immune globulin and vaccine)

• each case requires a full risk assessment and if indicated vaccination should be started immediately
• treatment may need to start before full information is available on the ownership and condition of the biting animal
• risk assessment should always be carried out even if the exposure occurred many months or years previously
• treatment should still be considered even if the interval from exposure is lengthy (since the incubation period for rabies can be prolonged) (2)
• depending on the severity of the contact administering with the suspected rabid animal, administration of PEP is recommended (see categories of contact and recommended post exposure prophylaxis)
• vaccine and HRIG should NEVER be given at the same anatomical site

Management after development of symptoms

• death is almost always inevitable in patients who develop neurological signs and symptoms due to treatment failure or non-immunisation
• only supportive measures are recommended
• palliative measures such as sedation and physical and emotional support is recommended since patients tend to be severely agitated and anxious
• respiratory, cardiovascular and nutritional support may be necessary.
• post-exposure prophylaxis is not required for hospital contacts of patients with rabies (unless they are bitten or their mucous membranes or any open wounds come into contact with the saliva, cerebrospinal fluid, or brain tissue of affected patients)

Treatment before exposure:

• recommended for persons at risk of rabies - details in rabies vaccination.

Reference:

• (1) Crowcroft NS, Thampi N.The prevention and management of rabies. BMJ. 2015;350:g7827.  
• (2) Immunisation Against Infectious Disease - "The Green Book".Chapter 27 Rabies (November 2012)