Body Fluid Exposures Treatment & Management

The single most useful element in prehospital care 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.

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.^[11] 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.

Body fluid exposure management is shown in the flowsheet below.

Wound management

Copiously irrigate wounds with antiseptic soap.

Copiously irrigate exposed mucous membranes with water or saline (3-6 L is a good start).

Tetanus prophylaxis

Administer tetanus booster 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

Recommendations are that HIV prophylaxis be given within 2 hours of the exposure when possible. Therefore, the first dose should be given in the ED. Most authorities recommend that this treatment should be started in patients with high-risk exposure that occurred within 36 hours of the ED visit. If the exposure occurred more than 36 hours prior to the visit, then an HIV infectious disease specialist should be consulted before initiating treatment.^[6] Treatment should be continued for 4 weeks.

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.

Individual states may have their own medication regimen for postexposure prophylaxis. Become familiar with your state's Web site in order to determine if your choice coincides with your state's regimen.

The Centers for Disease Control and Prevention (CDC) recommends postexposure prophylaxis (PEP) with 2 nucleoside reverse transcriptase inhibitors (NRTIs) for lower-risk exposures and the addition of 1 or more drugs for higher-risk exposures.^[6]

Preferred basic postexposure prophylaxis (PEP) 2-drug regimen options include the following:

• Zidovudine (ZDV) 600 mg/day PO divided bid/tid PLUS lamivudine (3TC) 150 mg bid (or Combivir 1 PO bid)
• Zidovudine (ZDV) 600 mg/day PO divided bid/tid PLUS emtricitabine (FTC) 200 mg PO qd
• Tenofovir 300 mg PO qd PLUS lamivudine 300 mg PO qd or divided bid
• Tenofovir 300 mg PO qd PLUS emtricitabine 200 mg PO qd

As per CDC recommendations, one of the following regimens should be used for high-risk exposures: (Please note that if the source is known to have HIV and is on treatment for it, an alternate regimen may be required, because of the possibility of resistance and, if possible, an HIV specialist should be consulted).

• Preferred expanded PEP 3-drug regimen includes the basic regimen plus lopinavir/ritonavir 400/100 mg PO bid.
• Alternate expanded regimen options include the basic regimen plus 1 of the following antiretroviral agents (ARTs):

  • Atazanavir (ATV) 400 mg PO qd; if administered with basic regimen containing tenofovir, use ritonavir boosted regimen of ATV 300 mg PO qd PLUS ritonavir 100 mg PO qd
  • Fosamprenavir 1400 mg PO bid, OR boosted with ritonavir 200 mg PO and administered qd
  • Indinavir (IDV) 800 mg q8h, OR boosted with ritonavir 100 mg PO and administered bid
  • Saquinavir 1000 mg PO bid PLUS ritonavir 100 mg PO bid
  • Nelfinavir 1250 mg PO bid
  • Efavirenz 600 mg PO qhs

The New York State Department of Health AIDS Institute in their 2008 guidelines^[4] recommended one of the following easy to use regimens for prophylaxis in health care workers with significant exposures:

• Zidovudine 300 mg PO bid PLUS lamivudine 150 mg PO bid (this is equivalent to Combivir 1 PO bid) PLUS tenofovir 300 mg PO qd, OR
• Zidovudine 300 mg PO bid PLUS emtricitabine 200 mg PO qd PLUS tenofovir 300 mg PO qd (emtricitabine and tenofovir is equivalent to Truvada 1 PO qd)

Another popular regimen is Truvada or Combivir for moderate-risk exposures and then adding lopinavir-ritonavir (Kaletra) 2 tablets bid to either Truvada or Combivir for high-risk sticks.

No good studies compare the efficacy of one regimen to another.

Note that recommended regimens may need to be modified because of the patient's underlying condition or adverse effects of the medication. For example, efavirenz, the combination of stavudine and didanosine, and indinavir should be avoided in pregnant patients. Lamivudine, tenofovir, and emtricitabine require dosing adjustments in patients with renal disease. Truvada has much less GI side effects than Combivir. As noted above, when in doubt as to what regimen to use, an HIV specialist should be consulted.

Hepatitis B prophylaxis

Provide hepatitis B immunoglobulin (HBIG) and HBV vaccine if indicated as per vaccination and immunity status.

If the patient has received hepatitis B vaccine in the past or has a history of hepatitis B, then nothing needs to be done acutely in the ED. Antibody titers should be sent and urgent follow-up should be given.

If the patient has not been previously immunized against or had hepatitis B and the source is either HBsAg positive or unknown, then the patient should be given HBIG at a dose of 0.06 mL/kg IM and the hepatitis B vaccination series should be started.

Though HBIG alone has also demonstrated effectiveness in preventing HBV transmission, it is still administered with the vaccine since the vaccine is available, is safe, and will give the patient long-term immunity.

HBIG should be given as soon as possible after the exposure, preferably within a day. It probably is not effective if given more than 7 days after the exposure. In order for postexposure prophylaxis to be effective, early administration of the initial dose of the vaccine is needed.^[12]

The vaccine is given in 3 doses (at 0, 1, 6 months). If the patient refuses vaccination, then HBIG can be repeated in 1 month.

Hepatitis C prophylaxis

No effective Food and Drug Administration (FDA)–approved treatment currently exists for hepatitis C. Prophylactic use of interferon has not proven to be effective.^[8] Management is expectant, with close follow-up as appropriate

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 are 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.

• American Nurses Association
• NIOSH Alert: Preventing Needlestick Injuries in Health Care Settings
• National Alliance for the Primary Prevention of Sharps Injuries
• Needlestick.org