Rabies Post-Exposure Prophylaxis Management Summary with Intradermal Preference (หมากัด แมวข่วน)

💉 Rabies PEP Management Summary with ID Preference

Exposure Category	Immune Status	Vaccination History	Management	Vaccine Schedule	RIG Required?
CAT 1	All	Any	❌ No treatment needed	–	❌ No
CAT 2	Normal	Vaccinated <6 months	Booster	✅ Day 0 only (1 dose) • IM or ID 2-site	❌ No
CAT 2	Normal	Vaccinated >6 months	Booster	✅ Day 0, 3 • IM or ID 2-site or ID 4-site Day 0	❌ No
CAT 2	Normal	Never vaccinated	Full vaccine	✅ ID 2-site Days 0, 3, 7, 28 or IM Days 0, 3, 7, 14, 28	❌ No
CAT 2	Immuno compromised	Any	Full vaccine + RIG	❗ IM only: Days 0, 3, 7, 14, 28	✅ Yes
CAT 3	Normal	Vaccinated <6 months	Booster + RIG	✅ Day 0 only (1 dose) • IM or ID 2-site	✅ Yes
CAT 3	Normal	Vaccinated >6 months	Booster + RIG	✅ Day 0, 3 • IM or ID 2-site or ID 4-site Day 0	✅ Yes
CAT 3	Normal	Never vaccinated	Full vaccine + RIG	✅ ID 2-site Days 0, 3, 7, 28 or IM Days 0, 3, 7, 14, 28	✅ Yes
CAT 3	Immuno compromised	Any	Full vaccine + RIG	❗ IM only: Days 0, 3, 7, 14, 28	✅ Yes

💉 Vaccine Administration Details

🧪 Intradermal (ID) Regimens

• Dose: 0.1 mL per injection site

• Sites:

  • 2-site: One injection in each deltoid

  • 4-site: Both deltoids + both anterior thighs or scapulae (only Day 0)

💉 Intramuscular (IM) Regimens

• Dose: 0.5–1.0 mL depending on brand

• Site: Deltoid (or anterolateral thigh for infants)

⚠️ Do NOT mix ID and IM regimens during the course — EXCEPTION: if vaccine shortage on Day 3.

🧪 Rabies Immune Globulin (RIG)

Type	Dose	Administration
ERIG (Equine)	40 IU/kg	Infiltrate around the wound as much as anatomically feasible
HRIG (Human)	20 IU/kg	Same as above; dilute for mucosal contact (1:10 with NSS if to eye/oral mucosa)

❗ Do not inject remaining RIG elsewhere (e.g., gluteus)✅ Administer only once, within 7 days of first vaccine dose

Excellent question! Understanding the distinction between “booster” and “full course” of tetanus immunization is very important in rabies or wound care settings.

💉 Tetanus Immunization Table

Situation	Action
No or unknown tetanus history	🧷 Full course (3 doses) + TIG if dirty wound day 0, 4 wks , 6 mo after 2nd dose
<3 doses	🧷 Complete the course (add missing doses) Continue where left off Do NOT restart + TIG if dirty wound
≥3 doses, dirty wound, last dose >5 yrs	💉 Booster dose (1 dose Td/Tdap)
≥3 doses, clean wound, last dose <10 yrs	✅ No booster needed

Dose: Td or Tdap 0.5 mL IM x1 🧪 TIG (Tetanus Immune Globulin) Use

• Used only in:

  • High-risk dirty wounds

  • AND inadequate or unknown vaccine history

• Dose: 250 IU IM (may be higher for very contaminated wounds)

• Administer separate site from vaccine
  

📌 Remember:In exams or clinical settings, be precise:

• “Full course” = 3 doses to initiate protection

• “Booster” = 1 dose after full course to maintain protection