Rabies medical therapy: Difference between revisions
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== Overview == | |||
While considering rabies for treatment, 2 different scenarios should be considered: Patients entering emergency department due to symptomatic rabies with delay seeking medical care, they have a low survival rate and the best treatment choice for this group of patients far by now is a protocol known as "Milwaukee protocol" which is still under investigation. And patients with a suspicious interact with the disease or early diagnosed rabies patients that are asymptomatic. This group can benefit from complete wound cleaning followed by a combined rabies vaccination and immune globulin protocol, and they have a good prognosis. | |||
==Medical Therapy== | ==Medical Therapy== | ||
While considering rabies for treatment, 2 different scenarios should be considered: | |||
* | * Patients introducing to emergency department due to symptomatic rabies with delay seeking medical care | ||
* | * Patients with suspicious interact with the disease or an early diagnosed rabies patient that is asymptomatic | ||
In the first case the survival rate is very low. The best treatment choice for this group of patients far by now is a protocol known as "Milwaukee protocol" which is still under investigation. The second group can benefit from a combined vaccine and immune globulin, with a good prognosis. | In the first case the survival rate is very low. The best treatment choice for this group of patients far by now is a protocol known as "Milwaukee protocol" which is still under investigation. The second group can benefit from a combined vaccine and immune globulin, with a good prognosis. | ||
Revision as of 19:03, 27 September 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
While considering rabies for treatment, 2 different scenarios should be considered: Patients entering emergency department due to symptomatic rabies with delay seeking medical care, they have a low survival rate and the best treatment choice for this group of patients far by now is a protocol known as "Milwaukee protocol" which is still under investigation. And patients with a suspicious interact with the disease or early diagnosed rabies patients that are asymptomatic. This group can benefit from complete wound cleaning followed by a combined rabies vaccination and immune globulin protocol, and they have a good prognosis.
Medical Therapy
While considering rabies for treatment, 2 different scenarios should be considered:
- Patients introducing to emergency department due to symptomatic rabies with delay seeking medical care
- Patients with suspicious interact with the disease or an early diagnosed rabies patient that is asymptomatic
In the first case the survival rate is very low. The best treatment choice for this group of patients far by now is a protocol known as "Milwaukee protocol" which is still under investigation. The second group can benefit from a combined vaccine and immune globulin, with a good prognosis.
The flowchart of patient treatment behavior is summarized in the algorithm below:
Rabies Treatment Flowchart
Patient with Symptomatic Rabies
Milwaukee protocol
The Milwaukee protocol, sometimes referred to as the Wisconsin protocol, is an experimental course of treatment of an infection of rabies in a human being. The treatment involves putting the patient into a chemically induced coma and administering antiviral drugs.
Clinical trials
Out of 36 rabies patients treated with the Milwaukee Protocol, 5 have survived. Giese's treatment regimen has undergone revision (the second version omits the use of ribavirin). Two of 25 patients treated under the first protocol survived. A further 10 patients have been treated under the revised protocol, with a further two survivors.[1][2]
In June 2011, another child survived infection with rabies without receiving the vaccine before showing symptoms. Precious Reynolds, an eight-year-old girl from Willow Creek, California, contracted the disease in April 2011 but did not receive medical care until mid-May, after her grandmother took her to the doctor because of influenza-like symptoms that grew so serious, her grandmother said they resembled polio. The hospital said doctors followed the protocol established for Giese. Reynolds was placed in a drug-induced coma and received antiviral medications. She survived after spending two weeks in intensive care undergoing the treatments.[3][2]
Some critics say those survivors are due to the patients having a genetic rabies immunity and that the Milwaukee protocol has nothing to do with the survival rate;[4] however this would imply the five patients all happened to coincidentally survive rabies while receiving the Milwaukee protocol—despite no documented survivors before them. Medical experts disagree about the effectiveness of the Milwaukee treatment, pointing out that a certain antibody type appears in all survivors. This suggests that a genetic or other immunological factor may affect survival.[2]
Ketamine has been shown to have a direct effect against the rabies virus.[5]
Asymptomatic Patient Suspicious of Rabies
Treatment management in these patients start with wound care, postexposure vaccination, and human immune globulin injection:
Wound Care
Regardless of the risk of rabies, bite wounds can cause serious injuries such as:
- Nerve or tendon laceration
- Infections (local and system infection)
In the wound treatment procedure, cosmetic issues should be considered.
For many types of bite wounds, immediate gentle irrigation with water or a dilute water povidone-iodine solution has been shown to markedly decrease the risk of bacterial infection. 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.
Patient should receive a tetanus shot if has not been immunized in the previous ten years. Decisions regarding the use of antibiotics, and primary wound closure should be considered.
Rabies Post-exposure Vaccinations
For people who have never been vaccinated against rabies previously, postexposure anti-rabies vaccination should always include administration of both passive antibody and vaccine. The combination of human rabies immunoglobulin (HRIG) and vaccine is recommended for both bite and non-bite exposures, regardless of the interval between exposure and initiation of treatment. People who have been previously vaccinated or are receiving preexposure vaccination for rabies should receive only vaccine.
Post-exposure prophylaxis recommendations based on contact type
In countries or areas at risk of rabies, the circumstances of an animal bite or other contact with an animal suspected to be rabid may require post-exposure prophylaxis. In such situations, medical advice should be obtained immediately. Strict adherence to the WHO-recommended guidelines for optimal post-exposure rabies prophylaxis virtually guarantees protection from the disease. The administration of vaccine, and of immunoglobulin if required, must be conducted by, or under the direct supervision of, a physician.
| Category | Type of contact with a suspected or confirmed rabid domestic or wild (a) animal or animal unavailable for testing | Type of exposure | Recommended post-exposure prophylaxis |
|---|---|---|---|
| I |
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None |
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| II |
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Minor |
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| III |
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Severe |
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a) Exposure to rodents, rabbits and hares seldom, if ever, requires specific anti-rabies post-exposure prophylaxis.
b) If an apparently healthy dog or cat in or from a low-risk country or area is placed under observation, the situation may warrant delaying initiation of treatment.
c) This observation period applies only to dogs and cats. Except in the case of threatened or endangered species, other domestic and wild animals suspected to be rabid should be humanely killed and their tissues examined for the presence of rabies virus antigen using appropriate laboratory techniques.
d) Post-exposure prophylaxis should be considered for individuals who have been in close contact with bats, particularly following bites or scratches or exposure to mucous membranes.
| Type | Name | Route | Indications |
|---|---|---|---|
| Human Diploid Cell Vaccine (HDCV) | Imovax® Rabies | Intramuscular | Preexposure or Postexposure |
| Purified Chick Embryo Cell Vaccine (PCEC) | RabAvert® | Intramuscular | Preexposure or Postexposure |
| Human Rabies Immune Globulin | Imogam® Rabies-HT | Local infusion at wound site, with additional amount intramuscular at site distant from vaccine | Postexposure |
| Human Rabies Immune Globulin | HyperRab TM S/D | Local infusion at wound site, with additional amount intramuscular at site distant from vaccine | Postexposure |
| Vaccination status | Intervention | Regimen |
|---|---|---|
| Not previously vaccinated | Wound cleansing | All PEP should begin with immediate thorough cleansing of all wounds with soap and water. If available, a virucidal agent (e.g., povidone-iodine solution) should be used to irrigate the wounds. |
| HRIG | Administer 20 IU/kg body weight. If anatomically feasible, the full dose should be infiltrated around and into the wound(s), and any remaining volume should be administered at an anatomical site (intramuscular [IM]) distant from vaccine administration. Also, HRIG should not be administered in the same syringe as vaccine. Because RIG might partially suppress active production of rabies virus antibody, no more than the recommended dose should be administered. | |
| Vaccine | Human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) 1.0 mL, IM (deltoid area†), 1 each on days 0, 3, 7 and 14. | |
| Previously vaccinated | Wound cleansing | All PEP should begin with immediate thorough cleansing of all wounds with soap and water. If available, a virucidal agent such as povidone-iodine solution should be used to irrigate the wounds. |
| HRIG | HRIG should not be administered. | |
| Vaccine | HDCV or PCECV 1.0 mL, IM (deltoid area†), 1 each on days 0 and 3. |
HRIG= Human rabies immune globulin, PEP= Postexposure prophylaxis, HDCV=Human diploid cell vaccine, PCECV= Purified chick embryo cell vaccine, IM= Intramuscular
Considerations:
- Previously vaccinated persons are anyone with:
- A history of pre-exposure vaccination with HDCV, PCECV, or rabies vaccine adsorbed (RVA)
- Prior PEP with HDCV, PCECV or RVA
- Previous vaccination with any other type of rabies vaccine and a documented history of antibody response to the prior vaccination[6]
- For persons with immunosuppression, rabies PEP should be administered using all 5 doses of vaccine on days 0, 3, 7, 14, and 28.
Adverse Reactions to Rabies Vaccine and Human Rabies Immune Globulin
Adverse reactions to rabies vaccine and immune globulin are not common. Newer vaccines in use today cause fewer adverse reactions than previously available vaccines. The most common adverse reaction reported with rabies vaccine/immune globulin injection include:
- Mild local reactions to the rabies vaccine, such as:
- Local pain
- Injection site erythema
- Injection site swelling
- Injection site itching at the injection site
- Rarely, general symptoms may develop following rabies vaccine, such as:
- Local pain and low-grade fever may follow injection of rabies immune globulin.
Human Rabies Immune Globulin
Human rabies immune globulin (HRIG) is administered only once, at the beginning of anti-rabies prophylaxis, to previously unvaccinated persons. This will provide immediate antibodies until the body can respond to the vaccine by actively producing antibodies of its own. If possible, the full dose of HRIG should be thoroughly infiltrated in the area around and into the wounds. Any remaining volume should be injected intramuscularly at a site distant from vaccine administration.
HRIG should never be administered in the same syringe or in the same anatomical site as the first vaccine dose. However, subsequent doses of vaccine in the four-dose series can be administered in the same anatomic location where the HRIG dose was administered.
If HRIG was not administered when vaccination was begun, it can be administered up to seven days after the administration of the first dose of vaccine. Beyond the seventh day, HRIG is not recommended since an antibody response to the vaccine is presumed to have occurred.
Dosage:
- Preferred regimen: Because HRIG can partially suppress active production of antibody, no more than the recommended dose should be administered. The recommended dose of HRIG is 20 IU/kg body weight. This formula is applicable to all age groups, including children.
References
- ↑ Willoughby RE (2009). "Are we getting closer to the treatment of rabies?: medical benchmarks". Future Virology. MedScape. 4 (6): 563&ndash, 570. doi:10.2217/fvl.09.52.
- ↑ 2.0 2.1 2.2 "Human Rabies --- Indiana and California, 2006".
- ↑ "UC Davis Children's Hospital patient becomes third person in U.S. to survive rabies". UC Davis Medical Center. Retrieved 3 May 2012.
- ↑ "Undead: The Rabies Virus Remains a Medical Mystery". Retrieved May 15, 2015.
- ↑ Lockhart BP, Tordo N, Tsiang H (1992). "Inhibition of rabies virus transcription in rat cortical neurons with the dissociative anesthetic ketamine". Antimicrob Agents Chemother. 36 (8): 1750–5. doi:10.1128/AAC.36.8.1750. PMC 192041. PMID 1416859.
- ↑ Rupprecht CE, Briggs D, Brown CM, Franka R, Katz SL, Kerr HD, Lett SM, Levis R, Meltzer MI, Schaffner W, Cieslak PR (2010). "Use of a reduced (4-dose) vaccine schedule for postexposure prophylaxis to prevent human rabies: recommendations of the advisory committee on immunization practices". MMWR Recomm Rep. 59 (RR-2): 1–9. PMID 20300058.