Body Fluid Exposures Medication

Updated: Jul 12, 2017
  • Author: Muhammad Waseem, MBBS, MS, FAAP, FACEP, FAHA; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
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Medication

Medication Summary

Tetanus toxoid should be administered intramuscularly. Health care workers who sustain a significant exposure to HBV and have not been immunized or are nonresponders should receive passive immunization with HBIG. Guidelines on the management of occupational exposures to HIV and PEP are available from the US Public Health Service. [7]

HIV prophylaxis

HIV prophylaxis for standard exposure (the presence of an identified risk factor for occupational exposure) is raltegravir 400 mg PO twice daily plus tenofovir DF 300 mg/emtricitabine 200 mg (Truvada) 1 tablet PO once daily.

Risk factors include the following:

  • Deep injury
  • Presence of visible blood on the instrument causing the exposure
  • Injury with a device that was placed in a vein or artery of the source patient
  • Terminal illness in the source patient

Currently, prophylaxis for high-risk exposure is the same for any exposure that is deemed risky enough to warrant HIV prophylaxis. Prophylaxis for any significant exposure now involves at least 3 drugs. The two-drug regimens are generally no longer used. If there is any confusion about whether HIV prophylaxis should be administered or which regimen should be used, an expert in this field should be consulted. The preferred regimen for HIV prophylaxis as noted above is raltegravir plus Truvada. The initial dose should be given as a stat dose in the ED, and the therapy should be continued for 28 days.

Pediatric dosing is as follows:

  • Raltegravir: If the patient weighs less than 25 kg, 6 mg/kg twice daily to a maximum of 600 mg/day; if the patient weighs more than 25 kg, the adult dose of 400 mg BID film coated tablet should be used
  • Emtricitabine: If the patient is aged 0-3 months, 3 mg/kg; if the patient is older than 3 months, 6 mg/kg to a maximum of 200 mg capsule per day or 6 mg/kg solution PO QD; not to exceed 240 mg/day
  • Tenofovir DF: If the patient is aged 2-12 years, 8 mg/kg once a day to a maximum of 300 mg/day
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Nucleoside Reverse Transcriptase Inhibitors (NRTIs)

Class Summary

These agents inhibit reverse transcriptase and cause chain termination when incorporated into a growing viral strand.

Zidovudine (Retrovir)

Zidovudine is a thymidine analogue that inhibits viral replication. Retrovir in combination with lamivudine is known as Combivir; in combination with abacavir and lamivudine, it is known as Trizivir. Combivir and Trizivir should not be used in patients with renal insufficiency.

Lamivudine (Epivir, Epivir-HBV)

Lamivudine is a cytosine analogue that inhibits viral replication. In addition to anti-HIV activity, this agent also suppresses hepatitis B viral deoxyribonucleic acid (DNA) replication.

Emtricitabine (Emtriva)

Emtricitabine is a synthetic nucleoside cytosine analogue. It competes with deoxycytidine-5'-triphosphate and is incorporated into viral DNA, causing chain termination.

Tenofovir disoproxil fumarate (Viread)

Tenofovir is an antiretroviral agent used in the treatment of acquired immunodeficiency syndrome (AIDS). It inhibits the activity of HIV reverse transcriptase by competing with the natural substrate deoxyadenosine 5'-triphosphate and, after incorporation into DNA, by DNA chain termination.

It is administered as the prodrug bis-isopropoxycarbonyloxymethyl ester derivative of tenofovir, which is converted, through various enzymatic processes, to tenofovir, an acyclic nucleoside phosphonate (nucleotide) analog of adenosine 5'-monophosphate. Bioavailability is enhanced by a high-fat meal. Prolonged intracellular distribution allows for once-daily dosing.

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Nonnucleoside Reverse Transcriptase Inhibitors (NNRTIs)

Class Summary

These agents inhibit HIV-1 viral replication.

Efavirenz (Sustiva)

Efavirenz is a nonnucleoside reverse transcriptase inhibitor that derives its activity against HIV-1 by binding to reverse transcriptase. Efavirenz blocks ribonucleic acid (RNA)-dependent and DNA-dependent DNA polymerase activities, including HIV-1 replication. It does not require intracellular phosphorylation for antiviral activity.

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HIV, Protease Inhibitors

Class Summary

These agents block the modification of precursor polyproteins that are responsible for the synthesis of reverse transcriptase and HIV-1 protease.

Indinavir (Crixivan)

Indinavir prevents formation of protein precursors necessary for HIV infection of uninfected cells and viral replication.

Nelfinavir (Viracept)

Nelfinavir inhibits HIV-1 protease, resulting in the production of an immature and noninfectious virus.

Darunavir (Prezista)

Darunavir selectively inhibits HIV-encoded Gag-Pol polyprotein cleavage in infected cells, thereby preventing mature virus particle formation. Indicated for HIV disease that has not responded to treatment with other antiretroviral agents. Coadminister with low-dose ritonavir (ritonavir-boosted therapy decreases elimination and increases darunavir serum concentration). Typically coadministered with other anti-HIV agents (eg, nucleoside reverse transcriptase inhibitors). Food increases bioavailability. Indicated for HIV infection in antiretroviral treatment–experienced adults (eg, those with HIV-1 strains resistant to more than one protease inhibitor).

Ritonavir (Norvir)

Ritonavir is used in a drug combination of a double or triple therapy with nucleosides and other protease inhibitors.

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Immune Globulins

Class Summary

Patients who may not have been immunized against Clostridium tetani products should receive tetanus immunoglobulin (HyperTet).

Tetanus immunoglobulin (HyperTET S/D)

This agent is used for the passive immunization of any person with a wound that might be contaminated with tetanus spores.

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Vaccines, Inactivated, Bacterial

Class Summary

These agents are used for tetanus immunization. A booster injection against tetanus in previously immunized individuals is recommended to prevent this potentially lethal syndrome.

Tetanus toxoid adsorbed or fluid

This induces active immunity against tetanus in selected patients. Tetanus, diphtheria, and acellular pertussis toxoids (TDAP) are the immunizing agents of choice for most adults and children (>7 y). Booster doses are necessary to maintain tetanus immunity throughout life. Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen–containing product.

The immunizing agent may be administered into the deltoid or midlateral thigh muscles of children and adults. In infants, the preferred site of administration is the midthigh laterally.

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Antiretroviral agents, integrase inhibitor

Class Summary

These agents inhibit the incorporation of viral DNA into the genome of the host's cell, thereby inhibiting HIV-1 viral replication.

Raltegravir (Isentress)

Raltegravir is a human immunodeficiency virus integrase strand transfer inhibitor (HIV-1 INSTI). Prevents the integration of the proviral gene into human DNA by inhibiting the catalytic activity of integrase.

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HIV, ART Combos

Class Summary

These agents inhibit HIV-1 viral replication by inhibiting nucleoside reverse transcriptase through different mechanisms.

Emtricitabine and tenofovir (Truvada)

Emtricitabine: Nucleoside Reverse Transcriptase Inhibitor (NRTI); following phosphorylation, interferes with HIV viral DNA polymerase and inhibits viral replication; cytosine analogue

Tenofovir: Emtricitabine: Nucleoside Reverse Transcriptase Inhibitor (NRTI); following phosphorylation, interferes with HIV viral DNA polymerase and inhibits viral replication; cytosine analogue

Lamivudine and zidovudine (Combivir)

Lamivudine: NRTI; following phosphorylation, inhibits HIV reverse transcriptase by viral DNA chain termination; cytosine analog

Zidovudine: NRTI; interferes with HIV viral RNA-dependent DNA polymerase (inhibits viral replication); thymidine analog

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