Rabies post-exposure prophylaxis in children: adherence to national guidelines in a country at ongoing risk

Rabies is a preventable but fatal zoonotic disease, and children account for a large share of exposures worldwide. Türkiye is regarded as rabies-endemic because of ongoing circulation in terrestrial animals, particularly dogs, although human cases are rare because of effective surveillance and post-exposure prophylaxis. Adherence to post-exposure prophylaxis guidelines is crucial for prevention. This study evaluated the appropriateness of initial rabies post-exposure prophylaxis administered to pediatric patients according to the 2019 Turkish Ministry of Health guideline. This retrospective descriptive study included children under 18 years who presented to the emergency department of a tertiary hospital with suspected rabies exposure and were evaluated in the pediatric infectious diseases clinic between January and December 2024. Demographics, animal type, exposure category, and administration of rabies vaccine and immunoglobulin were recorded. Compliance was determined by comparing actual management with guideline recommendations. A total of 523 patients (median age 8 years; 56.4% male) were evaluated. Cats were the main exposure source (71.1%), and 84.1% were Category II. Although all patients received the rabies vaccine, 71.3% of these administrations were deemed unnecessary based on guideline criteria, mostly due to minor, provoked, non-bleeding cat scratches. Of 41 patients requiring rabies immunoglobulin, only 6 (14.6%) received it appropriately. Full compliance was achieved in 21.9% of cases. Inappropriate vaccination predominated in cat exposures, while immunoglobulin underuse was common in dog bites (p < 0.001). Major inconsistencies exist between practice and national rabies post-exposure prophylaxis guidelines in children. Over-vaccination and inadequate immunoglobulin use highlight the need for standardized risk assessment and ongoing professional education.