Basics
Description
- Mechanisms of exposure to blood or body fluid:
- Percutaneous
- Mucous membrane
- Skin
- General prevention:
- Universal precautions
- Avoid recapping of needles
- Wear gloves: Decreases amount of blood exposure by 50%
- Double gloving
- Follow body " “substance isolation protocols.
- Hepatitis B virus vaccination
- Risk factors:
- Risk of seroconversion from a single needlestick exposure without prior immunization:
- Hepatitis B virus: 37 " “62% from HBsAg-positive and HBeAg-positive source, 23 " “37% from HBsAg-positive and HBeAg-negative source
- Hepatitis C virus: 1.8%
- HIV: Blood 0.3%, mucous membrane 0.09%
- Infectiousness of various body fluids for HIV:
- Plasma/serum: 10 " “5,000 ppm
- CSF: 10 " “1,000 ppm
- Semen: 10 " “50 ppm
- Vaginal secretions, urine, saliva, tears, breast milk: <1 ppm
- Factors affecting risk:
- Viral load
- Actual injection volume
- Type and size of needle
- Portal of entry (depth of inoculation)
- Duration of contact
- Level of disease in source patient
- Host susceptibility
- Barriers (e.g., through gloves)
Diagnosis
Signs and Symptoms
History
Exposure to blood or body fluid: ‚
- Date, time, circumstances, details of exposure, source
- Immunizations
Diagnosis Tests & Interpretation
Women with body fluid exposure who are considering antiviral therapy must have serum or urine pregnancy testing. ‚
Lab
To be done with occupational health if possible: ‚
- Baseline serology for HIV (enzyme immunoassay, western blot), hepatitis B virus, hepatitis C virus (anti-HCV), ALT. Assess adequacy of hepatitis B virus vaccination.
- HIV-Ab, HCV-Ab, HBsAg, HBsAb titer
- Obtain consent from source patient for HIV (consider rapid HIV-antibody test), hepatitis B virus, hepatitis C virus (anti-HCV) testing.
Imaging
Not applicable unless concerned for retained tissue foreign body ‚
Differential Diagnosis
Principally concerned with transmission of hepatitis B virus, hepatitis C virus, and HIV ‚
Treatment
Pre-Hospital
- Pre-hospital personnel should always maintain universal precautions to prevent needlestick or other body fluid exposure.
- Patients with exposure should be evaluated within hours for prophylactic therapy.
Initial Stabilization/Therapy
- Copious cleaning, wound care
- Direct and immediate referral to occupational health, when available, to ensure strictest confidentiality in lab testing and treatment
- In the ED, after hours, patients with needlestick exposure must be triaged with high priority. It is important to initiate prophylactic therapy quickly after exposure.
Ed Treatment/Procedures
- If referral to occupational health is unavailable, initiate prophylactic therapy in ED.
- Tetanus prophylaxis if necessary
- HIV:
- Begin basic vs. expanded antiretroviral prophylaxis regimen after considering HIV status of source and severity of exposure. Some organizations advocate only the expanded 3-drug regimen. Treat for 28 days.
- CDC guidelines: For less severe percutaneous exposure, if source patient is:
- HIV negative: No prophylaxis
- Unknown source: Consider basic regimen
- Patient with risk factors: Consider basic regimen
- HIV positive, low viral load: Recommend basic regimen
- HIV positive, high viral load: Recommend expanded regimen ≥3 drugs
- CDC guidelines: For more severe percutaneous exposure, if source patient is:
- HIV negative: No prophylaxis
- Unknown source: Consider basic regimen
- Patient with risk factors: Consider basic regimen
- HIV positive, low viral load: Recommend expanded regimen 3 drugs
- HIV positive, high viral load: Recommend expanded regimen ≥3 drugs
- CDC guidelines: For less severe mucous membrane or nonintact skin exposure, if source patient is:
- HIV negative: No prophylaxis
- Unknown source: No prophylaxis
- Patient with risk factors: No prophylaxis
- HIV positive, low viral load: Consider basic regimen
- HIV positive, high viral load: Recommend basic regimen
- CDC guidelines: For more severe mucous membrane or nonintact skin exposure, if source patient is:
- HIV negative: No prophylaxis
- Unknown source: Consider basic regimen
- Patient with risk factors: Consider basic regimen
- HIV positive, low viral load: Recommend basic regimen
- HIV positive, high viral load: Recommend expanded regimen ≥3 drugs
- CDC preferred basic regimen:
- Zidovudine (AZT) + lamivudine (3TC); sold as combination drug Combivir; or
- Tenofovir DF (TDF) + emtricitabine (FTC);
- Zidovudine (AZT) + emtricitabine (FTC); or
- Lamivudine (3TC) + tenofovir DF (TDF); or
- CDC alternative basic regimen:
- Lamivudine (3TC) + stavudine (d4T); or
- Emtricitabine (FTC) + stavudine (d4T) or
- Lamivudine (3TC) + didanosine (ddI) or
- Emtricitabine (FTC) + didanosine (ddI)
- CDC preferred expanded regimen: Basic regimen and:
- Lopinavir/ritonavir (Kaletra)
- CDC alternative expanded regimen: Basic regimen and:
- Atazanavir (ATV) ‚ ± ritonavir (RTV) or
- Fosamprenavir ‚ ± ritonavir (RTV) or
- Indinavir (IDV) ‚ ± ritonavir (RTV) or
- Saquinavir (SQV) + ritonavir (RTV) or
- Nelfinaviror
- Efavirenzor
- Consider others after expert consultation: These include abacavir, delavirdine, zalcitabine, nevirapine, enfuvirtide.
- Counseling to prevent secondary infection:
- Safer sex advice
- Avoid becoming pregnant
- Do not donate blood/tissue.
- Do not breast-feed.
- Hepatitis B virus:
- Known HBsAg-positive source:
- Complete vaccination confirmed by titer: No prescription
- Unvaccinated: Hepatitis B immune globulin ASAP, begin hepatitis B virus vaccine series.
- Nonresponder to vaccine: Hepatitis B immune globulin ASAP, may repeat in 30 days; consider revaccination with 3-dose series.
- Unknown responder to vaccine with inadequate titer: Hepatitis B immune globulin ASAP, vaccine booster
- Known HBsAg-negative source:
- Vaccinated: No prescription
- Unvaccinated: Begin hepatitis B virus vaccine series
- Unknown source:
- Complete vaccination confirmed by titer: No prescription
- Unvaccinated: Begin vaccine series. If high-risk exposure, consider hepatitis B immune globulin
- Nonresponder to vaccine: Hepatitis B immune globulin ASAP with revaccination 3-dose series. If high-risk exposure, repeat hepatitis B immune globulin in 30 days.
- Unknown responder to vaccine with inadequate titer: Vaccine booster and recheck titer in 1 " “2 mo
- Hepatitis C virus:
- Use of immunoglobulins or antivirals (interferon, ribavirin) inconclusive as prophylaxis, but possibly beneficial if initiated early when infection evident
Medication
- HIV:
- Zidovudine:
- 300 mg PO BID or 200 mg PO TID
- Side effects: GI symptoms, headache, fatigue, myalgias, marrow suppression, seizure
- Zidovudine should be taken in conjunction with lamivudine
- Lamivudine:
- 300 mg PO QD or 150 mg PO BID
- Side effects: GI symptoms, headache, fatigue, neuropathy, congestion, cough (caution with trimethoprim/sulfamethoxazole)
- Combivir (combination zidovudine + lamivudine) (300 mg + 150 mg tab):
- 1 tablet PO BID
- Side effects: See side-effect profiles of zidovudine and lamivudine
- Emtricitabine:
- 200 mg/d PO
- Side effects: Rash, hyperpigmentation
- Emtricitabine must be taken in conjunction with efavirenz and zidovudine
- Tenofovir DF:
- 300 mg/d PO
- Side effects: GI symptoms, headache, fatigue, neuropathy, dizziness
- Tenofovir must be taken in conjunction with efavirenz and emtricitabine
- Didanosine:
- <60 kg 250 mg/d PO as delayed-release
- Side effects: Pancreatitis, GI symptoms, lactic acidosis, neuropathy
- Stavudine:
- 60 kg 40 mg PO BID or
- If wt <60 kg, then 30 mg PO BID
- Side effects: Peripheral neuropathy, GI symptoms, headache, pancreatitis, elevated liver function tests, neutropenia, anemia
- Lopinavir/ritonavir (Kaletra) (200 mg + 50 mg cap):
- 2 capsules PO BID
- Side effects: GI symptoms, hyperlipidemia
- Atazanavir:
- 400 mg/d PO
- If used with tenofovir, then decrease to 300 mg/d PO and add ritonavir 100 mg/d PO
- Side effects: Be wary with medications that prolong PR interval, hyperbilirubinemia
- Fosamprenavir:
- 1,400 mg PO BID
- If used with ritonavir, then decrease to 1,400 mg/d PO or 700 mg PO BID
- Side effects: GI symptoms, rash, drug interactions, depression
- Indinavir:
- 800 mg + ritonavir 100 mg PO BID, in combination with (lamivudine + zidovudine) or (emtricitabine + zidovudine) or(lamivudine + tenofovir) or (emtricitabine + tenofovir);
- If used with ritonavir, then decrease to 800 mg PO BID
- Side effects: Nephrolithiasis, hyperbilirubinemia, GI symptoms
- Saquinavir:
- 1,000 mg + ritonavir 100 mg PO BID
- Side effects: GI symptoms, hepatitis
- Nelfinavir:
- 1,250 mg PO BID
- Side effects: Potential carcinogenic and teratogenic warning, GI symptoms, weakness, rash
- Efavirenz:
- Alternate expanded regimen for HIV postexposure prophylaxis: 600 mg PO in combination with (lamivudine + zidovudine) or(emtricitabine + zidovudine) or (lamivudine + tenofovir) or (emtricitabine + tenofovir)
- Side effects: Stevens " “Johnson syndrome, rash, sleep disruption, dizziness, psychiatric, teratogen
- For some of the antiretroviral agents, the oncogenic and teratogenic effects are unknown.
- NRTIs and NtRTIs can result in lactic acidosis with hepatic steatosis.
- All can have serious drug interactions that lead to significant harm or death.
- Hepatitis B:
- Hepatitis B immune globulin: 0.06 mL/kg IM
- Hepatitis B virus booster: Unit-dose vial
Follow-Up
Disposition
Admission Criteria
Admission not necessary ‚
Discharge Criteria
Manage as outpatients with appropriate follow-up in occupational medicine clinic ‚
Additional Reading
- Beltrami ‚ EM, Williams ‚ IT, Shapiro ‚ CN, et al. Risk and management of blood-borne infections in health care workers. Clin Microbiol Rev. 2000;13:385 " “407.
- Panlilio ‚ AL, Cardo ‚ DM, U.S. Public Health Service, et al. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR Recomm Rep. 2005;54(RR-9):1 " “17.
- U.S. Public Health Service. Updated U.S. Public Health Service Guidelines for the management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. MMWR Recomm Rep. 2001;50(RR-11):1 " “52.
- National Clinicians ' Post-Exposure Prophylaxis Hotline: Phone (888) 448-4911; Available at Http://www.nccc.ucsf.edu. Accessed on January 29, 2013.
- Centers for Disease Control and Prevention (CDC). Update: Influenza activity " “United States, September 30-December 1, 2007. MMWR Morb Mortal Wkly Rep. 2007;56(49):1287 " “1291.
Codes
ICD9
- V01.79 Contact with or exposure to other viral diseases
- V07.8 Other specified prophylactic or treatment measure
- V15.85 Personal history of contact with and (suspected) exposure to potentially hazardous body fluids
ICD10
- Z20.5 Contact with and (suspected) exposure to viral hepatitis
- Z20.6 Contact w and (suspected) exposure to human immunodef virus
- Z77.21 Contact w and exposure to potentially hazardous body fluids
SNOMED
- 417981005 exposure to blood and/or body fluid (event)
- 444491009 Exposure to viral hepatitis (event)
- 444356002 exposure to Human immunodeficiency virus (event)