Rabies PEP
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CDC rabies post-exposure prophylaxis HRIG vaccine schedule wound care 2025
Rabies post-exposure prophylaxis (PEP) is urgent care after a possible rabies exposure, such as a bite, scratch that breaks skin, or saliva contacting the eyes, mouth, or an open wound. Rabies is almost invariably fatal after symptoms begin, but PEP is highly effective when started before symptoms. Seek urgent medical care or contact your local public-health service today after a possible exposure.
Immediately
- Wash the wound thoroughly with soap and running water for about 15 minutes.
- If available, irrigate with povidone-iodine or another virucidal antiseptic.
- Do not try to capture or handle the animal. Report the exposure so the animal can be assessed, observed, or tested.
PEP if never previously vaccinated
In the US CDC schedule, PEP includes:
| Component | What is given |
|---|---|
| Wound care | Immediate, extensive washing and irrigation |
| HRIG | Human rabies immune globulin, 20 IU/kg once on day 0. It should be infiltrated into and around all wounds as much as anatomically feasible. Any remainder is injected IM at a site distant from the vaccine. |
| Rabies vaccine | IM doses on days 0, 3, 7, and 14. Day 0 is the day the first dose is received. |
| If immunocompromised | Add a fifth vaccine dose on day 28 and arrange antibody testing as advised. |
Do not administer vaccine in the buttock. HRIG must not be mixed with the vaccine or injected into the same anatomical site. If HRIG was missed at day 0, it can generally be administered up to day 7 after the first vaccine dose. The current CDC PEP guidance has the administration details.
If previously vaccinated
- No HRIG
- Rabies vaccine on days 0 and 3
When PEP may or may not be needed
This decision depends on the animal, location, exposure type, and whether the animal can be observed or tested.
- Bats: A bite may be tiny or unnoticed. Get urgent assessment after direct contact, or if a bat was in the room with a sleeping person, unattended child, intoxicated person, or someone unable to reliably exclude contact.
- Dogs, cats, ferrets: A healthy animal may sometimes be observed for 10 days, depending on local public-health advice. Do not delay assessment yourself.
- Wild mammals: Bats, raccoons, skunks, foxes, and mongooses are higher-risk in many regions. PEP is often started promptly.
- Rodents and rabbits: Usually low risk, but exceptions exist and public-health advice still matters.
- Licks on intact skin: Generally not an exposure. Saliva on broken skin or mucous membranes is potentially an exposure.
Pregnancy and breastfeeding are not reasons to withhold needed PEP. PEP can still be indicated even if days or weeks have passed, provided symptoms have not begun.
The treatment framework is supported by Tintinalli's Emergency Medicine, which describes wound care, HRIG, and a four-dose vaccine regimen for unvaccinated people, with five doses for immunocompromised people. A recent systematic review also evaluated vaccine immunogenicity during PEP (PMID 41997000).
If this is about a real exposure, tell me: country/region, animal, date and type of contact, whether skin was broken, and whether you have had rabies vaccine before.
Grades of dog bite and treatment
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WHO rabies exposure categories I II III post exposure prophylaxis wound washing vaccine immunoglobulin
WHO grades/categories of dog-bite exposure and treatment
| Category | Type of contact | Rabies treatment |
|---|---|---|
| Category I | Touching/feeding dog; lick on intact skin | Wash exposed area with soap and water. No rabies vaccine or immunoglobulin needed. |
| Category II | Nibbling of uncovered skin; minor scratches or abrasions without bleeding | Thorough wound washing plus immediate rabies vaccine. No rabies immunoglobulin (RIG) is usually required. |
| Category III | One or more transdermal bites or scratches, bleeding wounds; lick on broken skin; saliva in eyes, mouth, or other mucosa; direct bat exposure | Thorough wound washing plus immediate rabies vaccine and RIG (or approved rabies monoclonal antibodies where used). |
This is the WHO exposure-category guidance.
Immediate care for every bite or scratch
- Wash and flush the wound vigorously with soap and running water for at least 15 minutes.
- Apply povidone-iodine or another suitable antiseptic if available.
- Seek medical care promptly for wound assessment, tetanus protection, and the rabies decision.
- Avoid primary suturing when possible. If closure is necessary, it should generally be done after RIG infiltration for Category III exposure.
- Antibiotics may be needed for high-risk wounds, especially deep punctures, crush wounds, bites to the hand/face/genitals, delayed presentation, immunocompromise, or signs of infection.
Rabies PEP summary
Previously unvaccinated
- Category II: vaccine course.
- Category III: vaccine course plus RIG, infiltrated into and around the wounds as much as possible. RIG is given once, ideally on day 0. It should not be injected into the same site as vaccine.
Previously vaccinated
- Category II or III: wound care plus a shortened vaccine booster schedule.
- Do not give RIG.
Important
A bite that breaks the skin or causes bleeding is Category III, even if it seems small. Do not wait for symptoms in the dog or person before getting assessed. Whether a dog can be observed for 10 days, tested, or whether PEP can be modified depends on local public-health policy and the animal's status.
Pregnancy and breastfeeding are not contraindications to indicated rabies PEP. WHO recommends prompt PEP for both Category II and III exposures; Category III requires passive antibody treatment in addition to vaccine when indicated.
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