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Animal Bites (Mammal): Post-Exposure Prophylaxis Vaccine and Immunoglobulin Recommendations

Pathogen

Source of Bite

Recommendations

Post-Exposure Prophylaxis Dosing and Administration

Rabiesa



 

Dogs, cats, and ferrets

Healthy domestic pets without initial signs of rabies
(regardless of vaccination status)

Observe the animal(s) for 10 days to see if they subsequently develop signs of rabies

Post-exposure prophylaxis should be initiated immediately if:
a) Severe bites to the head, neck, or trunk after an unprovoked attack
b) Observation cannot be completed

No prior rabies immunizations – Administer both of the following:

  • Human rabies immune globulin (RIG) 20 units/kg as a single dose administered via local wound infiltration/intramuscular

    • The full dose should be infiltrated around any wound(s) and any remaining volume should be administered IM at an anatomical site distant from rabies vaccine administration.

    • Do not give more than recommended as it may partially suppress the active production of antibodies

  • Rabies vaccine 1.0 mL/dose intramuscularly on days 0, 3, 7, and 14

    • Administer in the deltoid area or anterolateral aspect of the thigh in smaller children opposite the RIG administration site.

    • Do not administer in the gluteal region as it may decrease efficacy

  • A fifth dose on day 28 is recommended for persons with a confirmed or suspected immune disorder.

 

 

Previously immunized individuals:

  • RIG should NOT be administered.

  • Rabies vaccine 1.0 mL/dose intramuscularly on days 0 and 3. 
    Administer in the deltoid area or anterolateral aspect of the thigh in smaller children

  • Do not administer in the gluteal region as it may decrease efficacy

 

 

Patients outside of rabies immunization schedule:
Every attempt should be made to adhere to recommended schedules; for most minor deviations (e.g., delays of a few days for individual doses), vaccination can be resumed as though the patient were on schedule. When substantial deviations occur, assess immune status by serologic testing 7 - 14 days after the final dose is administered.

Animals with initial signs of rabies

Immediate post-exposure prophylaxis indicated

Bats, skunks, raccoons, foxes, mongooses, and most other carnivores; groundhogs

Immediate post-exposure prophylaxis is indicated UNLESS the animal is captured and can be tested

Livestock, rodents, and lagomorphs (rabbits, hares, and pikas)

May consult public health officials for guidance; rabies post-exposure prophylaxis is not generally required

Tetanus

All wounds

Assess immunization status

For clean, minor wounds:

  • Tetanus immunoglobulin (TIG) should NOT be administered

  • Administer tetanus toxoid vaccine if vaccination history:

    • a) Uncertain

    • b) < 3 doses 
 

    • c) > 3 doses and > 10 years since last dose


 For all other wounds:

  • Administer tetanus toxoid vaccine plus TIG if vaccination history:
    a) Uncertain

  • b) < 3 doses

  • In a fully vaccinated patient (i.e., has had > 3 doses of a tetanus toxoid vaccine), administer a tetanus toxoid vaccine only if their last dose was given > 5 years ago (or if the date of their most recent vaccine is uncertain)

  • TIG 250 units IM as single dose

    • Administer in lateral aspect of thigh or deltoid muscle of upper arm in an anatomical site distant from tetanus toxoid vaccine

    • Do not give in gluteal region due to risk of injury to sciatic nerve

 

  • Tetanus toxoid vaccine

    • < 7 years old 
      DTaP 0.5 mL IM x 1 dose

    • > 7 years old 
      Tdap 0.5 mL IM x 1 doseb or

    • Td 0.5 mL IM x 1 dose


For unimmunized or under-immunized patients, completion of catch-up vaccines should be recommended/encouraged as well

Hepatitis B, Hepatitis C, HIV
(link to HIV nPEP pathway)

Human 

Post-exposure prophylaxis is not routinely recommended

In general, the risk of acquiring HIV, hepatitis B, or hepatitis C from a human bite is minimal, though reported cases do exist. Transmission may occur if the biter was bleeding from the mouth during the bite and caused a break in the skin of the person bitten.

  

aPublic health officials can be consulted for advice regarding rabies at the following phone numbers:

  • Kansas Epidemiology Hotline: 877-427-7317
  • Missouri Section for Disease: 573-751-6113

bTdap is preferred for children 7-10 years old who are not fully immunized against pertussis, diphtheria or tetanus and in patients >=11 years of age if the patient has not previously been vaccinated with Tdap, if Tdap history is unknown, or if the patient is pregnant.

References:
Lexicomp. (n.d.). Amoxicillin: Dosage & administration. In Lexi-Drugs Online. Retrieved November 11, 2024, from https://online.lexi.com
American Academy of Pediatrics. (2024). Bite wounds. In Red Book: 2024 Report of the Committee on Infectious Diseases (31st ed., pp. 574-9784). American Academy of Pediatrics. https://doi.org/10.1542/9781610025782-S2_008

These pathways do not establish a standard of care to be followed in every case. It is recognized that each case is different, and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare a pathway for each. Accordingly, these pathways should guide care with the understanding that departures from them may be required at times.

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