Administration of rabies immunoglobulin: Improving evidence-based guidance for wound infiltration

P. Brandon Bookstaver, Peter Akpunonu, Huy Binh Nguyen, Joshua T. Swan, Gavin T. Howington

Research output: Contribution to journalComment/debate

3 Scopus citations


Rabies virus causes a fatal infection of the brain and spinal cord, accounting for approximately 59,000 deaths globally each year. Rabies postexposure prophylaxis (PEP), including both rabies immunoglobulin (RIG) and vaccination, is administered to 55,000 patients annually in the United States. With a nearly 100% case fatality rate, the optimal administration of rabies PEP cannot be understated. Updated rabies PEP guidelines issued by the World Health Organization (WHO) in 2018 recognized that local wound infiltration of RIG is the primary mechanism of protection, and the WHO now recommends only infiltration of wounds without distal intramuscular injection. We highlight potential points of failure involving wound infiltration of RIG, small-volume doses, and large-volume doses that may lead to suboptimal care and discuss implications of recent shifts toward evidence-based guidelines using wound type and RIG volumes.

Original languageEnglish
Pages (from-to)644-648
Number of pages5
Issue number8
StatePublished - Aug 2021

Bibliographical note

Funding Information:
PBB, PA, and GTH received stipends and JTS’s employer received a stipend from Kedrion Biopharma, Inc. for participation in a human rabies immune globulin advisory board that directly supported this manuscript. JTS receives research funding from Kedrion Biopharma, Inc. and Grifols Biologics, LLC for rabies postexposure prophylaxis research. PBB has received funding from TRC Healthcare for antimicrobial stewardship content development and speaking; received speaker's honorarium from PTCe for discussion on influenza management; received speaker's honorarium from Physicians’ Education Resources, LLC for discussion on COVID‐19 monoclonal antibody therapy. HBN is an employee of Kedrion Biopharma Inc.

Publisher Copyright:
© 2021 Pharmacotherapy Publications, Inc.


  • guidelines
  • immunoglobulins
  • implementation
  • medication error
  • rabies

ASJC Scopus subject areas

  • Pharmacology (medical)


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