Treatment of rabies
- Alan C Jackson, MD, FRCPC
Alan C Jackson, MD, FRCPC
- Professor of Internal Medicine
- Head of the Section of Neurology
- University of Manitoba
- Section Editors
- Martin S Hirsch, MD
Martin S Hirsch, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — Viral Infections
- Professor of Medicine
- Harvard Medical School
- Morven S Edwards, MD
Morven S Edwards, MD
- Section Editor — Pediatric Infectious Diseases
- Professor of Pediatrics
- Baylor College of Medicine
Rabies remains an important disease because there are at least 60,000 human deaths every year worldwide, particularly in Asia and Africa where dog rabies is endemic . In geographic locations where human rabies is rare, the diagnosis may not be considered until relatively late in the clinical course. There is no known effective treatment for rabies.
Although rabies is usually preventable after recognized exposures with post-exposure rabies prophylaxis (eg, wound cleansing and administration of rabies vaccine and rabies immune globulin), the need for prophylaxis is not always recognized and may not be readily available in some areas. In addition, human rabies may present without a history of an animal exposure, usually because a bat bite was not recognized.
This topic will address the approach to managing patients with suspected or confirmed rabies. The epidemiology, clinical manifestations, diagnosis, and prevention of rabies are discussed elsewhere. (See "Clinical manifestations and diagnosis of rabies" and "Rabies immune globulin and vaccine" and "When to use rabies prophylaxis".)
CHOOSING A TREATMENT APPROACH
In patients with confirmed or suspected rabies, management options include a palliative or aggressive approach. As of June 2017, there have been 15 well-documented rabies survivors as described in the table (table 1) [2-19]. These cases do not include patients who had atypical features of rabies without the development of rabies virus neutralizing antibodies (since they were likely not cases of rabies) [20,21] or reports that did not have sufficient documentation [22,23].
Many factors influence the therapeutic approach in patients with rabies, including prognostic factors (table 2) and the risks of treatment (see 'Combination therapies' below). Although the relative importance of each of these factors is uncertain, in general:
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- CHOOSING A TREATMENT APPROACH
- PALLIATIVE APPROACH
- AGGRESSIVE APPROACH
- Supportive care in a critical care unit
- Combination therapies
- - Immunotherapies
- - Antiviral therapy
- - Neuroprotective therapies
- - Therapies to avoid
- Therapeutic coma
- Prophylaxis of cerebral vasospasm
- Drug delivery into the central nervous system
- INFECTION PREVENTION
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS