Difference between revisions of "Healthcare occupational exposure to blood or other body fluids"

(Evaluation)
 
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BLOOD BODY FLUID EXP
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==Background==
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*The majority of persons (e.g. source patients) chronically infected with hepatitis B and C (65% to 75%) are not aware of their infection <ref>[https://www.ncbi.nlm.nih.gov/pubmed/23740193 Fretz R, Negro F, Bruggmann P et al. Hepatitis B and C in Switzerland - healthcare provider initiated testing for chronic hepatitis B and C infection. Swiss Med Wkly. 2013 May 17;143:w13793.]</ref>
  
HIV
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==Clinical Features==
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*Frequently from needlestick injuries or other occupational exposures to bodily fluids
  
- risk is 0.3% xmission rate for needle stick- less for mucous mem
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==Differential Diagnosis==
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*[[Laceration]]
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*Retained [[foreign body]]
  
- risk increases with quantity of blood, needle in vein or art, or deep inj, or source pt terminal with high viral titre
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==Evaluation==
 +
''Most commonly, the only actionable lab on the day of exposure is a rapid [[HIV]] test from the source-patient (for consideration of [[PEP]])''
 +
*Less severe percutaneous exposures are associated with solid and blunt tip needles
 +
*More severe percutaneous exposures are associated with deep punctures, large bore hollow needles, visible blood on the device, and needles used in patients arteries and veins.
 +
*Smaller volume (few drops) exposures are considered to be lower risk than higher volume (major blood splash) for mucous membranes and non-intact skin exposures.
 +
*Most occupational exposures to HIV are not associated with transmission.
 +
===Source-patient labs===
 +
*Rapid HIV
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*Consider [[hepatitis]] panel and possibly RPR
 +
**Hepatitis B and C infectivity of source patient:
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***HBs-Ag (active infection)
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***HBc-Ab IgM (window period)
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***HepC-Ab, plus or minus viral load
  
- may get PEP failure if resist strain of hiv, high titre, large volume, delayed initiation of PEP or too short course, weak host immune syst, syncytia forming strains of hiv
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===Exposed-patient labs===
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*In some systems, NO immediate laboratory testing is performed
 +
*In many systems, a standardized baseline lab panel is sent in the ED and then followed up at employee health the next day
 +
*If giving HIV [[PEP]]:
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**Rapid [[HIV]] (to confirm they do not ''already'' have HIV)
 +
**CBC, C7, LFTs, pregnancy test
  
- rec use rapid hiv test to test source pt to decrease need for unnessasary hiv prophylaxsis. give at least one dose until source pt confirmed as neg
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==Management==
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===[[HIV]]===
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*Consider [[HIV post-exposure prophylaxis]]
  
- 3 drug therapy only is skin puntured and source pt hiv+
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{{HIV post-exposure prophylaxis regimens}}
  
- HIV PEP consists of:
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===[[Hepatitis B]]===
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*Not normally indicated, assuming patient has had full course of Hepatitis B vaccination (as all healthcare workers should have)
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**If exposed-patient NOT already vaccinated, see [[Hepatitis_B#Hepatitis_B_Post-Exposure_Prophylaxis|Hepatitis B Post-Exposure Prophylaxis]]
  
4 wks of ZDV and 3TC or
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===[[Hepatitis C]]===
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*No prophylaxis regimen has any benefit
  
3TC and d4t or
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==Disposition==
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*Outpatient management with employee health follow-up
  
d4T and ddI
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==See Also==
 
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*[[HIV post-exposure prophylaxis]]
- side effects- NVD, pancreatittis, dm, kidney stone, skin reactions
 
 
 
- may add third drug for expanded risk of xmission- source pt resistant if dz progressing, viral load still high, cd4 count dropping despite tx
 
 
 
- if source pt resistant, choose drug accordingly
 
 
 
- if source pt hiv neg, and no sxs of aids or acute retroviral syndrome, chance of source pt being in "window" period small and no further testing of stuck pt needed
 
 
 
- no testing of sharps or needles
 
 
 
- if don't know about source pt, start tx for 4 wks. if source pt later known to be neg, can stop
 
 
 
Feces, snot, spit, sweat, tears, vomit, urine not infectious unless contain blood.
 
 
 
Human bite- tx both pt and source. rare route of xmission
 
 
 
 
 
 
Hep B
 
 
 
- risk of infc 2- 30% after needle stick
 
 
 
- can survive on dried blood for 1 wk
 
 
 
- found in all fluids but highest conc in blood and therefore highest risk with blood
 
 
 
- hep b surface antibodies confers life long immunity
 
 
 
- don't need to test pt or source if pt certain fully/ successfully immunized- antibodies > 10 IU at some time
 
  
- if pt not successfully immunized, give hep b immune globulin
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==References==
 
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<references/>
- failed 3 shots/ 1 series- give hep booster and immune globulin x 2 doses over 1 mo
 
 
 
- failed 6 shots/ 2 series- give sequential immune globulin
 
 
 
 
 
 
Hep C
 
 
 
- no prophylaxsis
 
 
 
- no interferon, no antivirals, no globulin
 
 
 
- not xmitted efficiently through needle stick- 2% rate
 
 
 
- get basline hcv test and ALT
 
 
 
 
 
 
Post Exp Viral Hep Counseling
 
 
 
- can still breast feed
 
 
 
- no organ/ blood donation
 
 
 
- no worry about modifiying sex pattern or becoming preg
 
 
 
www.needlestick.mednet.ucla.edu
 
 
 
 
 
 
6/06 MISTRY
 
 
 
 
 
 
 
 
 
 
 
 
---------------------------------
 
 
 
hep b core antibody if unvaccinated
 
 
 
hep b surface antibody if vaccinated
 
 
 
tx c
 
 
 
combivir 300/150 1 po bid
 
 
 
indinavir IDV 400mg 2 po tid
 
 
 
 
 
 
6/06 MISTRY
 
 
 
 
 
HEP B
 
 
 
Patient Source
 
 
 
Unvaccinated Pos
 
 
 
--> HBIG + vaccine
 
 
 
 
 
==See Also==
 
See ID: HIV (Occupational)
 
  
 
[[Category:ID]]
 
[[Category:ID]]

Latest revision as of 15:31, 17 June 2019

Background

  • The majority of persons (e.g. source patients) chronically infected with hepatitis B and C (65% to 75%) are not aware of their infection [1]

Clinical Features

  • Frequently from needlestick injuries or other occupational exposures to bodily fluids

Differential Diagnosis

Evaluation

Most commonly, the only actionable lab on the day of exposure is a rapid HIV test from the source-patient (for consideration of PEP)

  • Less severe percutaneous exposures are associated with solid and blunt tip needles
  • More severe percutaneous exposures are associated with deep punctures, large bore hollow needles, visible blood on the device, and needles used in patients arteries and veins.
  • Smaller volume (few drops) exposures are considered to be lower risk than higher volume (major blood splash) for mucous membranes and non-intact skin exposures.
  • Most occupational exposures to HIV are not associated with transmission.

Source-patient labs

  • Rapid HIV
  • Consider hepatitis panel and possibly RPR
    • Hepatitis B and C infectivity of source patient:
      • HBs-Ag (active infection)
      • HBc-Ab IgM (window period)
      • HepC-Ab, plus or minus viral load

Exposed-patient labs

  • In some systems, NO immediate laboratory testing is performed
  • In many systems, a standardized baseline lab panel is sent in the ED and then followed up at employee health the next day
  • If giving HIV PEP:
    • Rapid HIV (to confirm they do not already have HIV)
    • CBC, C7, LFTs, pregnancy test

Management

HIV

Preferred HIV PEP Regimen[2][3]

PEP should be started as soon as possible after significant exposure and continued for 28 days[4]

  • Raltegravir (Isentress; RAL) 400 mg PO twice daily, plus
  • Truvada, 1 PO once daily (Tenofovir DF [Viread; TDF] 300 mg emtricitabine [Emtriva; FTC] 200 mg)

Other Considerations

  • If known source patient with resistant HIV strain, consult HIV service for source-patient-specific PEP
  • Consider interactions with current medication interactions and contraindications, such as renal impairment with Truvada

Hepatitis B

  • Not normally indicated, assuming patient has had full course of Hepatitis B vaccination (as all healthcare workers should have)

Hepatitis C

  • No prophylaxis regimen has any benefit

Disposition

  • Outpatient management with employee health follow-up

See Also

References

  1. Fretz R, Negro F, Bruggmann P et al. Hepatitis B and C in Switzerland - healthcare provider initiated testing for chronic hepatitis B and C infection. Swiss Med Wkly. 2013 May 17;143:w13793.
  2. Kuhar D, et al. Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis. September 2013. 34(9):875-892. DOI: 10.1086/672271. http://www.jstor.org/stable/10.1086/672271
  3. Updated Guidelines for Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV—United States, 2016. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services
  4. Kuhar DT et al. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol. 2013 Sep;34(9):875-92. doi: 10.1086/672271.