Body Fluid Exposures

Updated: Jun 19, 2019
Author: Muhammad Waseem, MBBS, MS, FAAP, FACEP, FAHA; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD 

Overview

Background

Blood and any body fluid visibly contaminated with blood should be considered capable of transmitting hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). Semen and vaginal secretions should also be considered potentially able to transmit these viruses. Similarly, cerebrospinal fluid, amniotic fluid, pleural fluid, synovial fluid, and peritoneal and pericardial fluids carry a significant risk of transmitting these viruses.

In contrast, unless blood is visibly present, saliva, sputum, sweat, tears, feces, nasal secretions, urine, and vomitus carry a very low risk of transmission of HCV and HIV. It should be noted that saliva can also carry HBV.[1] (See Pathophysiology.)

Occupational transmission of blood-borne infections may also occur through parenteral, mucous membrane, and non-intact skin exposure. The greatest risk for transdermal transmission is via a skin penetration injury that is fairly deep and sustained with a sharp hollow-bore needle that has visible blood on it that had recently been removed from a blood vessel of a patient with a high viral load.[2] Although many infectious agents may be transmitted by such contact, the most consequential include HBV, HCV, and HIV. (See Pathophysiology and Prognosis.)

In addition, skin and soft-tissue infection at the site of the inoculation, through introduction of staphylococcal species, is an issue of concern and must not be neglected. Tetanus prophylaxis is also an important issue of concern. Another important issue is the fact that many medical institutions adopt clinical pathways, algorithms, and plans for management of their own health care personnel but are woefully lacking when faced with the outside individual at significant risk for these diseases from needlesticks, mucous membrane splashes, or sexual encounters. (See Treatment and Medication.)

Zika virus has emerged as a pathogen of greater notice, as the incidence of this infection has increased in the Caribbean and Brazil. Consequently, there is greater interest of Zika virus being imported into the Unites States by travelers from these areas. Although most individuals with Zika virus infection are asymptomatic or have a benign viral illness characterized by fever, rash, arthralgia, and conjunctivitis, it can cause severe brain defects, such as microcephaly, in the fetuses of women who become infected with Zika virus during pregnancy. These defects may cause fetal demise. Zika virus infection in adults has been associated with Guillain-Barré syndrome and meningoencephalitis.

Although Zika virus is mainly transmitted via infected mosquitos, it has also been shown to be transmitted by sexual contact (especially from men to women [including from asymptomatic men]) and by blood, including from mother to fetus. A 2019 study conducted in Puerto Rico showed that the 95th percentile for the time until the loss of Zika virus RNA detection was 54 days in serum, 34 days in urine, and 81 days in semen. Few participants had detectable Zika virus RNA in saliva or vaginal secretions. The CDC recommends that the minimum interval from potential exposure to Zika virus and blood donation is 120 days. The CDC also recommends that men with possible Zika virus exposure, regardless of symptom status, should abstain from sexual contact or should use condoms for at least 6 months. Finally, the CDC recommends that women who have been infected or exposed to Zika virus wait at least 8 weeks from symptom onset or last possible exposure to Zika virus before attempting conception.[3]

Health care personnel include employees, volunteers, attending clinicians, students, contractors, and any public safety workers whose activities involve contact with patients and their environment such that exposure to blood or other body fluids can occur. Nurses, trainees, and students are at especially high risk for significant morbidity from these exposures.[4, 5, 6]

Non–health care personnel may be exposed by way of social interaction, sexual encounters (including sexual assault), trauma scenarios, intentional inoculations consistent with contemporary terrorist activity, or drug abuse. A flow chart for the management of body fluid exposure is shown below.

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

Infection risk

Body fluid exposures carry a risk of transmitting HIV, HBV, and HCV. The risk of developing HIV after a needlestick injury involving an HIV-infected patient is around 0.3%. Factors that increase the odds of HIV transmission after percutaneous exposure include a deep injury, the presence of visible blood on the instrument causing the exposure, injury via a needle that was placed in a vein or artery of the source patient, and terminal illness in the source patient.[7, 8] Viral titers are also very high during the initial stages of infection, when seroconversion is taking place.[9] Wearing gloves may reduce (>50%) the volume of blood introduced through an injury. (See Prognosis.)

Note that the risk of HIV transmission in health care workers from exposure of the mucosa to HIV-infected fluids was extremely low (0.09%) and that no cases of HIV conversion after exposure of intact skin to HIV-contaminated fluids or from bites (unless visible blood was present) were reported.[10]

Pathophysiology

When intact, the integumentary system serves as an effective physical barrier to the entry of infectious elements into the body. However, a special situation exists in terms of mucous membranes. Across these membranes lies a layer of mucus secreted by specialized columnar cells that are closely associated with each other through gap junctions. These junctions are little more than specialized cell surface projections that allow intercellular communication.

The presence of a moist mucous layer tends to prolong the viability of fragile viruses, such as HIV and HBV, which cannot survive long in drier environments. However, HBV has been found to be capable of surviving on countertops for 7 days and remain capable of causing infection,[11] while HCV has been shown to be able to survive on environmental surfaces for a minimum of 16 hours, but not for as long as 4 days.[12]

Higher vascularity coupled with a relatively permeable cellular layer gives rise to a presumed heightened risk of transmission of HBV, HCV, or HIV across mucous membranes and into the bloodstream.

After initial exposure, animal models have shown that HIV replicates within dendritic cells of the skin and mucosa within the first 48 hours before spreading through lymphatic vessels and becoming a systemic infection. This interval from initial introduction of the virus to systemic spread provides an opportunity to inhibit the replication of the virus using PEP.[13] In addition, some individuals who are exposed to HIV or HCV may have the ability to clear these infections due to inherent cellular immunity and may not demonstrate an antibody response to these organisms. This is referred to as aborted infection.[9]

Fortunately, viral transmission is rare in cases of occupational HIV exposures. Intact keratinized skin does not possess the mucous membrane characteristics that encourage the transmission of HIV, and it is virtually impermeable unless disrupted.

Etiology

Most exposures are caused by a departure from universal precautions on some level, whether they are the result of recapping or of failure to use personal protective equipment or are due to a sharp unintentionally left in an inappropriate place or placed in the wrong container for disposal. (See Presentation.)

Blood exposure is a particularly high risk during surgical procedures (up to 6.3 exposures per 1000 surgical procedures). Risk factors for blood exposure during surgical procedures increase with higher levels of patient blood loss, longer procedure duration, higher number of surgical personnel involved in the procedure, and the use of suture needles rather than other device types. The use of blunt surgical needles, when appropriate, reduced the risk of blood exposure from needlesticks, as did the use of double gloving for certain procedures.[14]

It has also been recommended that oculofacial plastic surgeons strongly consider using eye protection during procedures that have the potential to cause “splash exposures."[15]

Although the incidence of body fluid exposures and percutaneous injuries have been significantly reduced overall, likely owing to safety-engineered devices, these devices are still associated with a significant number of percutaneous injuries. More prevention strategies and education are still needed in this area.[16] One strategy that may help prevent these injuries is calling a “surgical time out” and making a “high-risk announcement” when there is a high risk of needlestick injuries during a surgical procedure. Procedures that were found to be high risk included administering skin injections, placing intravenous catheters, drawing blood, recapping needles, and using sharp suture needles.[17]

Safety during autopsies is another subject that has not received much publicity. The “Autopsy Checklist” is a standardized way of documenting safety and risk management issues during the autopsy process. However, the effectiveness of this procedure relies on the accurate completion of this list, which often goes undone.[18]

Recently, because of the Ebola virus and severe acute respiratory syndrome (SARS) outbreaks, there has been a great deal of publicity concerning the use of personal protection equipment (PPE). Unfortunately, no high-quality studies have addressed which types of equipment protect best, the best way to don and doff the PPE, and how to ensure that healthcare workers (HCWs), who are at a higher risk of these diseases than the general population, should use them properly. It appears that more active training on the use of PPE is needed by HCWs.[19] One method for studying the effectiveness of PPE, along with the best way to don and doff this equipment by providers, is by using UV tracers.[20]

When dealing with blood and body fluid exposures, document whether the exposure represents a departure from universal precautions or Occupational Safety and Health Administration (OSHA) standards or whether it represents a true accident (eg, projectile vomiting, precipitous labor with spontaneous rupture of membranes). This information is vital to the institutional safety committee, whose function is to monitor the safety of the environment for the entire facility and make recommendations for upgrades and policy changes.

Epidemiology

In the United States, sharps injuries occur at a rate of 1.8 per year per physician and 0.98 per year per nurse while working on the same medical ward. Statistically, however, twice as many nurses as doctors have been reported with occupationally acquired HIV infection. Whether this is a function of the significance of the exposure (ie, severity of the stick) or the route of exposure remains to be studied.

In a retrospective study of first responders presenting to an ED for body fluid or blood exposure, the incidence was 23.29 ED visits per 100,000 ambulance runs.[21]

Body fluid exposures appear to be a significant problem in developing countries, but no reliable statistics are available. A 2019 study from India showed that fatigue due to working excessive hours was a major risk factor for needlesticks among junior medical officers.[22]

Prognosis

Prognosis is associated with risk of infection and its sequelae. This is difficult to specify in any given patient. However, since the risk of HIV transmission is less than 1%, the prognosis of any given patient exposed to HIV may be listed as good but may remain so only with vigilant follow-up and consistent use of prophylaxis against infection.

Patients who develop hepatitis or HIV infection face significant morbidity and mortality. However, meaningful treatments now exist for HIV, HBV, and HCV infections.

Morbidity and mortality

Health care workers who have a significant exposure to HBV (ie, inoculation with an open-bore needle from a source known to have active HBV disease) but have not previously received HBV vaccine and do not receive PEP have a 6%-30% risk of becoming infected, depending on the presence of hepatitis B e antigen (HBeAg). The HBV viral DNA level correlates better with the infectivity of HBV than does the presence of HBeAg.[9]

The risk of HCV transmission from a known HCV-positive source by a sharps injury is 0%-7%. Approximately 80% of those infected with HCV will develop active liver disease, and 10%-20% will develop cirrhosis; 1%-5% of cirrhosis cases will lead to liver cancer over a period of years.[23]

As noted above, the rate of HIV transmission from a known infected individual via a sharps injury is 0.3%, whereas that for exposure to mucous membrane is 0.09%.[24] The rate is higher if the injury was sustained by a hollow-bore needle, if the injury was deeply penetrating, or if blood was injected during the injury. Risk to the injured health care worker is greater if the source patient had a high HIV viral load and/or a lower CD4 count.

Complications

The main complication of body fluid exposure is acquisition of hepatitis and HIV infection. Acquiring a significant bacterial skin infection from a needlestick is also possible. The risk of acquiring tetanus is extremely low.

Patient Education

Education regarding universal precautions and safety protocols to employees prior to any body fluid exposure may prevent exposures. Although universal guidelines have decreased the incidence of needlesticks, these injuries have continued to occur, albeit at a much lower rate. The healthcare workers at highest risk include surgeons, emergency room personnel, laboratory room professionals, and nurses. In many cases, the needlestick injuries occur because of failure to follow safety guidelines on the proper use and disposal of sharps. Many needlesticks are preventable by strictly following established procedures.[25]

Once the patient has been exposed, the patient must be educated regarding the risks, in addition to the risks versus benefits of postexposure prophylaxis (PEP).

If the patient opts for HIV PEP, the importance of adherence for 28 days must be emphasized. Also, the patient should understand to return to the emergency department (ED) immediately for any complications of the body fluid exposure or the PEP regimen. The importance of outpatient follow-up should be stressed to the patient.

For additional patient education information, see the Healthy Living Center and the Sexual Health Center, as well as Hepatitis B, Hepatitis C, and HIV/AIDS.

 

Presentation

History

Patients present with a history of exposure. Typically, this is a splash-type exposure to mucosal or non-intact skin, or it is an exposure resulting from a needlestick injury to intact skin. Patients often report exposures to intact keratinized skin out of uninformed concern, or they may be aware of some preexisting injury that predisposes them to infection. Reassurance through awareness of the risks for viral transmission in various scenarios is of significant importance to the health care provider and the patient.

In addition, the history should include any illnesses that may increase susceptibility to infection and/or to adverse reactions to the medications usually used for prophylaxis. The history should also include any medications the patient is taking that may interact with the PEP medications and any allergies.

A history of immunizations for tetanus and HBV should be obtained.

Physical Examination

During the physical examination, be sure to assess the body area of exposure and the depth of any wounds. The neurovascular status in the setting of extremity wounds is an important and often omitted element. The clinician should remain suspicious of occult injury, such as paper cuts or abrasions, which may threaten the integrity of the skin. For mucosal exposures, especially on the face, keep in mind that the exposure may not be limited to only one area and may occur simultaneously in nasal, oral, and conjunctival mucosal surfaces.

 

DDx

Diagnostic Considerations

In addition to the health care worker involved becoming ill because of the exposure, the worker may become a potential health risk to patients in the future, and this may need to be addressed. Also, if the worker becomes too ill to work, this will adversely affect his or her economic well-being, and the worker may need worker’s compensation and/or disability.

Differential Diagnoses

 

Workup

Approach Considerations

Testing for HBV surface antigen, HCV, and HIV is recommended at the time of injury. This is useful primarily as a baseline evaluation, because patients will not have undergone seroconversion in such a short time frame. Accurate results from rapid HIV tests can be available within 30 minutes, and new-generation HIV tests can detect HIV seroconversion much earlier than the standard enzyme-linked immunoassays (ELISA).

Although a number of states require written informed consent for HIV serologic testing, in the event that a patient is unable to provide consent, some institutions allow surrogates to sign. Surrogates may be family members, legal guardians, or 2 attending physicians. When a source patient refuses to consent, some states waive the required informed consent.

Many clinicians obtain routine laboratory evaluations, such as a complete blood cell (CBC) count and chemistries including liver function tests, which likely are not of much value acutely but are important as baseline values. However, sending rapid plasma reagent (RPR) to test for latent syphilis is prudent.

Women of child-bearing age should be tested for pregnancy, since the result may affect which HIV PEP regimen is used. In cases of sexual exposure, tests for gonorrhea and chlamydia should also be performed.

Imaging studies

Acutely, imaging studies are of little use, unless the presence of a foreign body or radiopaque material is suspected.

 

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.

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.

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.[26]

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.

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.[27]

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.[28, 8] 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.[9]

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.[28] 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).[28]

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.[28]

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.[28]

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.[8]

Hepatitis B Prophylaxis

Provide HBV immunoglobulin (HBIG) and HBV vaccine if indicated based on vaccination and immunity status.[29]

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.[30]

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.[31]

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.[32]

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.[31]

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.[30]

Neither pregnancy nor lactation should be considered a contraindication to vaccination in women.[31]

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.[23] 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.

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.[9]

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.

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.

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:

  • American Nurses Association

  • NIOSH Alert: Preventing Needlestick Injuries in Health Care Settings

  • National Alliance for the Primary Prevention of Sharps Injuries

  • National Clinician’s Post-Exposure Prophylaxis Website

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[28]

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.

 

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.[8]

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

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.

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.

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.

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.

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.

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.

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