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Critical Appraisal of the Milwaukee Protocol for Rabies: This Failed Approach Should Be Abandoned

  • Frederick A. Zeiler (a1) and Alan C. Jackson (a2) (a3)


The Milwaukee protocol has been attributed to survival in rabies encephalitis despite a lack of scientific evidence supporting its therapeutic measures. We have reviewed the literature with reference to specific treatment recommendations made within the protocol. Current literature fails to support an important role for excitotoxicity and cerebral vasospasm in rabies encephalitis. Therapies suggested in the Milwaukee protocol include therapeutic coma, ketamine infusion, amantadine, and the screening/prophylaxis/management of cerebral vasospasm. None of these therapies can be substantiated in rabies or other forms of acute viral encephalitis. Serious concerns over the current protocol recommendations are warranted. The recommendations made by the Milwaukee protocol warrant serious reconsideration before any future use of this failed protocol.

Évaluation critique du protocole de Milwaukee pour le traitement de la rage: cette approche inefficace devrait être abandonnée. La survie dans l’encéphalite rabique a été attribuée au protocole de Milwaukee malgré l’absence de données scientifiques à l’appui. Nous avons revu la littérature traitant des recommandations spécifiques de traitement faites dans le cadre de ce protocole. Aucune donnée de la littérature actuelle ne supporte que l’excitotoxicité et le vasospasme cérébral jouent un rôle important dans l’encéphalite rabique. Les traitements suggérés dans le protocole de Milwaukee incluent le coma thérapeutique, l’infusion de kétamine, l’amantadine et le dépistage, la prévention et le traitement du vasospasme cérébral. Il n’existe aucune preuve que de ces traitements soient efficaces contre la rage ou toute autre forme d’encéphalite virale aigüe. Il est donc justifié d’entretenir de graves réserves au sujet des recommandations contenues dans le protocole actuel. Les recommandations contenues dans le protocole de Milwaukee méritent d’être reconsidérées dans leur ensemble avant toute utilisation future du protocole actuel qui s’est avéré inefficace.

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Corresponding author

Correspondence to: Dr. Alan C. Jackson, Health Sciences Centre, GF-543, 820 Sherbrook Street,Winnipeg, MB R3A 1R9 Canada. E-mail:


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