Rabies is almost uniformly fatal but is nearly always preventable with appropriate postexposure prophylaxis during the incubation period. Only seven pts have survived infection with rabies virus, and only one of these pts had not received rabies vaccine before disease onset.

• An algorithm for rabies postexposure prophylaxis is depicted in Fig. 104-1.
  • - Local wound care (e.g., thorough washing, debridement of devitalized tissue) can greatly reduce the risk of rabies.
  • - All previously unvaccinated pts should receive human rabies immune globulin (RIG, 20 IU/kg; 40 IU/kg for equine RIG) no later than 7 days after the first vaccine dose. The entire dose should be infiltrated at the site of the bite; if not anatomically feasible, the residual RIG should be given IM at a distant site.
  • - Inactivated rabies vaccine should be given as soon as possible (1 mL IM in the deltoid region), with doses repeated on days 3, 7, and 14 for previously unvaccinated pts; previously vaccinated pts require booster doses only on days 0 and 3.
• Preexposure prophylaxis is occasionally given to persons at high risk (including certain travelers to rabies-endemic areas). A primary vaccine schedule is given on days 0, 7, and 21 or 28.