Body Fluid Exposures Treatment & Management

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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Treatment

Approach Considerations

Infection is still a significant concern at any given exposure to body fluid, especially an exposure involving disruption of the normal integumentary barrier. Antibiotic prophylaxis should be considered.

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Prehospital Care

The single most useful element in prehospital care is the limitation of exposure and immediate cleaning of the area that has been exposed. Copious amounts of soap and water are appropriate. Many health care workers use rapid acting antiseptic solutions, but while theoretically applicable, no studies support any benefit from this practice. Mucous membranes should be flushed with copious amounts of water.

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Emergency Department Care

The treating clinician should obtain and assess potential risk factor information concerning the source patient. The clinician must also be mindful of any risks to the source patient. For example, if the source patient bit the exposed patient, the source patient may be at risk, especially if there is blood in the wound of the exposed patient. Detailed information regarding the volume of blood/body fluid transmission, duration, and extent of the exposure is also important. [23]

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 affects 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 outlined in the flow chart below.

Flowsheet for management of blood/body fluid expos Flowsheet for management of blood/body fluid exposures.

If it is believed that HIV prophylaxis is warranted, the patient should be given a stat dose in the ED and a prescription for the PEP regimen for 28 days.

If indicated, HBIG and the HBV vaccine should be given as stat doses in the ED and follow-up doses of the vaccine given in the OPD in one month and then 6 months later. If the patient refuses the vaccine, he or she should receive another dose of HBIG one month later in the OPD.

Wound management

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

Tetanus prophylaxis

Administer a tetanus booster when the patient’s immunization status is not up-to-date. Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen–containing product.

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Lavage and Wound Cleaning

The single most pertinent procedure to undertake in the patient after exposure is lavage. Copious amounts of irrigation fluid are appropriate in cases of mucosal exposure (ocular and oral), as well as soap-and-water washing in cases of needlestick injury. Although no regimen has been shown to affect viral transmission rates, this is an empiric regimen aimed at decreasing the level of exposure to the viral agent in order to decrease the associated risk of transmission.

Small wounds and punctures may be cleaned with an antiseptic such as an alcohol-based hand hygiene agent; alcohol is virucidal to HIV, HBV, and HCV. Other agents that inactivate HIV are iodophors, chloroxylenol, and chlorhexidine. [24]

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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. The 2013 guidelines published by the US Public Health Service recommend that this treatment be started in patients with high-risk exposure that occurred within 72 hours of the ED visit. For extremely high-risk exposures, PEP may be considered even after more than 72 hours postexposure. [25, 7] Treatment should be continued for 4 weeks. It is critical that the physician emphasize the importance of the patient taking the medications for the entire 28 days.

Generally, most EDs stock only 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. In the case of exposure on a weekend or weekend/holiday, a supply to cover 3-5 days is provided. Given the risk of contracting HIV infection, it is the ethical obligation of the clinician to ensure that the patient is able to obtain enough medication to last until the follow-up visit. This should apply to not only health care workers but also non–healthcare workers who have significant exposure.

Individual states may have their own medication regimen for PEP. The clinician should become familiar with his or her state’s Web site in order to determine whether his or her choice coincides with the state’s regimen.

The US Centers for Disease Control and Prevention (CDC) recommends use of PEP based on the exposure type, with consideration of the infection status of the source. If the source’s HIV status is negative, no PEP is recommended. A positive rapid HIV test result should be confirmed with an EIA test and eventually with a Western blot test. However, a negative conventional EIA test result is enough to exclude the diagnosis of HIV unless there is clinical evidence of primary HIV infection or HIV-related disease. [8]

It was once believed that a source patient who tested negative for HIV might still be in the window phase (phase after HIV transmission but before detectability) and therefore could still transmit the virus via occupational exposure. However, no cases of conversions to HIV positivity have been reported in patients who had occupational exposures during the “window phase” of the source patient.

If the HIV status of the source is unknown, the decision of whether to administer PEP should be made on a case-by-case basis in consultation with an expert, taking into account risk versus benefit. [25] However, if the source is HIV-positive and the exposure is felt to be potentially significant, then PEP is recommended and should be given even if the patient was exposed to only a small volume.

Per guidelines that were published by the US Public Health Service in 2013, therapy is initiated with 3 drugs for all exposures that are believed to place the patient at risk for HIV infection. No distinction is now made between low-risk exposures (which required only 2 drugs) and high-risk exposures (which required 3 drugs). [25]

The CDC now recommends PEP with 2 nucleoside reverse transcriptase inhibitors (NRTIs) and a protease inhibitor (PI) for all exposures in which PEP is believed to be necessary. [25]

The currently preferred HIV PEP drug regimen is tenofovir DF (Viread; TDF) 300 mg PO QD plus  emtricitabine (Emtriva; TDF) 200 mg (Truvada) PO QD plus  raltegravir (Isentress; RAL) 400 mg PO BID. Please note that Truvada is a fixed combination of tenofovir DF and emtricitabine and is given as 1 tablet QD. This is also the preferred regimen for sexual exposures, as well as needlesticks and mucous membrane exposures. [25]

Acceptable alternatives are as follows:

  • Tenofovir DF 300 mg PO QD plus  lamivudine 300 mg PO QD plus raltegravir 400 mg PO BID
  • Tenofovir DF 300 mg/emtricitabine 200 mg (Truvada) 1 tab PO QD plus darunavir 800 mg/ritonavir 100 mg PO QD
  • Tenofovir DF 300 mg PO QD plus  lamivudine 300 mg PO QD plus darunavir 800 mg/ritonavir 100 mg PO QD
  • Zidovudine (ZDV) 300 mg/lamivudine (3TC) 150 mg (Combivir) 1 tab PO BID plus raltegravir 400 mg PO BID
  • Zidovudine (ZDV) 600 mg/day PO divided BID/TID plus  emtricitabine (FTC) 200 mg PO QD plus raltegravir 400 mg PO BID
  • Zidovudine (ZDV) 300 mg/lamivudine (3TC) 150 mg BID (Combivir) 1 tab PO BID plus darunavir 800 mg/ritonavir 100 mg PO QD
  • Zidovudine (ZDV) 600 mg/day PO divided BID/TID plus  emtricitabine (FTC) 200 mg plus darunavir 800 mg/ritonavir 100 mg PO QD

Tenofovir DF, emtricitabine, zidovudine, and lamivudine are all NRTIs. Raltegravir and darunavir/ritonavir are PIs. As noted above in PEP regimens, in most cases, 2 NRTIs are paired with one PI.

Other alternative regimens are also acceptable. In these alternative regimens, a different PI (eg, etravirine, rilpivirine, atazanavir/ritonavir, or lopinavir/ritonavir) can be used to replace raltegravir or darunavir/ritonavir in the above regimens. One of these other PIs is combined with 2 of the NRTIs in the above regimens. For more information on these regimens, the reader is referred to the Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis.

Other alternative regimens also exist but should not be used without expert consultation (see Consultations).

Regimens may need to be modified or alternative regimens may need to be used if the patient has comorbid conditions, if the patient is pregnant or breastfeeding, if the patient is not tolerating the initial regimen, or if a medication is not available or is too expensive (see below).

Older patients usually have more comorbidities than younger patients and are usually taking more medications. Elderly patients are also more likely to have adverse drug reactions. All of these factors must be taken into consideration when choosing a PEP regimen to prevent HIV.

Truvada, although it has better GI tolerance than Combivir, should not be used in patients with renal failure because it may worsen renal function. The dose of Combivir should be modified in patients with renal insufficiency.

Efavirenz should not be used in pregnancy, as it is teratogenic.

Saquinavir/ritonavir is a cost-efficient alternative to raltegravir.

The following antiretroviral agents are not recommended to be used for PEP because of their potential toxicity:

  • Nevirapine
  • Didanosine
  • Nelfinavir
  • Tipranavir

High-risk exposures

If the source is known to have HIV and is undergoing HIV treatment, an alternate regimen may be required because of the possibility of resistance; if possible, an HIV specialist should be consulted (see Consultations).

Adherence

Failure to complete courses of recommended regimens has been due to adverse effects, such as headache, diarrhea, or nausea. These symptoms can be managed with acetaminophen, antimotility and antiemetic agents. Alternatively, the dose interval of the medication (within the manufacturer’s recommendation) can be changed in order to ensure adherence to the regimen. [7]

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Hepatitis B Prophylaxis

Provide HBV immunoglobulin (HBIG) and HBV vaccine if indicated based on vaccination and immunity status. [26]

If the patient has received HBV vaccine in the past and has completed the full series or has a history of HBV, then nothing needs to be done acutely in the ED. Antibody titers for HBV surface antibody should be sent and urgent follow-up should be given. If the titers are less than 10 mIU/mL, indicating that the vaccine was ineffective and the patient is not immune, then the patient should be given HBIG, and the HBV revaccination series should be started. [27]

If the patient has not been previously fully immunized against or has not had HBV and the source is either HBsAg-positive or unknown, the patient should be given HBIG at a dose of 0.06 mL/kg intramuscularly (IM) and the HBV vaccination series should be started. If HBIG is given with the vaccine, it does not need to be repeated. If given for some reason without the vaccine, it should be repeated in 1 month.

Although HBIG alone has also demonstrated effectiveness in preventing HBV transmission, it is still administered with the vaccine, since the vaccine is available and safe; HIBG gives 3-6 months of protection from HBV, while the vaccine can give lifelong protection. [28]

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 PEP to be effective, early administration of the initial dose of the vaccine is needed. [29]

The recommended series is given in 3 intramuscular doses. In adults and children, the vaccine should be administered only in the deltoid muscle; when given in the buttocks, the immunogenicity of the vaccine is lower. [28]

The vaccine is given in 3 doses (at 0, 1, 6 months). If the patient refuses vaccination, HBIG can be repeated in 1 month. The CDC is now recommending serologic testing for immunity 1-2 months postvaccination in health care workers who are at risk for HBV to ensure that the vaccine was effective. [27]

Neither pregnancy nor lactation should be considered a contraindication to vaccination in women. [28]

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Hepatitis C Prophylaxis

No effective Food and Drug Administration (FDA)–approved prophylaxis currently exists for HCV. Prophylactic use of interferon has not been proven effective. [21] Management is expectant, with close follow-up as appropriate. If the patient develops HCV antibodies, he or she can then be treated for HCV infection by a specialist.

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Counseling

Patients should receive immediate counseling about the risk of their exposure to infectious agents and the indications for antiviral prophylaxis. Failure to provide appropriate counseling and HBV/HIV prophylaxis when indicated could leave the ED physician vulnerable to adverse liability if the injured patient seroconverts. However, such counseling is of paramount importance not just medicolegally, but also in terms of the overall management of the exposed individual. These efforts serve to "close the loop" in the quest to eliminate preventable occurrences. Patients who have been exposed to HIV virus should be counseled to avoid possible transmission of the virus during the follow-up period, for example by using condoms. [8]

Importantly, exposure to body fluids that may carry a potentially fatal disease such as HIV infection is alarming to patients. It has been shown that body fluid exposure has negative psychological effects. It is imperative that the physician caring for such a patient be very empathetic and caring. It is not enough for the physician to treat only the exposure, but the provider must give the patient psychological support as well. Also, the physician must make certain that all necessary care and follow-up is done in an expeditious manner without any hitches.

Still, one of the greatest difficulties remains in "making the call" as to whether an exposure warrants prophylaxis. While leaving the decision up to the patient will result in a higher than necessary rate of medication dispensing, until methods of HIV detection and management can provide greater and more timely reassurance, this will likely remain the course most practitioners will take.

Pregnancy should not preclude the use of optimal regimens, and PEP should not be denied to an individual solely on the basis of pregnancy. Issues that must be discussed with a pregnant patient 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 an appropriate and reliable site for outpatient counseling and long-term testing for seroconversion. Patients will need testing for the subsequent 6 months or, if new-generation HIV testing is used, for the subsequent 4 months.

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Deterrence and Prevention

OSHA standards are to be encouraged and reinforced by all hospital employees consistently because prevention is the single best weapon against blood/body fluid exposures. The following universal precautions should be followed in all patient contact situations:

  • Wash hands between care of each patient
  • Use gloves when handling body fluids or performing procedures in which exposure is possible, including contact with mucous membranes
  • Use protective gowns, eyewear, and masks during procedures when the risk of splash or spray of body fluids exists
  • Never recap needles - If recapping is necessary, the cap should not be held by hand; rather, lay the cap on a firm surface and insert the needle; then, the entire system is lifted, and the cap is secured in place.

OSHA requirements are now moving toward needleless and needlestick prevention systems as basic requirements in health care facilities. Institutions must evaluate these systems and utilize those that function best within their departments.

As per OSHA, health institutions are required to have policies in place to decrease the risk of body fluid exposure among their employees. To the extent possible, they are also to use as many “needleless” systems as possible to prevent needlestick injuries; to educate their staff on the risks and prevention of body fluid exposures, emphasizing the need to use universal precautions at all times; and to make HBV vaccination available to all their employees at no cost.

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Consultations

Referral to an infectious disease specialist may be warranted, especially when pregnancy is suspected or confirmed. In addition, exposures from HIV-positive sources who are undergoing treatment 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 when the clinician is seeking consultation. Health care providers are encouraged to use consultation services such as the National Clinician's Post-Exposure Prophylaxis Hotline, which provides advice regarding management of blood and body fluid exposures, including risk assessment, choice of PEP medications, and assistance with difficult-to-manage scenarios (eg, pregnancy). This service 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, including the following:

Consultation is always available and should be used if there are any questions about what regimen to use for PEP. Most institutions have an infectious disease expert on call for this purpose; if not, the National Clinician’s Post-Exposure Hotline at telephone number (888-448-4191) is always available for consultation.

Expert consultation should be obtained in the following circumstances:

  • The patient presents more than 72 hours after the exposure
  • The source patient is unknown (eg, a needlestick from a sharp in the sharp’s container)
  • The exposed patient is pregnant
  • The exposed patient is breastfeeding
  • Suspected resistance of the source virus
  • Toxicity of the initial PEP regimen
  • Significant underlying disease in the exposed patient [25]
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Long-Term Monitoring

Patients receiving HIV prophylaxis should be given a follow-up appointment to an occupational health clinic (employees), an HIV/infectious disease clinic, or a primary care physician who is experienced in managing body fluid exposures within 72 hours to monitor for any adverse effects of the medications, tolerance of the regimen, and adherence.

In addition, any blood tests with pending results that were sent from the ED should be checked in the clinic. For example, if the HIV test from the source patient was pending but now shows a negative result, the HIV prophylaxis regimen should be stopped if it had been initiated.

Results related to hepatitis infection and immunity are usually unavailable prior to discharge from the ED, and those results may be important for ongoing treatment. For example, the source may have turned out to be positive for HBV infection, and the patient may have turned out not to be immune, but the patient was not treated in the ED with HBIG and HBV vaccine pending the results of these tests. In this case, treatment with HBIG and the vaccination series should be started.

If the patient had a previous history of HBV vaccinations but the anti–HBV surface antigen antibodies now measure less than 10 mIU/mL, HBIG and HBV vaccine injection are indicated. Note that HBIG needs to be administered within 7 days of exposure for efficacy, and the sooner it is given (preferably within 24 hours), the more likely that it will work.

Patients who were exposed to an HIV-, HBV-, or HCV-positive source patient require retesting for the positive virus. Patients exposed to an HIV-positive source require retesting at 6 weeks, 12 weeks, and 6 months postexposure, although some evidence has shown that patients may only need to be tested for up to 4 months when fourth-generation HIV tests are used.

Patients who have been exposed to an HBV-positive source and are not immune should be vaccinated at the time of exposure and undergo HBV testing at 1-2 months postexposure.

Patients who have been exposed to an HCV-positive source need to undergo anti-HCV antibody retesting at 4-6 months postexposure.

If the patient originally tested negative for HBV, was not immune for HBV, and never received HBV vaccination, the patient will need follow-up to receive the full HBV vaccination series.

Hospital employees who have been exposed to body fluids should be reported to and referred to the hospital’s occupational health service. This is important not only for the health care provider who was exposed but also for the other hospital employees who may be exposed in the future, as this reporting may prompt the institution’s administration to take steps to prevent future incidents.

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