What is included in inpatient care of rabies?

Updated: Jun 21, 2019
  • Author: Sandra G Gompf, MD, FACP, FIDSA; Chief Editor: Michael Stuart Bronze, MD  more...
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Answer

Symptomatic rabies cannot be managed in the outpatient setting. Intensive cardiopulmonary supportive care is the only treatment available for patients with symptomatic rabies. Rabies vaccination and administration of HRIG is ineffective at this point, since the CNS does not possess humoral immune mechanisms to mount antibody and inflammation is insufficient to allow B lymphocytes to cross the blood-brain barrier and mount a defense. In animal studies, rabies immunoglobulin has been associated with “early death”; it has been suggested that HRIG may also pose a risk of early death in humans and should be avoided. [44]

However, it must be noted that there is no current scientific consensus on the management of rabies, and management is symptomatic. Therapeutic coma is no longer recommended, and sedation should be limited to that required for comfort and management of spasms. Nimodipine may be used for cerebrovascular spasm but may cause severe hypotension. [20]

Regardless of treatment, symptomatic rabies is almost invariably fatal, with autonomic dysfunction leading to cardiac arrhythmia and hypotension. Some role for combination treatments including ribavirin, interferon, ketamine, and immunomodulatory therapies has been proposed and may be considered in future cases under investigational protocols.

The survival of a teenaged girl from Wisconsin received substantial attention in October 2004 as the first reported case of human survival of rabies in the absence of preceding vaccination or postexposure prophylaxis. [45] Notably, she received an investigational regimen of ribavirin, amantadine, and a ketamine-midazolam–induced coma. However, this therapy has not been validated and has not been reproducible in several subsequent cases. It is no longer recommended, and the University of Wisconsin no longer maintains the Rabies Registry website. Furthermore, the bat rabies virus isolated in this case may be less neurovirulent than canine or other variants that are responsible for most human cases of rabies. [20, 46]

The rarity of human rabies hinders timely testing of therapies. Immunomodulatory therapies such as rabies immunoglobulin, rabies vaccine, and interferon have not altered outcomes in trials.

Steroids, which are usually indicated in the treatment of local vaccine reactions or cerebral edema, are contraindicated because of increased mortality noted in animal studies and because they reduce the response to the vaccine.


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