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

(occupational exposure)
(Evaluation)
 
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==Background==
 
==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 <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>
 +
 +
==Clinical Features==
 
*Frequently from needlestick injuries or other occupational exposures to bodily fluids
 
*Frequently from needlestick injuries or other occupational exposures to bodily fluids
  
==Workup==
+
==Differential Diagnosis==
 +
*[[Laceration]]
 +
*Retained [[foreign body]]
 +
 
 +
==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
 
*In many systems, a standardized baseline lab panel is sent in the ED and then followed up at employee health the next day
*Frequently, the only actionable lab on the day of exposure is a rapid HIV test from the source patient (for consideration of [[PEP]])
+
*If giving HIV [[PEP]]:
*Source labs
+
**Rapid [[HIV]] (to confirm they do not ''already'' have HIV)
**Rapid HIV, hep pannel, RPR?
+
**CBC, C7, LFTs, pregnancy test
*Exposed labs
 
**Rapid HIV (if considering [[PEP]] only), hep pannel, RPR?
 
**If considering [[PEP]]
 
***CBC, C7, LFTs, pregnancy test
 
  
 
==Management==
 
==Management==
===HIV===
+
===[[HIV]]===
 
*Consider [[HIV post-exposure prophylaxis]]
 
*Consider [[HIV post-exposure prophylaxis]]
  
===Hep B===
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{{HIV post-exposure prophylaxis regimens}}
====Dosing if indicated====
 
*HBIG dose: 0.06mL/kg IM
 
*Vaccination serires: Recombivax HB 10mcg IM or Engerix-B 20mcg IM at month 0,1, and 6
 
  
====Unvaccinated Patient====
+
===[[Hepatitis B]]===
*If source is HBsAg+ then give HBIG x 1 and start HBV vaccine series
+
*Not normally indicated, assuming patient has had full course of Hepatitis B vaccination (as all healthcare workers should have)
*If source is HBsAG- then initiate HBV vaccine series
+
**If exposed-patient NOT already vaccinated, see [[Hepatitis_B#Hepatitis_B_Post-Exposure_Prophylaxis|Hepatitis B Post-Exposure Prophylaxis]]
*If source of unknown status then start HBV vaccine series
 
  
====Previously Vaccinated Patient====
+
===[[Hepatitis C]]===
*No treatment if source is HBsAG+/- or if source is unknown
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*No prophylaxis regimen has any benefit
  
====Partially Vaccinated (one series) or Non-Responder====
+
==Disposition==
''Non responder defined as anti-HBs<10IU/ml''
+
*Outpatient management with employee health follow-up
*If source HBsAg+ then give HBIG and start HBV vaccine series
 
**Alternatively patients can have a HBIG vaccine with another dose in one month
 
*If source is HBsAg- then no treatment is needed
 
*If source is high risk then give HBIG and start HBV vaccine series
 
 
 
====Partially Vaccinated (two series) or Non Responder====
 
''Non responder defined as anti-HBs<10IU/ml''
 
*If source HBsAg+ then give two doses of HBIG (now and in 1 month)
 
*If source is HBsAg- then no treatment needed
 
*if source is high risk then treat if HBsAg+
 
 
 
===Hep C===
 
*No prophylaxis regimen has any benefit
 
*Draw anti-HCV on the source and the exposed patient
 
*Draw ALT level on exposed patient and repeat in 6 months or perform HCV RNA PCR in 4 weeks
 
**If the patient is anti-HCV positive then confirm the diagnosis with HCV RNA PCR.
 
  
 
==See Also==
 
==See Also==

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.