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A PEP Talk on Rabies

December 20, 2023

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Written by Ketan Patel

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Emergency physicians often encounter patients requesting postexposure prophylaxis (PEP) for rabies in the ED, yet studies show a lack of awareness among physicians about rabies PEP protocols. Prompt and accurate decision-making in managing potential exposures based on exposure types, animal categories, and prior vaccination history are crucial in the decision to initiate PEP.

Taking a bite out of the knowledge gap
Rabies remains a lethal zoonotic virus, posing a significant risk with over 55,000 potential exposures in the United States yearly. PEP in the correct context can be lifesaving, while inappropriate initiation, administration and/or adherence to protocols can be costly and ineffective.

In the US, the highest exposure risk remains through bites from infected animals. Other mechanisms of transmission do occur through infected materials and other modalities of exposure, but they pose much less risk.

In the U.S., while both wildlife and domestic animals can carry the virus, the former is the highest animal category posing risk. Bats, raccoons, and skunks remain the primary reservoirs of wildlife risk to rabies exposures, and all bites from these and other high-risk wildlife should be regarded as rabid with initiation of PEP immediately.  Domestic healthy animals should be observed for 10 days without initiation of PEP. 

The PEP regimen involves immediate wound cleansing, administration of rabies vaccine, and human rabies immune globulin (HRIG). For unvaccinated patients, a four-dose vaccine regimen initiates on Day 0, with HRIG administered simultaneously. Common pitfalls in proper administration of PEP include not administering HRIG at all or properly around the wounds themselves.

Special populations, including pregnant individuals and those with altered immunocompetence or HIV, may undergo modified PEP regimens. Cost implications are significant, but patient assistance programs exist, and physicians should be knowledgeable of options for financial aid for patients needing PEP.

How will this change my practice?
Rabies PEP is a common discussion in our Emergency Department. This is my new go to article to have a more informed discussion regarding the lack of necessity of PEP in the majority of patients while also serving as the framework for proper administration and financial barrier removal for those who do get PEP. 

Rabies postexposure prophylaxis: What the U.S. emergency medicine provider needs to know. Acad Emerg Med. 2023 Nov;30(11):1144-1149. doi: 10.1111/acem.14755. Epub 2023 Jun 14.

What are your thoughts?