Healthcare occupational exposure to blood or other body fluids

Revision as of 19:06, 19 November 2017 by Rossdonaldson1 (talk | contribs) (HIV)

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

  • 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)

Source-patient labs

  • Rapid HIV, hepatitis panel, 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

  • Most require NO laboratory testing
  • If giving HIV PEP:
    • Rapid 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 Post-Exposure Prophylaxis

Treatment is generally initiated after coordination with occupational health and infectious disease service and based the the exposed patient's vaccination history[5]

Unvaccinated

  • If the source is HBsAg(+) then give HBIG x1 and initiate HBV vaccine in two separate sites
  • If source is HGsAG(-) then start the HBV vaccine series
  • If source blood is unavailable and high risk then give HBIG x1 initiate the HBV series
    • If source blood is low risk and unavailable then begin HBV series

Previously vaccinated non responder (one series)

Non responder status is defined as anti-has <10mIU/mL

  • If the source is HBsAg(+) then give HBIG x 1 and begin revaccination series
    • Can also opt to perform second HBIG administration in one month
  • If source is HBsAg(-) then no treatment is needed
  • If source blood is unavailable and high risk then treat as if HBsAg(+)

Previously vaccinated non responder (two series)

Non responder status is defined as anti-has <10mIU/mL

  • If the source is HBsAg(+) then give HBIG x2 and no HBV series
  • If source is HGsAG(-) then no treatment is needed
  • If source blood is unavailable then initiate the HBV series

Treatment Dosing

No contraindications for pregnancy or breast feeding

  • HBIG 0.06 mL/kg IM
  • Vaccination series: HBV vaccine options:
    • Engerix-B 20mcg IM
    • Recombivax HB 10mcg IM

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.

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.
  5. Postexposure prophylaxis to prevent hepatitis b virus infection. CDC MMWR http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5516a3.htm?s_cid=rr5516a3_e