Evaluating the Appropriateness of Human Rabies Immune Globulin and Vaccinations

Introduction: Rabies is a fatal viral infection spread via bites and scratches of infected animals. Potential exposures require immediate medical attention to evaluate the necessity of post-exposure prophylaxis, (PEP). PEP consists of two steps: first, a dose of human rabies immune globulin (HRIG) and second, a vaccination series. HRIG is dosed by actual body weight at 20 units/kg and given via wound infiltration and intramuscular injection. HRIG is available in 300 units/mL in various vial sizes. Proper PEP administration is dependent on many factors, and not all exposures warrant the same administration schedule of HRIG and vaccinations. Based on the weight of an average American, the cost for a course of PEP is around $4,850.


Methods: This study was a single-center, retrospective chart review evaluating 48 patients at University Hospitals Ahuja Medical Center (UHAMC) in the emergency department from January 2024 through October 2024. The primary objective was evaluation of appropriate administration of HRIG. Secondary objectives evaluated patient compliance as well as a cost-savings analysis of a proposed dose rounding policy.


Results: All patients received the proper dose of calculated HRIG. Forty-three patients received HRIG via wound infiltration and intramuscular injection, 2 patients appropriately received HRIG via intramuscular injection only, and 3 patients received HRIG via intramuscular injection only, when they should have also received it via wound infiltration. All but 1 patient had proper indications to receive HRIG. 32 patients received all sequential vaccinations, while 16 did not. Of those patients who received all vaccinations, 24 were compliant with the recommended dosing regimen schedule. The proposed dose rounding policy demonstrated an extrapolated annual cost savings of $63,000.


Conclusions: HRIG was properly administered to the appropriate patient population, but improvements could be made in adhering to proper administration techniques. Most patients received all recommended vaccine doses, but a quarter of patients did not. A dose rounding policy was successfully implemented in the emergency department at UHAMC. Future opportunities could include implementing a dose rounding policy at other healthcare systems.