AUTHOR AND EDITOR INFORMATION

Section 1 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Concern regarding the management of occupational exposure to human immunodeficiency virus (HIV) was heightened when it was realized that HIV is transmitted by body fluids. In spite of this concern, the risk of hepatitis continues to be the greater occupational threat.

Pathophysiology

The major pathogens of concern in occupational body fluid exposure are HIV and hepatitis A, B, C, and D. These pathogens are viruses that require percutaneous or mucosal introduction for infectivity. The major target organs are the immune system (HIV) and the liver (hepatitis). A lesser theoretical concern is tetanus, which attacks the CNS.

Frequency

United States

The rate of occupational transmission from an HIV-positive source is believed to be 0.3% for a percutaneous exposure and 0.09% for a mucous membrane exposure. The rate of transmission from a hepatitis B-positive source to a nonimmunized host is 6-24% and 1-10% for exposure to hepatitis C.

CLINICAL

Section 3 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• No symptoms of disease should be expected from the needle-stick exposure, upon a timely presentation.
• The history should focus on the patient's medical history, including immunizations and risk factors for both HIV and hepatitis.
• Specific questions include the following:
• • Complete immunization record, including tetanus and hepatitis B
  • Previous occupational exposure to body fluids
  • Intravenous drug abuse
  • Sexual history
  • Body piercing or tattooing
  • Receiving blood and/or blood products
  • Any history of dialysis
  • Travel outside the United States in the last year

Physical

• No abnormal physical findings, other than evidence of the reported trauma, should be expected upon a timely presentation.
• At a minimum, a baseline screening examination of the lungs, liver, and lymph nodes should be documented for future reference.

Causes

• Risk factors for occupational exposure to body fluids include the following:
• • Failure to adhere to universal precautions
  • Using equipment designed without appropriate safety features
  • Performance of exposure-prone procedures

WORKUP

Section 4 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Source patient (if available)
• • HIV
  • Hepatitis B antigen
  • Hepatitis C antibody
  • Aspartate aminotransferase/alanine aminotransferase (AST/ALT) and alkaline phosphatase levels
• Victim/health care worker
• • Hepatitis B surface antibody
  • HIV
  • Hepatitis C antibody testing at 2 weeks, 4 weeks, and 8 weeks
• Prior to initiating retrovirals
• • Pregnancy test (stat)
  • CBC count with differential and platelets
  • Serum creatinine/BUN levels
  • Urinalysis with microscopic analysis
  • AST/ALT levels
  • Alkaline phosphatase level
  • Total bilirubin level

TREATMENT

Section 5 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Prehospital Care

• If the exposure is mucosal or the wound is large enough to irrigate, irrigate with copious amounts of saline or other clean fluid.

Emergency Department Care

• Irrigate and clean wound.
• The need for tetanus and/or hepatitis B prophylaxis is based on medical history. Health care providers should have been immunized against hepatitis B. Hepatitis A prophylaxis may (rarely) need to be considered depending on the source-patient situation.
• The need for HIV or chemoprophylaxis (antiretrovirals) is based on an assessment of the risk by using the 3-step process developed by the Centers for Disease Control and Prevention (CDC).
• Step 1: Determine exposure code.
• • Is the source material blood, bloody fluid, other potentially infectious material, or an instrument contaminated with one of these substances?
  • • If not, there is no risk of HIV transmission.
    • If yes, what type of exposure occurred?
  • If the exposure was to intact skin only, there is no risk of HIV transmission.
  • If the exposure was to mucous membrane or integrity-compromised skin, was the volume of fluid small (ie, few drops, short duration) or large (ie, several drops or major splash, long duration)?
  • • If small, the category is exposure code 1.
    • If large, the category is exposure code 2.
  • If the exposure was percutaneous, was it a solid needle or a superficial scratch (ie, less severe)?
  • • If yes, the category is exposure code 2.
  • Was it from a large-bore hollow needle, a device with visible blood, or a needle used in a source patient's artery or vein (ie, more severe)?
  • • If yes, the category is exposure code 3.
• Step 2: Determine HIV status code.
• • What is the HIV status of the exposure source?
  • • If HIV negative, no postexposure prophylaxis is needed.
    • If HIV positive, was the exposure low titer or high titer?
    • Low-titer exposures are asymptomatic patients with high CD4 counts. These are HIV status code 1.
    • High-titer exposures are patients with primary HIV infection, high or increasing viral load or low CD4 counts, or advanced acquired immunodeficiency syndrome (AIDS). These are HIV status code 2.
    • If HIV status is unknown or the source is unknown, the HIV status code is unknown.
• Step 3: Match exposure code with HIV status code to determine if any postexposure prophylaxis is indicated.
• • Postexposure prophylaxis recommendation
  • • Exposure code 1 and HIV status code 1: Postexposure prophylaxis may not be warranted. Exposure type does not pose a known risk. The exposed health care worker and the treating clinician should decide whether the risk for drug toxicity outweighs the benefit of postexposure prophylaxis.
    • Exposure code 1 and HIV status code 2: Consider the basic regimen. Exposure type poses a negligible risk for HIV transmission. A high HIV titer in the source may justify consideration of postexposure prophylaxis. The exposed health care worker and the treating clinician should decide whether the risk for drug toxicity outweighs the benefit of postexposure prophylaxis.
    • Exposure code 2 and HIV status code 1: Recommend the basic regimen. Most HIV exposures are in this category. No increased risk for HIV transmission has been observed, but use of postexposure prophylaxis is appropriate.
    • Exposure code 2 and HIV status code 2: Recommend expanded regimen. Exposure type represents an increased HIV transmission risk.
    • Exposure code 3 and HIV status code 1 or 2: Recommend expanded regimen. Exposure type represents an increased HIV transmission risk.
    • HIV status code unknown: If the source or, in the case of an unknown source, the setting where the exposure occurred suggests possible risk for HIV exposure and the exposure code is 2 or 3, consider the postexposure prophylaxis basic regimen.
• Basic regimen: 4 weeks of zidovudine (600 mg/d in 2-3 divided doses) and lamivudine (150 mg twice daily)
• Expanded regimen: Basic regimen plus either indinavir (800 mg q8h) or nelfinavir (750 mg 3 times/d).
• Interferon ribavirin prophylaxis decreases risk by 40%. Exposed workers should be counseled on the risks of disease transmission based upon their specific exposure.

Consultations

Consult an infectious disease specialist if risks and/or benefits of drug treatment cannot be easily defined.

MEDICATION

Section 6 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

When indicated, medications are used to prevent disease transmission.

Drug Category: Immunizations

Vaccines containing epitopes that can elicit an immune response are very effective in inducing a protective response.

Drug Category: Antiretrovirals

These agents are inhibitors of reverse transcriptase and thus, cause chain termination when incorporated into a growing viral strand.

FOLLOW-UP

Section 7 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Outpatient Care

• Follow up with occupational health or infectious disease in 24-72 hours.
• Discuss need for safe sex practices until follow-up laboratory testing is negative for HIV. Most now recommend a follow-up screen at 3 or 6 months.

In/Out Patient Meds

• Antiretrovirals, as indicated, by the 3-step assessment process (see Treatment section)

Deterrence/Prevention

• Universal precautions

Complications

• Infection

Prognosis

• Most health care workers with occupational exposure to body fluids do not develop disease. For those who do, prognosis is the same as for other routes of transmission.

Patient Education

• Refer to occupational health for extensive patient education. Having a brochure available to be given out in the ED is helpful to alleviate fear.
• For excellent patient education resources, visit eMedicine's Infections Center. Also, see eMedicine's patient education article Tetanus.

MISCELLANEOUS

Section 8 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• With the advent of CDC recommendations for HIV postexposure prophylaxis, failure to counsel patients on the existence of retroviral treatment (eg, explain its risk/benefits) could be the source of a significant judgment if the patient subsequently develops HIV.
• Involvement of an informed patient in the decision-making process is essential.

REFERENCES

Section 9 of 9

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Bassett IV, Freedberg KA, Walensky RP. Two drugs or three? Balancing efficacy, toxicity, and resistance in postexposure prophylaxis for occupational exposure to HIV. Clin Infect Dis. Aug 1 2004;39(3):395-401. [Medline].
• Cardo DM, Culver DH, Ciesielski CA, et al. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. Centers for Disease Control and Prevention Needlestick Surveillance Group. N Engl J Med. Nov 20 1997;337(21):1485-90. [Medline].
• CDC. Public Health Service guidelines for the management of health-care worker exposures to HIV and recommendations for postexposure prophylaxis. Centers for Disease Control and Prevention. MMWR Recomm Rep. May 15 1998;47(RR-7):1-33. [Medline].
• CDC. Recommendations for follow-up of health-care workers after occupational exposure to hepatitis C virus. MMWR Morb Mortal Wkly Rep. Jul 4 1997;46(26):603-6. [Medline].
• Houston SH, Sinnott JT, Palumbo SJ. Employee health and safety. In: Reese, ed. Practical Approach to Infectious Diseases. 1996:706-724, 1406-1409.
• Hsieh WB, Chiu NC, Lee CM, Huang FY. Occupational blood and infectious body fluid exposures in a teaching hospital: a three-year review. J Microbiol Immunol Infect. Aug 2006;(4):321-7. [Medline].
• Merchant RC, Becker BM, Mayer KH, Fuerch J, Schreck B. Emergency department blood or body fluid exposure evaluations and HIV postexposure prophylaxis usage. Acad Emerg Med. Dec 2003;10(12):1345-53. [Medline].
• Merchant RC, Keshavarz R. HIV postexposure prophylaxis practices by US ED practitioners. Am J Emerg Med. Jul 2003;21(4):309-12. [Medline].
• Moran GJ. Emergency department management of blood and body fluid exposures. Ann Emerg Med. Jan 2000;35(1):47-62. [Medline].
• Peate I. Occupational exposure of staff to HIV and prophylaxis therapy. Br J Nurs. Oct 28-Nov 10 2004;13(19):1146-50. [Medline].
• Rinnert KJ. A review of infection control practices, risk reduction, and legislative regulations for blood-borne disease: applications for emergency medical services. Prehosp Emerg Care. Jan-Mar 1998;2(1):70-5. [Medline].
• Schriger DL, Mikulich VJ, Centers for Disease Control and Prevention. The management of occupational exposures to blood and body fluids: revised guidelines and new methods of implementation. Ann Emerg Med. Mar 2002;39(3):319-21. [Medline].
• Sidwell RU, Green JS, Novelli V. Management of occupational exposure to HIV--what actually happens. Commun Dis Public Health. Dec 1999;2(4):287-90. [Medline]. [Full Text].
• 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. Jun 29 2001;50(RR-11):1-52. [Medline]. [Full Text].

Article Last Updated: Oct 11, 2007