Tetanus and Rabies Recommendations
Source of Evidence:
1. ACIP. Diphtheria, tetanus, and pertussis: recommendations for vaccine use and other preventive
measures – recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR
1991;40(No.RR-10).
2. CDC. Human Rabies prevention – United States, 1999:Recommendations of the Advisory Committee
on Immunization Practices (ACIP). MMWR 1999;48(44-01):1-21.
Target Population: All members who present with traumatic wounds or animal inflicted injuries,
particularly bites.
Settings for Application: All Internal Medicine, Family Practice, Urgent Care, and Emergency Care
departments.
Recommendations for Tetanus Prophylaxis in Wound Management
Number of prior
Tetanus
Vaccinations
Unknown or <3
3 or more
Clean, Minor Wounds
Tetanus toxoid
(vaccine)
Yes
No2
Tetanus Immune
Globulin
No
No
All Other Wounds1
Tetanus toxoid
(vaccine)
Yes
No3
Tetanus Immune
Globulin
Yes
No
1. Including but not limited to wounds contaminated with dirt, feces, soil or saliva; puncture wounds,
avulsions; wounds created by missiles, crushing, burns, or frostbite
2. Yes, if no tetanus toxoid in past 10 years.
3. Yes, if no tetanus toxoid in past 5 years.
Rabies Postexposure Prophylaxis
PLEASE NOTE: Questions concerning appropriate rabies PEP can be referred to the Public
Health Department at the following phone numbers.
Reporting of possible rabies exposure to Colorado Department of Public Health:
Mandatory reporting within 24 hours: bites by dogs, cats, bats, skunks, or other wild carnivores
Mandatory reporting within 7 days: bites by any other animal not listed above
Monday – Friday, 8:30 am – 5:00 pm: (303) 692-2700
All other times: (303) 370-9395
Report animal bites from animals whose whereabouts are known to the local animal control
agency. Please note there is not one central animal control agency for the entire Denver-metro area.
Refer to the phone book for the animal control department for your city / county government.
Bite wounds: Any penetration of the skin by teeth. Bite wounds cause nearly all cases of rabies.
Non-bite: Rarely do non-bite exposures from terrestrial animals cause rabies. Since there is a slight
potential for transmission the following thoughts should be kept in mind. Petting of or contact with
blood, urine or feces from a rabid or suspected rabid animal is not an exposure and does not warrant postexposure prophylaxis. Open wounds, abrasions or mucous membranes possibly contaminated with
animal saliva, or animal scratches with saliva present warrant consideration of PEP.
Recommendations for rabies postexposure prophylaxis*
Animal
Dogs, cats and ferrets
Evaluation of animal
Healthy and available for 10 days
observation
Rabid or suspected rabid
Unknown (e.g., escaped)
Skunks, raccoons, foxes, bats,
groundhogs, woodchucks,
foreign dogs (especially along
US-Mexican border) and most
other carnivores
Livestock, rodents (except for
groundhogs and woodchucks),
rabbits or hares, squirrels and
other mammals
Consider as rabid unless proven
otherwise
Consider each case individually exposures to these animals
almost never cause rabies
Recommendations
Do not begin prophylaxis unless
animal demonstrates signs of
rabies
Start postexposure prophylaxis
Consult I.D. or Public Health
Department
Start postexposure prophylaxis
Bite exposure: Consult I.D. or
Public Health Department
Nonbite exposure: Do not start
postexposure prophylaxis
*Important species notes:
 The risk of rabies from a domestic dog, cat or ferret in Colorado is extremely low. Most cases do not
require PEP. Questionable cases can be referred to ID or Public Health Department.
 In Colorado, bats are the major vector of rabies. Rabies in other terrestrial mammals is rare in
Colorado. Bat bites can be very difficult to notice upon physical examination. Because of this, a high
index of suspicion must be maintained in patients with bat exposures. Rabies PEP is usually warranted
in patients with possible rabies exposure from bats. Questionable cases can be referred to ID or Public
Health Department.
Recommended timing of rabies postexposure prophylaxis:
 Rabies PEP is a medical urgency, not a medical emergency.
 PEP should be started as soon as possible, but in many cases it is not essential that the person receive
PEP immediately.
 The urgency of PEP depends on the following factors:
 Type of exposure – if there is clear evidence by history and physical of a bite wound from a high risk
animal (e.g. bat) then PEP should be started promptly; alternatively if there is not a clear bite wound
or if the wound is from a low risk animal (e.g. domestic dog or cat) then it may be reasonable to defer
PEP until the next day if extra time is needed to obtain PEP products and schedule the patient for an
appointment.
 Location of wound – since rabies virus moves in a slow retrograde fashion to the central nervous
system, proximity of the wound to the central nervous system (either brain or spinal cord) can help
indicate the need for prompt PEP; patients with a bite wound to the face require prompt PEP, whereas
those with a bite wound to an extremity may be able to have PEP deferred until the next day if extra
time is needed to obtain PEP products and schedule the patient for an appointment.
 Availability of animal for observation / testing – in most situations where the biting animal is
available for observation / testing, it is reasonable to postpone rabies PEP until the results of rabies
testing of the animal is complete. Certain high risk situations, however, such as a known bat bite to
the face, would likely necessitate prompt rabies PEP administration, even if results of rabies testing
are pending.
 Providers should consider the type of exposure, the location of the wound and the availability of the
biting animal for observation / testing in determining the need for prompt PEP administration.
 Patients who require rabies PEP should receive rabies PEP regardless of the time elapsed since
exposure.
Rabies postexposure prophylaxis schedule (previously vaccinated patients)
Treatment
Wound cleansing
Rabies immune globulin
Rabies vaccine
Regimen
All treatment should begin with thorough wound cleansing, preferably with
virucidal agent such as povidone-iodine, otherwise use soap and water.
Do not administer
Schedule = 1.0 ml IM on days 0 and 3
1. Rabies vaccine should be administered IM in the deltoid muscle in older
children and adults.
2. In infants and small children rabies vaccine should be administered in the
midlateral thigh.
3. Rabies vaccine should not be administered at the same site as rabies
immune globulin.
Rabies postexposure prophylaxis schedule (not previously vaccinated patients)
Treatment
Wound cleansing
Rabies immune globulin
Dose = 20 IU/kg.
Rabies vaccine
Schedule = 1.0 ml IM on days
0,3,7,14,28
Regimen
All treatment should begin with thorough wound cleansing, preferably with
virucidal agent such as povidone-iodine, otherwise use soap and water.
1. If feasible, infiltrate full dose of 20 IU/kg around the wounds.
2. Administer any remaining dose IM at site distant from wound.
3. IM doses of RIG should not be administered at same site as rabies vaccine.
4. In older children and adults, IM doses of RIG should preferably be
administered in the deltoid muscle.
5. In infants and small children, IM doses of RIG should be administered in
the anterolateral thigh.
6. Doses greater than 5 ml should be divided and administered at separate
sites.
7. The gluteal muscle should only be used when administering large volumes
in divided doses to adults.
1. Rabies vaccine should be administered IM in the deltoid muscle in older
children and adults.
2. In infants and small children rabies vaccine should be administered in the
midlateral thigh.
3. Rabies vaccine should not be administered at the same site as rabies
immune globulin.
Note on administration – rabies PEP need not be administered in a specialty area. Rather, rabies PEP,
can be safely administered in non-specialty areas such as Primary Care and Urgent Care.
Procedure for Obtaining Rabies and Tetanus PEP Products
1.
Provider or designee to contact facility pharmacy to obtain product.
2.
Pharmacy to locate product at the nearest available location. If the product is unavailable from
the locations listed, contact St. Joseph’s Pharmacy Department (303) 837-7576 to borrow the
product. Utilize courier service to pick up and deliver the product.
PRODUCT
Rabies Vaccine
Rabies Immune Globulin (RIG)
Tetanus Immune Globulin (TIG)
3.
LOCATION
Warehouse / Arapahoe / Boulder / Franklin
Warehouse / Arapahoe / Boulder / Franklin
Warehouse / Boulder / Franklin / Lakewood / Westminster
/ East / Arapahoe
Pharmacy to arrange for courier service.

Monday through Friday 7:15am – 4:00pm: Call courier communications at (303) 8613446 to arrange for delivery. Indicate to the courier communications the following:
 Location to pick up product including the facility and department.
 Location to deliver product including the facility and department.
 Time frame in which product must arrive.

Monday through Friday after 4:00pm, weekends or holidays: Call AM Express at
(303) 367-3567. Indicate the following to the courier service:
 The name and phone number of the person placing the call.
 Location to pick up product. Include the facility name/number and department
name/number. (AM Express refers to this as the reference number). For example:
Westminster 07-3301.
 Location to deliver the product. Include the facility name/number and department
name/number (AM Express refers to this as the reference number).
 The account / billing code is 14560.
 Time frame in which product must arrive. AM Express offers 1 hour, 2 hour, or 3
hour delivery service.

For questions or concerns contact Denese Clark at (303) 326-6717 or pager (303) 2037808; Alex Matthews at (303) 344-7030 or pager (303) 203-8736; or Dave Schulte at
(303) 344-7025 or pager (303) 203-0767.