Comparing clinical protocols for the treatment of human rabies: the Milwaukee protocol and the Brazilian protocol (Recife)

Abstract INTRODUCTION: Rabies is a major and seriously neglected public health problem worldwide. A treatment consisting of supportive therapy with the use of drugs that show antiviral activity is called the Milwaukee Protocol. In Brazil, this protocol was adapted to the national reality and called the Recife Protocol. In this study, we compared the Milwaukee Protocol with the Recife Protocol, assessing the differences and how these differences may change the course of clinical management. METHODS We searched electronic databases for the use of anti-rabies treatments. A total of 65 articles were published between 2004 and 2019. RESULTS: The protocols have similarities in care related to rabies patients and are important for the treatment of patients in intensive care units. Both protocols indicate deep sedation, antiviral use, constant concern with electrolyte balance, and vasoconstriction related to the condition. Many differences were observed in this study. For the Milwaukee Protocol, sedation should be gradually removed after the eighth day, and on the twelfth day, the patient should be without sedation. In the Recife Protocol, in order to avoid immunomodulation, it is recommended to remove sedation according to the titers of neutralizing antibodies to the rabies virus in the cerebral spinal fluid. CONCLUSIONS: In addition to the differences and similarities raised, our findings indicate that these protocols require a large center for rabies treatment, but the disease most often occurs in places where resources and hospital infrastructure are scarce.

Research progress on some aspects of human rabies / 中华临床感染病杂志

In recent years,the rabies virus(RV)has been studied in more depth, including wild virus,vaccine strain, and the gene structure, replication, gene function and expression regulation of the newly identified isolates from bats.According to the homology of N protein base,the human pathogenic RV can be divided into 7 genotypes, which belong to the genetic pedigree Ⅰ,Ⅱ,Ⅲ, respectively.The pathogenesis of human rabies has not been fully understood,no breakthrough has been made in the treatment of rabies, and the Milwaukee protocol has not been recognized by expert consensus.From the current research progress of animal models,the development of novel therapeutic vaccines and drugs to inhibit viral replication and diffusion are promising for cure of rabies.This article reviews some new discoveries and information of rabies, including the characteristics of RV, the pathogenic mechanisms and the progress of treatments after onset,which would provide reference for prevention and control of human rabies.

Clinical rabies: is cure possible.

Rabies is a fatal disease in humans and till date survivors of the disease after the clinical onset of the illness are rare. The approach to management of rabies is usually palliative. In rare cases of paralytic rabies a trial for cure has been tried. No single therapeutic agent is likely to be effective, but a combination of specific therapies could be considered, including rabies vaccine, rabies immunoglobulin, monoclonal antibodies, ribavirin, interferon alpha, ketamine etc. the only reported cases in literature were with rare success of the Milwaukee protocol. This is the case report of a 45 year old male who presented with clinical rabies and was started on the trial. Has the treatment had any benefit is to be debated and further options discussed.