eMedicine Specialties > Emergency Medicine > Infectious Diseases
Body Fluid Exposures: Treatment & Medication
Updated: Nov 11, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Prehospital Care
The single most useful element here is the limitation of exposure and immediate cleaning of the area exposed. Copious amounts of soap and water are appropriate. Many health care workers use rapid sanitation solutions, but while theoretically applicable, no documentation supports any benefit in this scenario.
Emergency Department Care
The treating clinician should obtain and assess potential risk factor information concerning the source patient (he or she must also be mindful of any risks to the source patient on the behalf of the treating clinician). Detailed information regarding the volume of blood/body fluid transmission, duration, and extent of the exposure is also important.2 In addition, if the source patient is known to be HIV positive, a history of which antiretroviral medications are being used (as well as the patient's response to therapy, including CD4 counts and viral load data if known) should be obtained, as this directly impacts the therapy chosen for prophylaxis of the exposed individual. If a "significant" or highly suspicious exposure did occur and the source patient is potentially (or definitively) infected with HIV or HBV, then prophylaxis is to be offered and risk-versus-benefit counseling undertaken.
- Wound management
- Copiously irrigate wounds with antiseptic soap.
- Copiously irrigate exposed mucous membranes with saline (3-6 L is a good start).
- Tetanus prophylaxis: Administer when immunization status is not up-to-date.
- Counseling
- Patients should receive immediate counseling about the risk of their exposure to infectious agents and the indications for antiviral prophylaxis. Pregnancy should not preclude the use of optimal regimens, and postexposure prophylaxis should not be denied to an individual solely on the basis of pregnancy. Issues that must be discussed include HIV transmission to the fetus, the effects of the medications on the development of the fetus (the first trimester posing the maximal risk of teratogenesis), and the potential risk of fetal loss. Consultation with an infectious disease specialist should be sought.
- Patients should be referred to the appropriate and reliable site for outpatient counseling and long-term testing for seroconversion.
- HIV prophylaxis
- Generally, most emergency departments only stock a limited supply of these (currently) very expensive medications. In light of this, an appropriate supply of medication is often provided to allow the patient to follow up with the Occupational Health Service on the next available business day, or in the case of the weekend or frequent weekend/holiday exposures, a supply to cover 3-5 days.
- Consider one of the following regimens (if the source is known to have HIV, an alternate regimen may be required):
- Combivir 1 tab (300 mg) PO bid and nelfinavir 750 mg PO tid
- Combivir 1 tab (300 mg) PO bid and indinavir 800 mg PO q8h
- Hepatitis B prophylaxis: Provide hepatitis B immunoglobulin (HBIG) and HBV vaccine if indicated as per vaccination and immunity status.
- Hepatitis C prophylaxis: No effective Food and Drug Administration (FDA) – approved treatment currently exists for hepatitis C. Management is expectant, with close follow-up as appropriate.
Consultations
- Referral to an infectious disease specialist may be warranted, especially in cases where pregnancy is suspected or confirmed. In addition, HIV-positive sources require further consideration for a specialized regimen for prophylaxis of exposed individuals because of demonstrated insensitivity of HIV to some agents over time.
- Several resources have recently been made available. Health care providers are encouraged to use consultation services such as the National Clinician's Postexposure Prophylaxis Help Line, which is available 24 hours per day and provides advice regarding management of blood and body fluid exposures, including risk assessment, choice of postexposure prophylaxis medications, and assistance with difficult-to-manage scenarios (eg, pregnancy). They can be contacted toll free at (888) 448-4911. In addition, clinicians with on-site Internet access may use an ever-growing number of online resources.
Medication
A tetanus toxoid should be administered intramuscularly. Health care workers who sustain a significant exposure to HBV and have not been immunized should receive passive immunization with HBIG. Guidelines on management of occupational exposures to HIV and postexposure prophylaxis are available from the US Public Health Service.3
Information on HIV prophylaxis is as follows:
- Standard exposure (presence of identified risk factor* for occupational exposure) - Zidovudine 600 mg/d in divided doses plus lamivudine 150 mg bid for 4 wk
- High-risk exposure (presence of 2 or more risk factors* for occupational exposure) - Zidovudine plus lamivudine as above, plus indinavir 800 mg q8h or nelfinavir 750 mg q8h for 4 wk
- Pediatric dosing
- Zidovudine 180 mg/m2/dose bid (max 600 mg/d)
- Lamivudine (3TC) 4 mg/kg/dose bid (max 300 mg/d)
- Nelfinavir (Viracept) 50-55 mg/kg/dose bid (max 2500 mg/d)
- *Risk factors include (1) deep injury, (2) presence of visible blood on the instrument causing the exposure, (3) injury with a device that was placed in the vein or the artery of the source patient, or (4) terminal illness in the source patient.
Nucleoside reverse transcriptase inhibitors
These agents inhibit reverse transcriptase and cause chain termination when incorporated into a growing viral strand.
Zidovudine (AZT, ZDV, Retrovir)
Thymidine analog that inhibits viral replication.
Adult
200 mg PO tid
1-2 mg/kg/dose IV q4h
Pediatric
90-180 mg/m2/dose PO q6h
1-2 mg/kg/dose IV q4h
Usually, now the AZT 180 mg/m2/dose, given bid (max 600 mg/d)
Body surface area calculation
Usually confusing to most physicians; 5 equations are used currently, although the Mostellar equation is most often recommended.
The Mosteller formula
BSA (m²) = ([Height(cm) X Weight(kg)]/3600)½
For example, BSA = SQRT[(cm*kg)/3600]
In inches and pounds: BSA (m²) = ([Height(in) X Weight(lb)]/3131)½
The DuBois and DuBois formula
BSA (m²) = 0.20247 X Height(m)0.725 X Weight(kg)0.425
A variation of DuBois and DuBois that gives virtually identical results: BSA (m²) = 0.007184 X Height(cm)0.725 X Weight(kg)0.425
The Haycock formula
BSA (m²) = 0.024265 X Height(cm)0.3964 X Weight(kg)0.5378
The Gehan and George formula
BSA (m²) = 0.0235 X Height(cm)0.42246 X Weight(kg)0.51456
The Boyd formula
BSA (m2) = 0.0003207 X Height(cm)0.3 X Weight(grams)[0.7285 - ( 0.0188 X LOG(grams))]
For more information on BSA calculation, see Standardization of Body Surface Area Calculations.
Acetaminophen may decrease bioavailability of zidovudine; zidovudine toxicity increases when administered concurrently with amphotericin B, flucytosine, doxorubicin (Adriamycin), vincristine, vinblastine, cimetidine, indomethacin, probenecid, lorazepam, aspirin, acyclovir, ganciclovir, dapsone, and pentamidine
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in impaired hepatic or renal function; reduce or stop therapy in hematologic disorders such as thrombocytopenia, granulocytopenia, and severe anemia
Lamivudine (3TC, Epivir)
Thymidine analog that inhibits viral replication.
Adult
150 mg PO bid
Pediatric
4 mg/kg PO bid
Trimethoprim/sulfamethoxazole increases bioavailability of lamivudine; lamivudine increases concentration of zidovudine when administered concurrently
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Primary toxicities and/or adverse effects include headache, abdominal pain, diarrhea, and pancreatitis (rare); toxicity of zidovudine and 3TC when used in combination is approximately equal to that of zidovudine alone; adjust dose in renal impairment; caution in children with history of pancreatitis
Protease inhibitors (PI)
These agents block modification of precursor poly proteins responsible for the synthesis of reverse transcriptase and HIV-1 protease.
Indinavir (IDV, Crixivan)
Prevents formation of protein precursors necessary for HIV infection of uninfected cells and viral replication.
Adult
800 mg PO q8h on empty stomach
Pediatric
Not established
Indinavir increases blood concentrations of astemizole (recalled from US market), cisapride, midazolam, isoniazid, stavudine, trimethoprim, terfenadine (recalled from US market), triazolam, and PO contraceptives; fluconazole and rifampin decrease blood concentration of indinavir; quinidine and ketoconazole increase blood concentrations of indinavir; indinavir decreases blood concentration of lamivudine
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hepatic impairment; primary toxicities and/or adverse effects include nephrolithiasis, crystalluria, hematuria, nausea, headache, indirect hyperbilirubinemia, elevated LFT results, and hyperglycemia/diabetes mellitus; caution in hepatic impairment
Nelfinavir (Viracept)
Inhibits HIV-1 protease, resulting in production of an immature and noninfectious virus.
Adult
750 mg PO tid ac
Pediatric
<2 years: Not established
2-12 years: 20-30 mg/kg PO tid ac
>12 years: Administer as in adults
Nelfinavir increases blood concentrations of astemizole (recalled from US market), cisapride, midazolam, isoniazid, stavudine, trimethoprim, terfenadine (recalled from US market), triazolam, and PO contraceptives; fluconazole and rifampin decrease blood concentrations of nelfinavir; quinidine and ketoconazole increase nelfinavir blood concentrations; nelfinavir decreases lamivudine blood concentrations
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
If PO contraception desired, should use alternative or additional contraceptive measures while taking nelfinavir as opposed to standard oral contraceptive therapy
Primary toxicities and/or adverse effects include diarrhea and hyperglycemia/diabetes mellitus due to effects on pancreas; caution in hepatic impairment
Immunoglobulins
Patients who may not have been immunized against Clostridium tetani products should receive tetanus immune globulin (Hyper-Tet).
Tetanus immune globulins (Hyper-Tet)
Used for passive immunization of any person with a wound that might be contaminated with tetanus spores.
See Tetanus Immunoglobulin Drug Data Sheet.
Adult
Currently, only tetanus immunoglobulin for IM use is available from BPL (020 8258 2200 - 24 hours); no product suitable for IV use will be available in foreseeable future
Prophylaxis IM for tetanus prone wounds (licensed): 250 U for most uses (500 U if more than 24 h have elapsed or there is risk of heavy contamination or following burns)
Available in 1-mL ampules containing 250 U
Pediatric
Prophylaxis: 250 U IM in opposite extremity as tetanus toxoid
Clinical tetanus: 3,000-10,000 U IM
None reported
Administration within 3 mo of live-virus immune globulin because antibodies in globulin preparation may interfere with immune response to vaccination (may be necessary to revaccinate persons who received immune globulin shortly after live-virus vaccination)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Persons with isolated immunoglobulin A (IgA) deficiency have potential for developing antibodies to IgA and could have anaphylactic reactions to subsequent administration of blood products that contain IgA; do not perform skin testing because ID injection of concentrated gamma globulin may cause localized area of inflammation and can be misinterpreted, causing the medication to be withheld from a patient not allergic to this material; true allergic responses to human gamma globulin administered in prescribed IM manner are extremely rare; do not admix with other medications because usually incompatible
Toxoids
These agents are used for tetanus immunization. A booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome.
Tetanus toxoid
Induce active immunity against tetanus in selected patients. Tetanus and diphtheria toxoids are immunizing agents of choice for most adults and children (>7 y). Necessary to administer booster doses to maintain tetanus immunity throughout life.
Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen–containing product.
May be administered into deltoid or midlateral thigh muscles of children and adults. In infants, preferred site of administration is mid thigh laterally.
Adult
Primary immunization: 0.5 mL IM; administer 2 injections 4-8 wk apart and a third dose 6-12 mo after second injection
Booster dose: 0.5 mL q10y
Pediatric
Administer as in adults
Patients receiving immunosuppressants, including corticosteroids or radiation therapy, may remain susceptible despite immunization because of poor immune response; cimetidine may enhance or augment delayed-type hypersensitivity responses to skin test antigens; avoid concurrent use of medication with systemic chloramphenicol because it may impair amnestic response to tetanus toxoid; concurrent use of tetanus immune globulin may delay development of active immunity by several days (interaction is nevertheless clinically insignificant and does not preclude its concurrent use)
Documented hypersensitivity; history of any type of neurologic symptoms or signs following administration of this product; immunization during poliomyelitis outbreak (FDA recommends that elective tetanus immunization be deferred during any outbreak of poliomyelitis because tetanus toxoid injections are an important cause of provocative poliomyelitis)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use to treat actual tetanus infections or for immediate prophylaxis of unimmunized individuals (instead use tetanus antitoxin, preferably human tetanus immune globulin); diminished antibody response to active immunization may be observed in patients receiving immunosuppressive therapy; better to defer primary diphtheria immunization until immunosuppressive therapy discontinued; routine immunization of symptomatic and asymptomatic HIV-infected persons is recommended
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| Overview: Body Fluid Exposures |
| Differential Diagnoses & Workup: Body Fluid Exposures |
 Treatment & Medication: Body Fluid Exposures |
| Follow-up: Body Fluid Exposures |
| Multimedia: Body Fluid Exposures |
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References
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Vu T. Standardization of Body Surface Area Calculations. halls.md. Available at http://www.halls.md/bsa/bsaVuReport.htm.
Further Reading
Keywords
occupational exposure to disease, postexposure prophylaxis, exposure to HIV, needlestick, needlestick injury, body fluid exposures, splash exposures, mucous membrane exposures, sharps injury, hepatitis B virus, HBV, hepatitis C virus, HCV, human immunodeficiency virus, HIV
