When should I refer a patient for specialist assessment regarding rabies vaccination after potential exposure?

Refer a patient for specialist assessment regarding rabies vaccination urgently if they have had high-risk exposures such as severe or multiple bites to the head and neck, or bites from a confirmed rabid animal. Treatment should ideally start within 12 hours of reporting such exposures to maximise effectiveness.

Referral to secondary care is also indicated for: severe bite injuries with heavy bleeding causing haemodynamic instability; penetrating wounds involving arteries, joints, nerves, muscles, tendons, bones, or the central nervous system; penetrating bites to hands, feet, or head; children with scalp wounds and potential penetrating wounds to the skull; facial wounds (excluding very minor wounds) and bites to the eye or orbit; serious hand bites; bites with possible foreign bodies; devitalised wounds requiring debridement or closure; wounds needing reconstructive surgery; and people with signs of significant infection or systemic illness.

Additionally, patients with increased risk of infection (e.g., diabetes, asplenia, immunocompromised status, chronic liver disease, prosthetic heart valve or joint) should be referred for specialist assessment.

Referral should also be considered if the patient cannot take oral antibiotics or develops signs of significant infection while on prophylactic antibiotics.

Risk assessment for rabies exposure should be performed using the UKHSA Rabies post-exposure risk assessment form, and specialist advice can be sought from local health protection teams or the UKHSA Rabies and Immunoglobulin Service.