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Rabies Treatment and Follow-Up (102.151)

Rabies Treatment and Follow-Up (102.151) - Policies, Clinical, UWMF Clinical, UWMF-wide, Clinical Policies and Procedures, Wound and Skin

102.151

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UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
CLINICAL POLICY AND PROCEDURE

TITLE: RABIES TREATMENT and FOLLOW-UP

Effective Date: May, 2004 Approval: See Authorization
Supersedes Protocol: None Contact: Clinical Staff Education

Reviewed January, 2007 May, 2008 May 2009 October 2009 August 2011
August 2012 May 2013 May, 2015

PURPOSE: To provide guidelines for the treatment, documentation and follow-up of actual or potential rabies exposures
at University of Wisconsin Medical Foundation (UWMF) or Department of Family Medicine (DFM) clinics.

DEFINITIONS:

ξ Rabies: transmitted when the virus is introduced into a bite wound, open cuts, or onto mucous membranes such as
the mouth or eyes. Rabies is 100% fatal.
ξ Rabies Immune Globulin: known as “RIG”.
ξ Previously vaccinated persons: those who have received one of the recommended pre-exposure or post-
exposure regimens of HDCV, RVA, or PCECV, or those who received another vaccine and had a documented
rabies antibody titer.

BACKGROUND INFORMATION:

ξ Pharmacology - Directly neutralizes rabies virus.
ξ Contraindications - Repeated doses of Imogam once vaccine treatment has been initiated.
ξ Drug Interactions -Measles, mumps, polio, or rubella live vaccines.
ξ Other antibodies in RIGH preparation may interfere with response to these live vaccines. Do not give live
vaccines within 3 mo after RIGH.
ξ Adverse Reactions - Headache; malaise, Skin rash, local ain; soreness; stiffness of muscles; tenderness.
ξ Miscellaneous - Anaphylaxis; angioneurotic edema; mild temperature elevations; sensitization to repeated
injections.
ξ Precautions- Pregnancy Category C. Patient should be monitored for 20 minutes post administration
ξ Hypersensitivity to human immunoglobulins - Give drug with caution.
ξ IgA deficiency - Persons with specific IgA deficiency have increased potential for developing antibodies to IgA.
and could have anaphylactic reactions to subsequent administration of blood products containing IgA.

POLICY:

The clinical staff/provider will utilize the following guidelines to properly treat, document and follow-up rabies exposures
involving a UWMF/DFM patient.

Patients with suspected rabies exposure, presenting more than 6 days post exposure should be sent to the Urgent Care
during the hours of 8 am to 9pm and after hours to the emergency room for immediate treatment.

It is recommended that the RIG and Rabies Vaccine series be administered at the patient’s primary care clinic so the
primary care provider can follow the course of treatment.

SUPPLIES: RIG (rabies immune globulin), Rabies Vaccine, antibiotic (optional), Provider’s order, patient record.





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PROCEDURE:

1. Verify rabies exposure using the online algorithm available on the Wisconsin Department of Health Services website:
http://www.dhs.wisconsin.gov/communicable/Rabies/RabiesAlgorithm/Index.htm

Wound Care

1. Immediate thorough cleansing of wound with soap and water. If available, a virucidal agent such as povidine-
iodine solution should be used to irrigate the wounds has been shown to markedly decrease the risk of bacterial
infection.
2. Wound cleansing is especially important in rabies prevention since, in animal studies, thorough wound cleansing
alone without other postexposure prophylaxis has been shown to markedly reduce the likelihood of rabies.
3. Consider giving the patient a tetanus shot (CDC guidelines) if the patient has not been immunized in ten years.
4. Avoid bandaging the wound, use tincture iodine or suturing the wound.
5. If a patient is calling into the clinic discourage patient from local applicants like turmeric, red chili, lime, plant
juices, coffee powder, coin, etc. as these will act as irritants and propel the virus in the wound deeper to cause
nerve infection and resultant rabies encephalitis and potentially death.
Rabies Vaccine

1. Verify patient’s known allergies with patient and using patient’s medical record (RIG, Rabies Vaccines,
antibiotics and eggs).
NOTE: Some vaccines have a relationship to egg allergies.

2. Check with patient and the patient’s medical record to determine if patient has been vaccinated with any type of
rabies vaccine, prior to this exposure.
NOTE: previously vaccinated persons should receive two IM doses (1.0mg/ mL each) of vaccine, one
immediately and one three days later.

3. Ordering: RIG, Rabies Vaccine, and Antibiotic
Contact Pharmacy at 608-287-2406 with the amount of RIG and Rabies vaccine needed.

a) RIG- (rabies immune globulin) ordered per calculated dose.
Note: previously immunized individuals should not be given RIG

 Weigh the patient (document in kilograms)
 Calculate the dose of RIG (20 IU/kg body weight)
NOTE: The 20 IU/kg body weight is also appropriate for children.
NOTE: When ordering RIG from pharmacy the order placed needs to be stated in (ml) NOT in
(IU) International Units with RIG being dispensed in 150 IU/mL
EXAMPLE: patient is: 176 lbs ψ 2.2 lbs per kg = 80 kg
x 20 IU/kg = 1,600 IU ψ 150 IU/mL = 10.67 cc of RIG

b) Rabies vaccine ordered in standard dose of (4)1.0 cc syringes.
NOTE: Type of vaccine will depend on availability and patient’s known allergies.

c) Antibiotic (if needed)

4. Draw up medication, adhering to the five rights of drug administration.
a) Right – drug, dose, time, route, patient (including patient’s DOB)

b) Check the expiration date of the medication.


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5. Initiate Rabies Prophylaxis

a) Administer RIG – (rabies immune globulin)
1) RIG is not administered to previously immunized individuals.
2) No more than half the dose/volume is given intra-dermal (ID) evenly spaced around the wound site;
by the provider, using a TB needle.
3) Give no more than 0.1ml per injection site. The number of ID injection sites may be limited by the
space available. For example a small puncture wound in the finger or toe may only allow for 1 or 2
.1ml injections, while a large wound on the thigh may accommodate 5 or 6 injections.








4) Local injections should not be given directly into the wound.

5) The remainder of dose/volume is given IM in the deltoid.

Note: RIG is administered once at the beginning of prophylaxis to unvaccinated persons
to provide immediate antibodies until patient can respond to the vaccine. However,
should a patient begin receiving the Rabies Vaccine prior to the RIG injection, the
patient can only receive RIG up to seven days after the administration of the first dose of vaccine.











b) Administer Rabies Vaccine (1mg/mL) IM in deltoid, opposite arm of where the RIG was administered.
NOTE: Post exposure prophylaxis for Non-immunized Individuals –
day 0, then days 3, 7, & 14.
ξ For persons with immunosuppression, rabies Post exposure prophylaxis should be
administered using 5 doses of vaccine on days 0, 3, 7, 14, and 28.
NOTE: Postexposure Prophylaxis for Previously Immunized Individuals – day 0 and 3
NOTE: IM injections into the anterolateral aspect of thigh for children.
NOTE: The gluteal area should not be used for rabies vaccine injections because of the potential
of lower neutralizing antibody titers

c) Administer prescribed antibiotics, either IM or IV (if needed).

6. Document in the patient's record:
ξ the type and location on body of animal bite
ξ the patient's response to the treatment
ξ history of RIG or Rabies Vaccine
ξ date, time, name(s) and dose(s) of medication(s)
ξ patient education and date of follow-up visits





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ξ A comment MUST be added to the comment section (see example below). If a comment is not added at
time of administration of first dose of Rabies vaccine, subsequent doses will show as invalid in WIR:




7. Fax any necessary documentation to the facility assisting with follow up.

Note: Patients should be instructed where to return for treatment after initial visit.
Note: Contact primary care provider (provider to provider) if patient will be receiving RIG and Rabies
Vaccine at a different location than the initial treatment.


REVIEWED BY: Dr Steve Tyska, Medical Director Urgent Care, 2013
Dr Alexander Young, MD, Urgent Care, Health Link Specialty Content Liaison, 2013
Carrie Boeckelman, R.Ph., Pharmacy Director, 2013
Deb Craig, RN, Manager Urgent Care, 2013
REVISED BY: LaVay Morrison, RN, BSN, Clinical Staff Educator, 2013
WRITTEN BY: Ronnie Peterson, R.N., M.S., Manager of Clinical Support

REFERENCES: 1. CDC (2011). Retrieved April 8, 2013 from http://www.cdc.gov/rabies/medical_care/index.html
2. Wisconsin Department of Health Services: Rabies Prevention Flowchart (2012). Retrieved April 8,
2013 from http://www.dhs.wisconsin.gov/communicable/Rabies/RabiesAlgorithm/Index.htm
3. Wisconsin Department of Health Services: Rabies Postexposure Prophylaxis (PEP) Schedule.
Retrieved April 8, 2013 from
http://www.dhs.wisconsin.gov/communicable/Rabies/RabiesAlgorithm/PostexposureProphylaxis.htm



AUTHORIZED BY: Richard Welnick, MD, Medical Director, Ambulatory Clinic Operations, UWMF
Sandra A. Kamnetz M.D., Vice Chair, Department of Family Medicine


____________________________________________________________________________________________
Medical Director, UWMF Date

____________________________________________________________________________________________
Vice Chair, Department of Family Medicine Date















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