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.
How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.
Subscribe to access the complete flowchart to guide your clinical decision making.
Subscribe for full access to all Tables and Figures.
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
Bess Storch, MD
Jason Chu, MD; Edward Otten, MD, FACMT, FAWM
April 1, 2021
May 1, 2024
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