Rabies medical therapy: Difference between revisions
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===Treatment Flowchart=== | ===Treatment Flowchart=== | ||
[[Image:Milwaukeeprotocol.jpg|1000px|center|thumb|Courtesy dedicatetd to CDC]] | [[Image:Milwaukeeprotocol.jpg|1000px|center|thumb|Courtesy dedicatetd to CDC]] | ||
=== Milwaukee protocol === | === Milwaukee protocol === | ||
The Milwaukee protocol, sometimes referred to as the Wisconsin 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 ==== | ==== Clinical trials ==== | ||
Revision as of 15:50, 27 September 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Medical Therapy
Treatment Flowchart
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.[14] 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]
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.
You should receive a tetanus shot if you have not been immunized in ten years. Decisions regarding the use of antibiotics, and primary wound closure should be decided together with your doctor.
Postexposure Vaccinations
- Human Rabies Immune Globulin
- Rabies Vaccine
- Programs for uninsured and underinsured patients
Rabies postexposure prophylaxis consists of a dose of human rabies immune globulin and rabies vaccine given on the day of the exposure, and then a dose of vaccine given again on days 3, 7, and 14.
If a person has previously received postexposure vaccinations or received preexposure vaccinations, only two doses of vaccine (on the day of exposure and then 3 days later) are needed. Human rabies immune globulin is not required. Your doctor and local health department will be able to guide you through the process.
Also see:
- Preexposure Vaccinations
Rabies Postexposure 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 immune globulin (HRIG) and vaccine is recommended for both bite and nonbite 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.
Adverse reactions to rabies vaccine and immune globulin are not common. Newer vaccines in use today cause fewer adverse reactions than previously available vaccines. Mild, local reactions to the rabies vaccine, such as pain, redness, swelling, or itching at the injection site, have been reported. Rarely, symptoms such as headache, nausea, abdominal pain, muscle aches, and dizziness have been reported. Local pain and low-grade fever may follow injection of rabies immune globulin.
The vaccine should be given at recommended intervals for best results. Talk to your with your doctor or state or local public health officials if you will not be able to have shot at the recommended interval. Rabies prevention is a serious matter and changes should not be made in the schedule of doses.
People cannot transmit rabies to other people unless they themselves are sick with rabies. The prophylaxis you are receiving will protect you from developing rabies, and therefore you cannot expose other people to rabies. You should continue to participate in your normal activities.
| 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., povidine-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 povidine-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
† The deltoid area is the only acceptable site of vaccination for adults and older children. For younger children, the outer aspect of the thigh may be used. Vaccine should never be administered in the gluteal area.
§ Day 0 is the day dose 1 of vaccine is administered.
¶ For persons with immunosuppression, rabies PEP should be administered using all 5 doses of vaccine on days 0, 3, 7, 14, and 28.
** Any person 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]
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.
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.