Rabies: ED Management of Suspected Exposures

Management of Suspected Rabies Exposure in the Emergency Department (Infectious Disease CME)

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Table of Contents

About This Issue

Even after a mammalian bite or exposure occurs, rabies is completely preventable if the correct active/passive immunization regimen is followed in the ED. This issue discusses:

The incubation period of rabies, which can take months or years after exposure.

The reason bats are the predominant cause of human rabies cases in the United States.

The 5 stages of clinical rabies, what each stage looks like in the ED, how to test for it, and the prognosis.

The populations for whom pre-exposure prophylaxis (PrEP) is recommended and how the vaccination regimen is administered.

The categories of mammals that are safe and the categories that pose a rabies risk.

Animal testing: when it’s needed and how results will affect postexposure prophylaxis (PEP).

The correct PEP regimens for those who have had PrEP and those who have not.

Adjustment of the PrEP or PEP regimens for immunosuppressed patients.

When assistance from the CDC or local health department will be needed.

Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Etiology and Pathophysiology
  6. Differential Diagnosis
  7. Prehospital Care
  8. Emergency Department Evaluation
    1. Evaluation for Pre-exposure Prophylaxis
    2. Evaluation for Postexposure Prophylaxis
      1. Exposure to Wild Animals
      2. Bites From Domestic Animals
      3. Exposure to Bats
      4. Other Exposures
    3. Evaluation for Clinical Rabies
  9. Diagnostic Studies
    1. Laboratory Testing
      1. Rabies Testing
    2. Imaging
    3. Diagnostic Studies in Animals
  10. Treatment
    1. Pre-exposure Prophylaxis for Rabies
    2. Wound Care
    3. Postexposure Prophylaxis for Rabies
      1. Active Immunization with Rabies Vaccine
      2. Passive Immunization With Human Rabies Immune Globulin
    4. Postexposure Prophylaxis in Previously Vaccinated Patients
    5. Adverse Effects of Vaccination
    6. Failure of Postexposure Prophylaxis
    7. Treatment of Clinical Rabies
  11. Special Populations
    1. Immunosuppressed Patients
    2. Pediatric Patients
    3. Pregnant Patients
    4. Returning Travelers
  12. Controversies and Cutting Edge
  13. Disposition
  14. Summary
  15. Time- and Cost-Effective Strategies
  16. Risk Management Pitfalls For Patients With Suspected Rabies
  17. Case Conclusions
  18. Clinical Pathway for Administration of Postexposure Prophylaxis in Patients With Possible Rabies Exposure
  19. Tables and Figures
    1. Table 1. Differential Diagnosis of the Patient with Acute Encephalitis
    2. Table 2. Clinical Features of 43 Patients with Rabies at Hospital Admission
    3. Table 3. Rabies Postexposure Prophylaxis Schedule
    4. Figure 1. Rabies Cases in Humans and Domestic Animals in the United States, 1938-2018
    5. Figure 2. Silver-Haired Bat
    6. Figure 3. Pathogenesis of Rabies
  20. References


Rabies is a rare, yet nearly universally fatal diagnosis, responsible for over 59,000 deaths worldwide annually. Appropriate use of pre- and postexposure prophylaxis can eliminate the risk of developing rabies if administered according to the United States Centers for Disease Control and Prevention Advisory Committee on Immunization Practices guidelines. Though rabies is very rare, rapid recognition of potential exposures is vital to patient care and protection of public health. This review focuses on the challenges of managing patients who are at risk for or have had a potential rabies exposure, indications and guidelines for administering pre- or postexposure prophylaxis, and requirements for reporting, testing, and monitoring. Evidence regarding management of patients presenting with suspected clinical rabies is also reviewed.

Case Presentations

A 35-year-old woman presents to the ED for vaccinations prior to a 3-month adventure trip to Southeast Asia…
  • She said she plans on staying in remote areas and spelunking in jungle caves.
  • She asks you whether rabies vaccination is warranted…
A 2-year-old girl is brought in after her mother found a bat in the girl’s bedroom that morning...and she has the bat in a bag…
  • On your full-body exam, the child appears well, and no bite marks are evident.
  • You ask yourself: does the girl require rabies prophylaxis? What should you do with the bat?
The nurse rushes in to ask you to evaluate an elderly man, recently emigrated from rural India, who is behaving strangely, with neurological symptoms…
  • His family tells you that he developed fever and complained of pain and a tingling sensation in his right arm, and over the past 2 days has been intermittently agitated and confused. He chokes every time he tries to eat or drink. The family tells you that he is from a rural village in India and moved to the United States 2 months ago.
  • The son does not recall his father being bitten by an animal, but said there is a large population of feral dogs in his father’s village.
  • What are the next steps in diagnosing and managing this patient with possible rabies?

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Clinical Pathway for Administration of Postexposure Prophylaxis in Patients With Possible Rabies Exposure

Clinical Pathway for Administration of Postexposure Prophylaxis in Patients With Possible Rabies Exposure

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Tables and Figures

Table 1. Differential Diagnosis of the Patient with Acute Encephalitis

Table 2. Clinical Features of 43 Patients with Rabies at Hospital Admission
Table 3. Rabies Postexposure Prophylaxis Schedule
Figure 1. Rabies Cases in Humans and Domestic Animals in the United States, 1938-2018
Figure 2. Silver-Haired Bat

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. * Pieracci EG, Pearson CM, Wallace RM, et al. Vital signs: trends in human rabies deaths and exposures - United States, 1938-2018. MMWR Morb Mortal Wkly Rep. 2019;68(23):524-528. (Surveillance) DOI: 10.15585/mmwr.mm6823e1

3. * Fooks AR, Cliquet F, Finke S, et al. Rabies. Nat Rev Dis Primers. 2017;3(1):17091. (Review) DOI: 10.1038/nrdp.2017.91

5 * Nigg AJ, Walker PL. Overview, prevention, and treatment of rabies. Pharmacotherapy. 2009;29(10):1182-1195. (Review) DOI: 10.1592/phco.29.10.1182

8. US Centers for Disease Control and Prevention. “Domestic Animals.“ 2018. Accessed March 10, 2021. (CDC website)

12. * Hemachudha T, Laothamatas J, Rupprecht CE. Human rabies: a disease of complex neuropathogenetic mechanisms and diagnostic challenges. Lancet Neurol. 2002;1(2):101-109. (Review) DOI: 10.1016/s1474-4422(02)00041-8

25. * Manning SE, Rupprecht CE, Fishbein D, et al. Human rabies prevention--United States, 2008: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2008;57(RR-3):1-28. Accessed March

29. * Rupprecht CE, Briggs D, Brown CM, et al. Use of a reduced (4-dose) vaccine schedule for postexposure prophylaxis to prevent human rabies: recommendations of the advisory committee on immunization practices. MMWR 

Subscribe to get the full list of 58 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.

Keywords: rabies, bite, wild, animal, canine, bat, travel, pre-exposure prophylaxis, PrEP, post-exposure prophylaxis, PEP, vaccination, saliva, prodrome, encephalitis, furious, paralytic, dumb, hydrophobia, aerophobia, hnRT-PCR, HRIG, rabies immune globulin

Publication Information

Bess Storch, MD

Peer Reviewed By

Jason Chu, MD; Edward Otten, MD, FACMT, FAWM

Publication Date

April 1, 2021

CME Expiration Date

April 1, 2024    CME Information

CME Credits

4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits.
Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Infectious Disease CME credits

Pub Med ID: 33779128

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