Animal Bites and Rabies Risk AssessmentAPPROACH

INFECTIOUS DISEASE AND FEVER SYNDROMES · 19 SECTIONS

⚲

659 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Fever In The Immunocompromised Patient Fever With Rash Animal Bites And Rabies Risk Assessment Tick Exposure And Tick Borne Illness Concern Sepsis Concern Without Clear Source Soft Tissue Infection Concern Abscess And Skin Infection Concern Sore Throat Sore Throat And Pharyngitis Symptoms Meningitis Envenomation And Bites

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx119

Exposure details

›Bite exposure profile

›Species

›Dog

›Cat

›Bat

›Raccoon

›Skunk

›Fox

›Rodent

›Livestock

›Other wildlife

›Exposure type

›Bite

›Scratch

›Saliva contact with mucosa

›Saliva contact with non intact skin

›Aerosol exposure

›Provoked vs unprovoked

›Defensive bite during handling

›Unprovoked attack

›Location and setting

›Home pet

›Stray

›Farm

›Wilderness

›Travel exposure

›Time since exposure

›Less than 8 hours

›8 to 24 hours

›More than 24 hours

›Single vs multiple wounds

›Single wound

›Multiple wounds

Wound characteristics

›Wound profile

›Site

›Face

›Scalp

›Neck

›Hand

›Wrist

›Forearm

›Leg

›Foot

›Genital

›Wound type

›Puncture

›Laceration

›Crush injury

›Avulsion

›Depth indicators

›Visible tendon

›Visible bone

›Joint penetration concern

›Contamination

›Foreign material

›Soil

›Water exposure

Rabies specific history

›Rabies risk history

›Animal available for observation or testing

›Available

›Not available

›Animal health and behavior

›Ill appearing

›Neurologic signs

›Aggression

›Hypersalivation

›Animal vaccination status

›Documented current

›Unknown

›Unvaccinated

›Regional rabies epidemiology

›Known local rabies activity

›Unknown local rabies activity

›Prior rabies vaccination status

›Completed pre exposure series

›Completed post exposure series

›Never vaccinated

Infection prevention history

›Immunization status

›Tetanus vaccine date

›Up to date within 5 years

›Up to date within 10 years

›Unknown or more than 10 years

›Prior tetanus immune globulin

›Yes

›No

›Host factors affecting infection risk

›Diabetes mellitus (E11.9)

›Cirrhosis (K74.60)

›Alcohol use disorder (F10.20)

›Asplenia (Z90.81)

›Immunosuppression

›Chronic kidney disease (N18.9)

Associated symptoms

›Symptoms after bite

›Local

›Increasing pain

›Erythema

›Swelling

›Purulence

›Lymphangitic streaking

›Numbness

›Weakness

›Reduced range of motion

›Systemic

›Fever

›Chills

›Malaise

›Nausea

›Allergy and toxin

›Urticaria

›Wheeze

›Angioedema

›Dizziness

›Concerning for rabies

›Paresthesia at wound

›Hydrophobia

›Aerophobia

›Dysphagia

›Agitation

›Confusion

02Alarm Features/alarm45

Time critical triggers

›Immediate escalation triggers

›Airway compromise

›Facial or neck swelling

›Stridor

›Shock physiology

›Hypotension

›Altered mental status

›Rapidly progressive soft tissue infection

›Pain out of proportion

›Skin necrosis

›Bullae

›Crepitus

›Neurovascular compromise

›Absent distal pulses

›Progressive weakness

›Deep space or compartment concern

›Severe swelling

›Tense compartments

High risk wound patterns

›High risk wound features

›Hand bite

›Flexor tendon sheath pain

›Finger held in flexion

›Face bite

›Lip or eyelid involvement

›Through and through oral laceration

›Joint involvement

›Pain with passive motion

›Joint effusion

›Open fracture concern

›Deformity

›Bone exposure

Rabies high risk exposures

›Rabies high risk features

›Bat exposure

›Bite or scratch

›Mucosal exposure

›Unattended child with bat in room

›Sleeping person with bat in room

›Intoxicated or cognitively impaired with bat in room

›Wild terrestrial carnivore exposure

›Raccoon

›Skunk

›Fox

›Animal unavailable for testing or observation

›Escaped

›Unknown owner

03Medications/meds31

Current medications relevant to management

›Medication reconciliation focus

›Anticoagulants

›Warfarin

›Apixaban

›Rivaroxaban

›Dabigatran

›Antiplatelets

›Acetylsalicylic acid

›Clopidogrel

›Immunosuppressants

›Systemic corticosteroids

›Calcineurin inhibitors

›Antimetabolites

›Biologics

›Allergies affecting antibiotics

›Penicillin allergy

›Cephalosporin allergy

›Recent antibiotics

›Prior beta lactam exposure

›Prior MRSA active agent exposure

Rabies biologics considerations

›Rabies prophylaxis medication factors

›Prior rabies vaccination documentation

›Vaccine product if known

›Dates if known

›Immunocompromised status

›Solid organ transplant

›Hematologic malignancy

›Advanced HIV

›Pregnancy

›No contraindication to rabies PEP

›Obstetric follow up coordination

04Diet/diet10

Intake and hydration context

›Nutrition and hydration factors

›Oral intake tolerance

›Normal

›Reduced

›Hydration status indicators

›Poor oral intake

›Vomiting

›Alcohol exposure

›Recent heavy use

›Chronic use

05Review of Systems/ros22

Infection and systemic symptoms

›Infection ROS

›Fever

›Chills

›Night sweats

›Myalgias

›Headache

Neuro and cardiopulmonary symptoms

›Neuro cardiopulmonary ROS

›Paresthesia

›Weakness

›Confusion

›Dyspnea

›Wheeze

›Chest pain

›Palpitations

Local wound and limb symptoms

›Wound extremity ROS

›Increasing pain

›Swelling

›Redness

›Drainage

›Reduced range of motion

›Loss of sensation

›Loss of strength

06Collateral History and Family History/chafh10

Collateral and exposure verification

›Collateral sources

›Family or caregiver witness

›Animal owner report

›Veterinary record access

›Public health report

›Animal control report

Family and household context

›Household context

›Other exposed household members

›Children or dependent supervision reliability

›Household pets vaccination status

07Risk Factors/rf38

Bite infection risk factors

›Infection risk stratification

›High risk sites

›Hand

›Face

›Genital

›Foot

›High risk wound types

›Puncture wound

›Crush injury

›Deep laceration

›Delayed presentation

›More than 8 hours

›More than 24 hours

›Host risk factors

›Immunocompromised

›Diabetes mellitus (E11.9)

›Asplenia (Z90.81)

›Cirrhosis (K74.60)

Rabies exposure risk factors

›Rabies exposure risk stratification

›Species risk

›Bat

›Wild terrestrial carnivore

›Dog or cat in rabies endemic region

›Exposure severity

›Multiple bites

›Bites near head and neck

›Animal unavailable for assessment

›Unable to capture

›Unknown animal

Occupational and travel risk

›Exposure context risk

›Occupational

›Veterinarian

›Animal handler

›Wildlife control

›Laboratory exposure

›Travel related

›Dog bite in rabies endemic region

›Limited access to rabies biologics

08Differential Diagnosis/ddx42

Life threatening

›Life threatening diagnoses

›Necrotizing soft tissue infection (M72.6)

›Pain out of proportion

›Rapid progression

›Sepsis (A41.9)

›Fever

›Hypotension

›Anaphylaxis (T78.2)

›Hypotension

›Bronchospasm

›Rabies (A82.9)

›Paresthesia at wound

›Hydrophobia

Common

›Common diagnoses

›Local wound infection

›Cellulitis (L03.119)

›Abscess (L02.91)

›Bite wound without infection

›Dog bite (W54.0XXA)

›Cat bite (W55.01XA)

›Lymphangitis (I89.1)

›Streaking erythema

›Tender lymph nodes

Less common

›Less common diagnoses

›Flexor tenosynovitis (M65.9)

›Fusiform swelling

›Pain with passive extension

›Septic arthritis (M00.9)

›Joint effusion

›Severe pain with motion

›Osteomyelitis (M86.9)

›Persistent deep pain

›Delayed infection after puncture

›Capnocytophaga infection

›Asplenia (Z90.81)

›Sepsis pattern

›Pasteurella multocida infection

›Rapid onset within 24 hours

›Cat bites

›Bartonella henselae

›Cat scratch disease (A28.1)

›Regional lymphadenopathy

09Past Medical History/pmh23

Relevant baseline conditions

›Baseline risk conditions

›Immunocompromised state

›HIV (B20)

›Solid organ transplant (Z94.0)

›Diabetes mellitus (E11.9)

›Prior foot infections

›Peripheral neuropathy

›Peripheral vascular disease (I73.9)

›Poor wound healing history

›Prior revascularization

›Asplenia (Z90.81)

›Prior severe infections

›Vaccination history relevance

Prior bite and vaccine history

›Prior related history

›Prior bite infections

›Prior hospitalization

›Prior MRSA infection

›Rabies vaccination history

›Prior pre exposure prophylaxis

›Prior post exposure prophylaxis

›Tetanus immunization history

›Primary series completed

›Booster intervals

10Physical Exam/exam40

General and vital signs

›Global assessment

›Toxic appearance

›Hemodynamic status

›Tachycardia

›Hypotension

›Temperature pattern

›Fever

›Hypothermia

Wound and extremity exam

›Wound focused exam

›Wound inspection

›Location

›Depth

›Devitalized tissue

›Purulence

›Foreign body

›Surrounding tissue

›Erythema margins

›Warmth

›Induration

›Crepitus

›Neurovascular exam distal to wound

›Sensation

›Motor function

›Capillary refill

›Pulses

›Range of motion

›Active range

›Passive range

›Hand specific

›Kanavel signs cluster

›Thenar or hypothenar swelling

›Joint involvement screening

›Pain with axial loading

›Effusion

Head and neck exam when relevant

›Head and neck injury exam

›Facial nerve function

›Oral cavity lacerations

›Ocular injury screening

›Visual acuity change

›Globe injury concern

11Lab Studies/labs20

Infection and sepsis evaluation

›Labs for suspected infection

›CBC

›Leukocytosis support

›Neutropenia risk

›CRP

›Trend marker

›Non specific elevation

›Blood cultures

›Fever with systemic toxicity

›Immunocompromised host

›Serum lactate

›Sepsis concern

›Necrotizing infection concern

Wound microbiology

›Microbiology guidance

›Wound culture

›Purulent drainage present

›Deep space infection suspected

›Superficial swab limitations

›Poor correlation with deep pathogens

›Consider aspiration or deep sample

12Imaging/img38

Scoring Systems

›Exposure classification tools

›WHO rabies exposure categories

›Category I no exposure

›Category II minor exposure

›Category III severe exposure

›Clinical infection risk flags

›Hand bite high complication risk

›Cat puncture high infection risk

MRI

›MRI indications

›Osteomyelitis concern

›Persistent deep pain

›Poor response to antibiotics

›Deep space infection

›Tenosynovitis concern

›Fasciitis concern

›MRI limitations

›Availability and time

›Motion artifact

›CT indications

›Face bite deep structure injury

›Fracture concern

›Foreign body concern

›Necrotizing infection evaluation adjunct

›Gas in soft tissues

›Deep fascial fluid

›CT limitations

›Radiation exposure

›Contrast nephrotoxicity risk

Ultrasound

›Ultrasound applications

›Soft tissue abscess

›Drainable collection

›Cellulitis cobblestoning

›Retained foreign body

›Tooth fragment

›Wood or plastic

›Ultrasound limitations

›Operator dependence

›Limited deep space evaluation

13Special Tests/spec14

Rabies animal testing and public health interface

›Rabies testing pathway

›Animal capture and testing coordination

›Public health notification

›Animal control coordination

›Specimen handling precautions

›Avoid aerosol generating manipulation

›Use trained personnel

Procedural bedside assessments

›Bedside procedural tests

›Saline load test for joint violation

›Consider for periarticular wounds

›Orthopedics consultation alignment

›Tendon injury assessment

›Isolated tendon testing

›Wound exploration with anesthesia

14ECG/ecg7

Indications and high risk patterns

›ECG use cases

›Anaphylaxis with hypotension

›Tachyarrhythmia evaluation

›Ischemia in older patients

›Severe sepsis physiology

›Demand ischemia patterns

›Electrolyte disturbance clues

15Assessment/ax23

Working problems

›Problem list synthesis

›Bite wound

›Dog bite (W54.0XXA)

›Cat bite (W55.01XA)

›Rabies exposure risk

›Contact with and exposure to rabies (Z20.3)

›Need for immunization (Z23)

›Wound infection status

›No infection

›Local infection

›Systemic infection

Severity and complication risk

›Risk stratification summary

›Rabies risk level

›High risk species or scenario

›Animal unavailable

›Infection complication risk

›Hand bite

›Puncture wound

›Immunocompromised host

›Structural injury risk

›Tendon involvement

›Joint involvement

›Fracture concern

16Plan/plan118

First 5 minutes and stabilization

›Immediate priorities

›Airway and breathing

›Oxygen for hypoxemia

›Anaphylaxis protocol if airway symptoms

›Circulation

›IV access for systemic toxicity

›Fluid resuscitation for shock

›Analgesia

›Acetaminophen PO 650 mg

›Ibuprofen PO 400 mg

›Time critical consult triggers

›Hand surgery for tendon sheath concern

›ENT or plastics for complex facial injury

Wound care and closure strategy

›Wound management

›Irrigation

›High volume saline irrigation

›Pressure irrigation for contaminated wounds

›Debridement

›Remove devitalized tissue

›Remove foreign bodies

›Exploration

›Evaluate tendon and joint capsule involvement

›Evaluate neurovascular injury

›Closure approach

›Primary closure options

›Face wounds with good irrigation

›Low infection risk lacerations

›Avoid primary closure scenarios

›Puncture wounds

›Hand wounds high infection risk

›Grossly contaminated wounds

Antibiotics

›Antibiotic strategy

›Prophylaxis indications

›Hand bite

›Deep puncture

›Crush injury

›Delayed presentation more than 8 hours

›Immunocompromised host

›Treatment indications

›Cellulitis

›Abscess

›Lymphangitis

›First line oral

›Amoxicillin clavulanate

›Adult 875 mg 125 mg PO twice daily

›Prophylaxis duration 3 to 5 days

›Treatment duration 5 to 7 days

›Penicillin allergy options

›Doxycycline

›Adult 100 mg PO twice daily

›Avoid in pregnancy

›Avoid in children under 8 years

›Metronidazole

›Adult 500 mg PO twice daily

›TMP SMX

›Adult 160 mg 800 mg PO twice daily

›Clindamycin

›Adult 300 mg PO three times daily

›Pediatric examples

›Amoxicillin clavulanate

›Amoxicillin component 25 to 45 mg per kg per day divided twice daily

›Maximum per local pediatric protocol

›TMP SMX plus clindamycin

›TMP component 4 to 5 mg per kg per dose twice daily

›Clindamycin 10 mg per kg per dose three times daily

›IV antibiotics indications

›Systemic toxicity

›Rapid progression

›Deep space infection

Tetanus prophylaxis

›Tetanus prevention

›Vaccine indications

›Unknown or incomplete immunization

›More than 10 years since booster

›More than 5 years since booster for contaminated wounds

›Tetanus immune globulin indications

›Dirty wound with unknown or incomplete immunization

›Severe immunodeficiency with dirty wound

›Administration considerations

›Vaccine and immune globulin different sites

›Document product and lot if available

Rabies post exposure prophylaxis

›Rabies PEP decision and regimen

›Immediate wound cleansing

›Soap and water irrigation

›Virucidal agent if available

›Animal observation and testing logic

›Dog cat ferret available and healthy

›10 day observation local protocol dependent

›Unvaccinated regimen

›HRIG 20 IU per kg once

›Infiltrate as much as feasible into and around wound

›Remaining HRIG IM at site distant from vaccine

›Rabies vaccine IM series

›Day 0

›Day 3

›Day 7

›Day 14

›Immunocompromised regimen

›Add vaccine dose day 28

›Consider serologic confirmation per public health

›Previously vaccinated regimen

›No HRIG

›Rabies vaccine IM

›Day 0

›Day 3

›Administration pearls

›Deltoid IM adult

›Anterolateral thigh IM child

›Avoid gluteal injection

›Intradermal regimens

›Programmatic option in some settings

›Local protocol dependent

Reassessment loop

›Reassessment triggers

›Pain progression within hours

›Expanding erythema

›Fever development

›New neurologic deficits distal to wound

›Reduced range of motion

›Return evaluation window 24 to 48 hours for high risk wounds

17Disposition/dispo28

Level of care decision

›Disposition criteria

›ICU criteria

›Septic shock

›Airway compromise from anaphylaxis

›Inpatient admission criteria

›Rapidly progressive infection

›Deep space infection

›Need for IV antibiotics

›Infected hand bite with functional compromise

›Observation pathway criteria

›High risk wound needing serial exams

›Significant swelling without clear deep infection

›Discharge criteria

›No systemic toxicity

›Adequate irrigation completed

›Neurovascularly intact distal exam

›Reliable follow up and vaccine access if needed

Follow up coordination

›Follow up plan

›Wound check timing

›24 to 48 hours for hand bites and punctures

›48 to 72 hours for other high risk wounds

›Rabies vaccine schedule follow up

›Day 3 appointment

›Day 7 appointment

›Day 14 appointment

›Public health coordination

›Documentation of exposure and plan

›Animal control case number if applicable

18Discharge Instructions/di24

Copy discharge instructions

›Patient instructions

›Wound care

›Keep wound clean and dry for 24 hours

›Daily gentle washing with soap and water after 24 hours

›Apply clean dressing daily

›Medications

›Take antibiotics exactly as prescribed if provided

›Pain control with acetaminophen or ibuprofen as directed

›Rabies vaccines if started

›Return for scheduled vaccine doses on day 3 day 7 day 14

›Do not miss doses

›Return to emergency care now for

›Fever

›Spreading redness

›Increasing swelling

›Pus or foul drainage

›Severe pain

›Numbness or weakness

›Trouble moving fingers or joints

›Red streaks up the arm or leg

›Trouble breathing or swelling of lips or face

›Follow up

›See clinician for wound recheck within 24 to 48 hours if high risk wound

›Contact public health or animal control if animal is found after discharge

19References/r7

Guidelines and key references

›Core references

›CDC MMWR Human Rabies Prevention United States 2008

›CDC MMWR Use of a Modified Preexposure Prophylaxis Vaccination Schedule to Prevent Human Rabies 2022

›WHO Rabies vaccines position paper April 2018 Weekly Epidemiological Record

›Public Health Agency of Canada Canadian Immunization Guide Rabies vaccine updated 2025

›NICE guideline NG184 Human and animal bites antimicrobial prescribing 2020

›IDSA Clinical Practice Guideline for Skin and Soft Tissue Infections 2014

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Animal Bites and Rabies Risk AssessmentAPPROACH

INFECTIOUS DISEASE AND FEVER SYNDROMES · 19 SECTIONS

⚲

659 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx119

Exposure details

›Bite exposure profile

›Species

›Dog

›Cat

›Bat

›Raccoon

›Skunk

›Fox

›Rodent

›Livestock

›Other wildlife

›Exposure type

›Bite

›Scratch

›Saliva contact with mucosa

›Saliva contact with non intact skin

›Aerosol exposure

›Provoked vs unprovoked

›Defensive bite during handling

›Unprovoked attack

›Location and setting

›Home pet

›Stray

›Farm

›Wilderness

›Travel exposure

›Time since exposure

›Less than 8 hours

›8 to 24 hours

›More than 24 hours

›Single vs multiple wounds

›Single wound

›Multiple wounds

Wound characteristics

›Wound profile

›Site

›Face

›Scalp

›Neck

›Hand

›Wrist

›Forearm

›Leg

›Foot

›Genital

›Wound type

›Puncture

›Laceration

›Crush injury

›Avulsion

›Depth indicators

›Visible tendon

›Visible bone

›Joint penetration concern

›Contamination

›Foreign material

›Soil

›Water exposure

Rabies specific history

›Rabies risk history

›Animal available for observation or testing

›Available

›Not available

›Animal health and behavior

›Ill appearing

›Neurologic signs

›Aggression

›Hypersalivation

›Animal vaccination status

›Documented current

›Unknown

›Unvaccinated

›Regional rabies epidemiology

›Known local rabies activity

›Unknown local rabies activity

›Prior rabies vaccination status

›Completed pre exposure series

›Completed post exposure series

›Never vaccinated

Infection prevention history

›Immunization status

›Tetanus vaccine date

›Up to date within 5 years

›Up to date within 10 years

›Unknown or more than 10 years

›Prior tetanus immune globulin

›Yes

›No

›Host factors affecting infection risk

›Diabetes mellitus (E11.9)

›Cirrhosis (K74.60)

›Alcohol use disorder (F10.20)

›Asplenia (Z90.81)

›Immunosuppression

›Chronic kidney disease (N18.9)

Associated symptoms

›Symptoms after bite

›Local

›Increasing pain

›Erythema

›Swelling

›Purulence

›Lymphangitic streaking

›Numbness

›Weakness

›Reduced range of motion

›Systemic

›Fever

›Chills

›Malaise

›Nausea

›Allergy and toxin

›Urticaria

›Wheeze

›Angioedema

›Dizziness

›Concerning for rabies

›Paresthesia at wound

›Hydrophobia

›Aerophobia

›Dysphagia

›Agitation

›Confusion

02Alarm Features/alarm45

Time critical triggers

›Immediate escalation triggers

›Airway compromise

›Facial or neck swelling

›Stridor

›Shock physiology

›Hypotension

›Altered mental status

›Rapidly progressive soft tissue infection

›Pain out of proportion

›Skin necrosis

›Bullae

›Crepitus

›Neurovascular compromise

›Absent distal pulses

›Progressive weakness

›Deep space or compartment concern

›Severe swelling

›Tense compartments

High risk wound patterns

›High risk wound features

›Hand bite

›Flexor tendon sheath pain

›Finger held in flexion

›Face bite

›Lip or eyelid involvement

›Through and through oral laceration

›Joint involvement

›Pain with passive motion

›Joint effusion

›Open fracture concern

›Deformity

›Bone exposure

Rabies high risk exposures

›Rabies high risk features

›Bat exposure

›Bite or scratch

›Mucosal exposure

›Unattended child with bat in room

›Sleeping person with bat in room

›Intoxicated or cognitively impaired with bat in room

›Wild terrestrial carnivore exposure

›Raccoon

›Skunk

›Fox

›Animal unavailable for testing or observation

›Escaped

›Unknown owner

03Medications/meds31

Current medications relevant to management

›Medication reconciliation focus

›Anticoagulants

›Warfarin

›Apixaban

›Rivaroxaban

›Dabigatran

›Antiplatelets

›Acetylsalicylic acid

›Clopidogrel

›Immunosuppressants

›Systemic corticosteroids

›Calcineurin inhibitors

›Antimetabolites

›Biologics

›Allergies affecting antibiotics

›Penicillin allergy

›Cephalosporin allergy

›Recent antibiotics

›Prior beta lactam exposure

›Prior MRSA active agent exposure

Rabies biologics considerations

›Rabies prophylaxis medication factors

›Prior rabies vaccination documentation

›Vaccine product if known

›Dates if known

›Immunocompromised status

›Solid organ transplant

›Hematologic malignancy

›Advanced HIV

›Pregnancy

›No contraindication to rabies PEP

›Obstetric follow up coordination

04Diet/diet10

Intake and hydration context

›Nutrition and hydration factors

›Oral intake tolerance

›Normal

›Reduced

›Hydration status indicators

›Poor oral intake

›Vomiting

›Alcohol exposure

›Recent heavy use

›Chronic use

05Review of Systems/ros22

Infection and systemic symptoms

›Infection ROS

›Fever

›Chills

›Night sweats

›Myalgias

›Headache

Neuro and cardiopulmonary symptoms

›Neuro cardiopulmonary ROS

›Paresthesia

›Weakness

›Confusion

›Dyspnea

›Wheeze

›Chest pain

›Palpitations

Local wound and limb symptoms

›Wound extremity ROS

›Increasing pain

›Swelling

›Redness

›Drainage

›Reduced range of motion

›Loss of sensation

›Loss of strength

06Collateral History and Family History/chafh10

Collateral and exposure verification

›Collateral sources

›Family or caregiver witness

›Animal owner report

›Veterinary record access

›Public health report

›Animal control report

Family and household context

›Household context

›Other exposed household members

›Children or dependent supervision reliability

›Household pets vaccination status

07Risk Factors/rf38

Bite infection risk factors

›Infection risk stratification

›High risk sites

›Hand

›Face

›Genital

›Foot

›High risk wound types

›Puncture wound

›Crush injury

›Deep laceration

›Delayed presentation

›More than 8 hours

›More than 24 hours

›Host risk factors

›Immunocompromised

›Diabetes mellitus (E11.9)

›Asplenia (Z90.81)

›Cirrhosis (K74.60)

Rabies exposure risk factors

›Rabies exposure risk stratification

›Species risk

›Bat

›Wild terrestrial carnivore

›Dog or cat in rabies endemic region

›Exposure severity

›Multiple bites

›Bites near head and neck

›Animal unavailable for assessment

›Unable to capture

›Unknown animal

Occupational and travel risk

›Exposure context risk

›Occupational

›Veterinarian

›Animal handler

›Wildlife control

›Laboratory exposure

›Travel related

›Dog bite in rabies endemic region

›Limited access to rabies biologics

08Differential Diagnosis/ddx42

Life threatening

›Life threatening diagnoses

›Necrotizing soft tissue infection (M72.6)

›Pain out of proportion

›Rapid progression

›Sepsis (A41.9)

›Fever

›Hypotension

›Anaphylaxis (T78.2)

›Hypotension

›Bronchospasm

›Rabies (A82.9)

›Paresthesia at wound

›Hydrophobia

Common

›Common diagnoses

›Local wound infection

›Cellulitis (L03.119)

›Abscess (L02.91)

›Bite wound without infection

›Dog bite (W54.0XXA)

›Cat bite (W55.01XA)

›Lymphangitis (I89.1)

›Streaking erythema

›Tender lymph nodes

Less common

›Less common diagnoses

›Flexor tenosynovitis (M65.9)

›Fusiform swelling

›Pain with passive extension

›Septic arthritis (M00.9)

›Joint effusion

›Severe pain with motion

›Osteomyelitis (M86.9)

›Persistent deep pain

›Delayed infection after puncture

›Capnocytophaga infection

›Asplenia (Z90.81)

›Sepsis pattern

›Pasteurella multocida infection

›Rapid onset within 24 hours

›Cat bites

›Bartonella henselae

›Cat scratch disease (A28.1)

›Regional lymphadenopathy

09Past Medical History/pmh23

Relevant baseline conditions

›Baseline risk conditions

›Immunocompromised state

›HIV (B20)

›Solid organ transplant (Z94.0)

›Diabetes mellitus (E11.9)

›Prior foot infections

›Peripheral neuropathy

›Peripheral vascular disease (I73.9)

›Poor wound healing history

›Prior revascularization

›Asplenia (Z90.81)

›Prior severe infections

›Vaccination history relevance

Prior bite and vaccine history

›Prior related history

›Prior bite infections

›Prior hospitalization

›Prior MRSA infection

›Rabies vaccination history

›Prior pre exposure prophylaxis

›Prior post exposure prophylaxis

›Tetanus immunization history

›Primary series completed

›Booster intervals

10Physical Exam/exam40

General and vital signs

›Global assessment

›Toxic appearance

›Hemodynamic status

›Tachycardia

›Hypotension

›Temperature pattern

›Fever

›Hypothermia

Wound and extremity exam

›Wound focused exam

›Wound inspection

›Location

›Depth

›Devitalized tissue

›Purulence

›Foreign body

›Surrounding tissue

›Erythema margins

›Warmth

›Induration

›Crepitus

›Neurovascular exam distal to wound

›Sensation

›Motor function

›Capillary refill

›Pulses

›Range of motion

›Active range

›Passive range

›Hand specific

›Kanavel signs cluster

›Thenar or hypothenar swelling

›Joint involvement screening

›Pain with axial loading

›Effusion

Head and neck exam when relevant

›Head and neck injury exam

›Facial nerve function

›Oral cavity lacerations

›Ocular injury screening

›Visual acuity change

›Globe injury concern

11Lab Studies/labs20

Infection and sepsis evaluation

›Labs for suspected infection

›CBC

›Leukocytosis support

›Neutropenia risk

›CRP

›Trend marker

›Non specific elevation

›Blood cultures

›Fever with systemic toxicity

›Immunocompromised host

›Serum lactate

›Sepsis concern

›Necrotizing infection concern

Wound microbiology

›Microbiology guidance

›Wound culture

›Purulent drainage present

›Deep space infection suspected

›Superficial swab limitations

›Poor correlation with deep pathogens

›Consider aspiration or deep sample

12Imaging/img38

Scoring Systems

›Exposure classification tools

›WHO rabies exposure categories

›Category I no exposure

›Category II minor exposure

›Category III severe exposure

›Clinical infection risk flags

›Hand bite high complication risk

›Cat puncture high infection risk

MRI

›MRI indications

›Osteomyelitis concern

›Persistent deep pain

›Poor response to antibiotics

›Deep space infection

›Tenosynovitis concern

›Fasciitis concern

›MRI limitations

›Availability and time

›Motion artifact

›CT indications

›Face bite deep structure injury

›Fracture concern

›Foreign body concern

›Necrotizing infection evaluation adjunct

›Gas in soft tissues

›Deep fascial fluid

›CT limitations

›Radiation exposure

›Contrast nephrotoxicity risk

Ultrasound

›Ultrasound applications

›Soft tissue abscess

›Drainable collection

›Cellulitis cobblestoning

›Retained foreign body

›Tooth fragment

›Wood or plastic

›Ultrasound limitations

›Operator dependence

›Limited deep space evaluation

13Special Tests/spec14

Rabies animal testing and public health interface

›Rabies testing pathway

›Animal capture and testing coordination

›Public health notification

›Animal control coordination

›Specimen handling precautions

›Avoid aerosol generating manipulation

›Use trained personnel

Procedural bedside assessments

›Bedside procedural tests

›Saline load test for joint violation

›Consider for periarticular wounds

›Orthopedics consultation alignment

›Tendon injury assessment

›Isolated tendon testing

›Wound exploration with anesthesia

14ECG/ecg7

Indications and high risk patterns

›ECG use cases

›Anaphylaxis with hypotension

›Tachyarrhythmia evaluation

›Ischemia in older patients

›Severe sepsis physiology

›Demand ischemia patterns

›Electrolyte disturbance clues

15Assessment/ax23

Working problems

›Problem list synthesis

›Bite wound

›Dog bite (W54.0XXA)

›Cat bite (W55.01XA)

›Rabies exposure risk

›Contact with and exposure to rabies (Z20.3)

›Need for immunization (Z23)

›Wound infection status

›No infection

›Local infection

›Systemic infection

Severity and complication risk

›Risk stratification summary

›Rabies risk level

›High risk species or scenario

›Animal unavailable

›Infection complication risk

›Hand bite

›Puncture wound

›Immunocompromised host

›Structural injury risk

›Tendon involvement

›Joint involvement

›Fracture concern

16Plan/plan118

First 5 minutes and stabilization

›Immediate priorities

›Airway and breathing

›Oxygen for hypoxemia

›Anaphylaxis protocol if airway symptoms

›Circulation

›IV access for systemic toxicity

›Fluid resuscitation for shock

›Analgesia

›Acetaminophen PO 650 mg

›Ibuprofen PO 400 mg

›Time critical consult triggers

›Hand surgery for tendon sheath concern

›ENT or plastics for complex facial injury

Wound care and closure strategy

›Wound management

›Irrigation

›High volume saline irrigation

›Pressure irrigation for contaminated wounds

›Debridement

›Remove devitalized tissue

›Remove foreign bodies

›Exploration

›Evaluate tendon and joint capsule involvement

›Evaluate neurovascular injury

›Closure approach

›Primary closure options

›Face wounds with good irrigation

›Low infection risk lacerations

›Avoid primary closure scenarios

›Puncture wounds

›Hand wounds high infection risk

›Grossly contaminated wounds

Antibiotics

›Antibiotic strategy

›Prophylaxis indications

›Hand bite

›Deep puncture

›Crush injury

›Delayed presentation more than 8 hours

›Immunocompromised host

›Treatment indications

›Cellulitis

›Abscess

›Lymphangitis

›First line oral

›Amoxicillin clavulanate

›Adult 875 mg 125 mg PO twice daily

›Prophylaxis duration 3 to 5 days

›Treatment duration 5 to 7 days

›Penicillin allergy options

›Doxycycline

›Adult 100 mg PO twice daily

›Avoid in pregnancy

›Avoid in children under 8 years

›Metronidazole

›Adult 500 mg PO twice daily

›TMP SMX

›Adult 160 mg 800 mg PO twice daily

›Clindamycin

›Adult 300 mg PO three times daily

›Pediatric examples

›Amoxicillin clavulanate

›Amoxicillin component 25 to 45 mg per kg per day divided twice daily

›Maximum per local pediatric protocol

›TMP SMX plus clindamycin

›TMP component 4 to 5 mg per kg per dose twice daily

›Clindamycin 10 mg per kg per dose three times daily

›IV antibiotics indications

›Systemic toxicity

›Rapid progression

›Deep space infection

Tetanus prophylaxis

›Tetanus prevention

›Vaccine indications

›Unknown or incomplete immunization

›More than 10 years since booster

›More than 5 years since booster for contaminated wounds

›Tetanus immune globulin indications

›Dirty wound with unknown or incomplete immunization

›Severe immunodeficiency with dirty wound

›Administration considerations

›Vaccine and immune globulin different sites

›Document product and lot if available

Rabies post exposure prophylaxis

›Rabies PEP decision and regimen

›Immediate wound cleansing

›Soap and water irrigation

›Virucidal agent if available

›Animal observation and testing logic

›Dog cat ferret available and healthy

›10 day observation local protocol dependent

›Unvaccinated regimen

›HRIG 20 IU per kg once

›Infiltrate as much as feasible into and around wound

›Remaining HRIG IM at site distant from vaccine

›Rabies vaccine IM series

›Day 0

›Day 3

›Day 7

›Day 14

›Immunocompromised regimen

›Add vaccine dose day 28

›Consider serologic confirmation per public health

›Previously vaccinated regimen

›No HRIG

›Rabies vaccine IM

›Day 0

›Day 3

›Administration pearls

›Deltoid IM adult

›Anterolateral thigh IM child

›Avoid gluteal injection

›Intradermal regimens

›Programmatic option in some settings

›Local protocol dependent

Reassessment loop

›Reassessment triggers

›Pain progression within hours

›Expanding erythema

›Fever development

›New neurologic deficits distal to wound

›Reduced range of motion

›Return evaluation window 24 to 48 hours for high risk wounds

17Disposition/dispo28

Level of care decision

›Disposition criteria

›ICU criteria

›Septic shock

›Airway compromise from anaphylaxis

›Inpatient admission criteria

›Rapidly progressive infection

›Deep space infection

›Need for IV antibiotics

›Infected hand bite with functional compromise

›Observation pathway criteria

›High risk wound needing serial exams

›Significant swelling without clear deep infection

›Discharge criteria

›No systemic toxicity

›Adequate irrigation completed

›Neurovascularly intact distal exam

›Reliable follow up and vaccine access if needed

Follow up coordination

›Follow up plan

›Wound check timing

›24 to 48 hours for hand bites and punctures

›48 to 72 hours for other high risk wounds

›Rabies vaccine schedule follow up

›Day 3 appointment

›Day 7 appointment

›Day 14 appointment

›Public health coordination

›Documentation of exposure and plan

›Animal control case number if applicable

18Discharge Instructions/di24

Copy discharge instructions

›Patient instructions

›Wound care

›Keep wound clean and dry for 24 hours

›Daily gentle washing with soap and water after 24 hours

›Apply clean dressing daily

›Medications

›Take antibiotics exactly as prescribed if provided

›Pain control with acetaminophen or ibuprofen as directed

›Rabies vaccines if started

›Return for scheduled vaccine doses on day 3 day 7 day 14

›Do not miss doses

›Return to emergency care now for

›Fever

›Spreading redness

›Increasing swelling

›Pus or foul drainage

›Severe pain

›Numbness or weakness

›Trouble moving fingers or joints

›Red streaks up the arm or leg

›Trouble breathing or swelling of lips or face

›Follow up

›See clinician for wound recheck within 24 to 48 hours if high risk wound

›Contact public health or animal control if animal is found after discharge

19References/r7

Guidelines and key references

›Core references

›CDC MMWR Human Rabies Prevention United States 2008

›CDC MMWR Use of a Modified Preexposure Prophylaxis Vaccination Schedule to Prevent Human Rabies 2022

›WHO Rabies vaccines position paper April 2018 Weekly Epidemiological Record

›Public Health Agency of Canada Canadian Immunization Guide Rabies vaccine updated 2025

›NICE guideline NG184 Human and animal bites antimicrobial prescribing 2020

›IDSA Clinical Practice Guideline for Skin and Soft Tissue Infections 2014

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.