Rabies Prophylaxis

Rabies is a zoonotic viral disease that infects domestic and wild animals. It is transmitted to other animals and humans through saliva from infected animals such by means of bites, scratches, or licks on broken skin and mucous membranes. Once the symptoms of the disease develop, rabies is typically fatal to both animals and humans. There are fewer than five reports of people surviving rabies with intensive medical care (28-31).

Pet tiger

Human

Rats

Table 31.3. Antibiotics recommended for bite management.

Primary recommendation Alternatives

Table 31.3. Antibiotics recommended for bite management.

Primary recommendation Alternatives

Outpatient

Amoxicillin and clavulate potassium

- Clindamycin 300mg PO qid plus

875/125mg PO bid or 500/125 mg

Ciprofloxacin, 500mg bid

PO tid

- Clindamycin 300mg PO qid plus

TMP-SMZ, 160 mgTMP/800mg

SMZ bid

- cefurlxime 500 mg PO bid

- doxycycline 100 mg PO bid

(cannot use in children or pregnant

women)

Inpatient

Ampicillin sodium and sulbactam

- Piperacillin sodium and tazobactam

sodium, 3 g IV q6h

sodium, 3.375 g IV q6h

- Ticarcillin and clavulanate

potassium, 3.1 g IV q6h

- Cefriaxone sodium, 2 g IV q24 h,

plus clindamycin, 600 to 900 mg

IV q8h

- Ciprofloxacin, 200-400 mg IV q12h,

plus clindamycin, 600 to 900 mg

IV q8h

- TMP-SMZ, 8-10 mg/kg IV qd,

divided, q6 to 12h, plus clindamycin,

600 to 900 mg IV q8h

Source: Data from Goldstein (22), Armstrong (23), Rayan et al. (24), Brook (25), and Medeiros (27).

Note: TMP-SMZ is trimethoprim-sulfamethoxazole. Fluroquinolones are not approved for children younger than 16 years.

Source: Data from Goldstein (22), Armstrong (23), Rayan et al. (24), Brook (25), and Medeiros (27).

Note: TMP-SMZ is trimethoprim-sulfamethoxazole. Fluroquinolones are not approved for children younger than 16 years.

Table 31.4. Indications for tetanus prophylaxis in wound management (Td: tetanus toxoid, TIG: tetanus immune globulin)._

Number of previous tetanus vaccinations

Clean, minor wounds

All other wounds*

Give Tdt

Give TIG

Give Td

Give TIG

Unknown, uncertain,

Yes

No

Yes

Yes

or fewer than 3

3 or more'

No§

No

No11

No

*Such as, but not limited to: wounds contaminated with dirt, feces, and saliva; puncture wounds; avulsions; and wounds resulting from missiles, crushing, burns, and frostbite. tFor children <7 years of age DTaP or DTP (DT if pertussis vaccine is contraindicated) is preferred to tetanus toxoid alone. For persons > 7 years of age, Td (tetanus-diphtheria toxoid for adult use) is preferred to tetanus toxoid alone.

♦If only 3 doses of fluid toxoid have been received, then a fourth dose of toxoid, preferably an adsorbed toxoid, should be given.

^Administer a booster if more than 10 years have elapsed since the last dose.

"Administer a booster if more than 5 years have elapsed since the last dose. (More frequent boosters are not needed and can accentuate side effects.)

Source: Adapted from: Diphtheria, tetanus, and pertussis: recommendations for vaccine use and other preventive measures. MMWR 1991;40(No. RR-10):1-28 (21).

The first symptoms of rabies are usually non-specific, involving the respiratory, gastrointestinal, or central nervous system. In the acute stage, signs of hyperactivity (furious rabies) or paralysis (dumb rabies) predominate. In both furious and dumb rabies, paralysis eventually progresses to complete paralysis followed by coma and death due to respiratory failure. Without intensive treatment, death is within 7 days (28-31).

Worldwide incidence data are unreliable, but estimates range from 40,000 to 70,000 cases a year, mostly in Africa and Asia where rabies is endemic. It was thought that rabies had been eliminated from Europe, but recent cases found in animals have raised concern. In North America and Australia, bat rabies has emerged as an epidemiologic reservoir. Dramatic cases have been reported in China, Thailand, Sri Lanka, and Latin America where dogs remain the most common reservoir (with the exception of the Amazon region of Brazil where vampire bats have emerged as an important source). Humans are most frequently infected through bites of infected dogs, cats, wild foxes, raccoons, skunks, jackals, wolves, and bats. Recently, a rabies virus variant has been associated with the silver-haired (Lasionycteris noctivagans) and eastern pipistrelle (Pipistrellus subflavus) bats in North America. In Europe, North America, Japan, and other countries of low rabies incidence, a call to the health department may reveal which local animal species are currently at risk (28-31).

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