Rosen & Barkin's 5-Minute Emergency Medicine Consult (477 page)

• 101 Vincent’s angina
  
• 526.4 Inflammatory conditions of jaw
  
• 528.1 Cancrum oris
  

BASICS

• Mechanisms of exposure to blood or body fluid:
  
  • Percutaneous
    
  • Mucous membrane
    
  • Skin
    
• General prevention:
  
  • Universal precautions
    
  • Avoid recapping of needles
    
  • Wear gloves: Decreases amount of blood exposure by 50%
    
  • Double gloving
    
  • Follow body–substance isolation protocols.
    
  • Hepatitis B virus vaccination
    
• Risk factors:
  
  • Risk of seroconversion from a single needlestick exposure without prior immunization:
    
    • Hepatitis B virus: 37–62% from HB
      _s
      Ag-positive and HB
      _e
      Ag-positive source, 23–37% from HB
      _s
      Ag-positive and HB
      _e
      Ag-negative source
      
    • Hepatitis C virus: 1.8%
      
    • HIV: Blood 0.3%, mucous membrane 0.09%
      
  • Infectiousness of various body fluids for HIV:
    
    • Plasma/serum: 10–5,000 ppm
      
    • CSF: 10–1,000 ppm
      
    • Semen: 10–50 ppm
      
    • Vaginal secretions, urine, saliva, tears, breast milk: <1 ppm
      
  • Factors affecting risk:
    
    • Viral load
      
    • Actual injection volume
      
    • Type and size of needle
      
    • Portal of entry (depth of inoculation)
      
    • Duration of contact
      
    • Level of disease in source patient
      
    • Host susceptibility
      
    • Barriers (e.g., through gloves)
      

DIAGNOSIS

Exposure to blood or body fluid:

• Date, time, circumstances, details of exposure, source
  
• Immunizations
  

Women with body fluid exposure who are considering antiviral therapy must have serum or urine pregnancy testing.

To be done with occupational health if possible:

• Baseline serology for HIV (enzyme immunoassay, western blot), hepatitis B virus, hepatitis C virus (anti-HCV), ALT. Assess adequacy of hepatitis B virus vaccination.
  
  • HIV-Ab, HCV-Ab, HB
    _s
    Ag, HB
    _s
    Ab titer
    
• Obtain consent from source patient for HIV (consider rapid HIV-antibody test), hepatitis B virus, hepatitis C virus (anti-HCV) testing.
  
  • HIV-Ab, HCV-Ab, HB
    _s
    Ag
    

Not applicable unless concerned for retained tissue foreign body

Principally concerned with transmission of hepatitis B virus, hepatitis C virus, and HIV

TREATMENT

• Copious cleaning, wound care
  
• Direct and immediate referral to occupational health, when available, to ensure strictest confidentiality in lab testing and treatment
  
• In the ED, after hours, patients with needlestick exposure must be triaged with high priority. It is important to initiate prophylactic therapy quickly after exposure.
  

• If referral to occupational health is unavailable, initiate prophylactic therapy in ED.
  
• Tetanus prophylaxis if necessary
  
• HIV:
  
  • Begin basic vs. expanded antiretroviral prophylaxis regimen after considering HIV status of source and severity of exposure. Some organizations advocate only the expanded 3-drug regimen. Treat for 28 days.
    
  • CDC guidelines: For less severe percutaneous exposure, if source patient is:
    
    • HIV negative: No prophylaxis
      
    • Unknown source: Consider basic regimen
      
    • Patient with risk factors: Consider basic regimen
      
    • HIV positive, low viral load: Recommend basic regimen
      
    • HIV positive, high viral load: Recommend expanded regimen ≥3 drugs
      
  • CDC guidelines: For more severe percutaneous exposure, if source patient is:
    
    • HIV negative: No prophylaxis
      
    • Unknown source: Consider basic regimen
      
    • Patient with risk factors: Consider basic regimen
      
    • HIV positive, low viral load: Recommend expanded regimen 3 drugs
      
    • HIV positive, high viral load: Recommend expanded regimen ≥3 drugs
      
  • CDC guidelines: For less severe mucous membrane or nonintact skin exposure, if source patient is:
    
    • HIV negative: No prophylaxis
      
    • Unknown source: No prophylaxis
      
    • Patient with risk factors: No prophylaxis
      
    • HIV positive, low viral load: Consider basic regimen
      
    • HIV positive, high viral load: Recommend basic regimen
      
  • CDC guidelines: For more severe mucous membrane or nonintact skin exposure, if source patient is:
    
    • HIV negative: No prophylaxis
      
    • Unknown source: Consider basic regimen
      
    • Patient with risk factors: Consider basic regimen
      
    • HIV positive, low viral load: Recommend basic regimen
      
    • HIV positive, high viral load: Recommend expanded regimen ≥3 drugs
      
  • CDC preferred basic regimen:
    
    • Zidovudine (AZT) + lamivudine (3TC); sold as combination drug Combivir; o
      r
      
    • Tenofovir DF (TDF) + emtricitabine (FTC);
      
    • Zidovudine (AZT) + emtricitabine (FTC);
      or
      
    • Lamivudine (3TC) + tenofovir DF (TDF);
      or
      
  • CDC alternative basic regimen:
    
    • Lamivudine (3TC) + stavudine (d4T);
      or
      
    • Emtricitabine (FTC) + stavudine (d4T)
      or
      
    • Lamivudine (3TC) + didanosine (ddI)
      or
      
    • Emtricitabine (FTC) + didanosine (ddI)
      
  • CDC preferred expanded regimen: Basic regimen and:
    
    • Lopinavir/ritonavir (Kaletra)
      
  • CDC alternative expanded regimen: Basic regimen and:
    
    • Atazanavir (ATV) ± ritonavir (RTV)
      or
      
    • Fosamprenavir ± ritonavir (RTV)
      or
      
    • Indinavir (IDV) ± ritonavir (RTV)
      or
      
    • Saquinavir (SQV) + ritonavir (RTV)
      or
      
    • Nelfinavir
      or
      
    • Efavirenz
      or
      
    • Consider others after expert consultation: These include abacavir, delavirdine, zalcitabine, nevirapine, enfuvirtide.
      
  • Counseling to prevent secondary infection:
    
    • Safer sex advice
      
    • Avoid becoming pregnant
      
    • Do not donate blood/tissue.
      
    • Do not breast-feed.
      
• Hepatitis B virus:
  
  • Known HB
    _s
    Ag-positive source:
    
    • Complete vaccination confirmed by titer: No prescription
      
    • Unvaccinated: Hepatitis B immune globulin ASAP, begin hepatitis B virus vaccine series.
      
    • Nonresponder to vaccine: Hepatitis B immune globulin ASAP, may repeat in 30 days; consider revaccination with 3-dose series.
      
    • Unknown responder to vaccine with inadequate titer: Hepatitis B immune globulin ASAP, vaccine booster
      
  • Known HB
    _s
    Ag-negative source:
    
    • Vaccinated: No prescription
      
    • Unvaccinated: Begin hepatitis B virus vaccine series
      
  • Unknown source:
    
    • Complete vaccination confirmed by titer: No prescription
      
    • Unvaccinated: Begin vaccine series. If high-risk exposure, consider hepatitis B immune globulin
      
    • Nonresponder to vaccine: Hepatitis B immune globulin ASAP with revaccination 3-dose series. If high-risk exposure, repeat hepatitis B immune globulin in 30 days.
      
    • Unknown responder to vaccine with inadequate titer: Vaccine booster and recheck titer in 1–2 mo
      
  • Hepatitis C virus:
    
    • Use of immunoglobulins or antivirals (interferon, ribavirin) inconclusive as prophylaxis, but possibly beneficial if initiated early when infection evident
      

• HIV:
  
  • Zidovudine:
    
    • 300 mg PO BID or 200 mg PO TID
      
    • Side effects: GI symptoms, headache, fatigue, myalgias, marrow suppression, seizure
      
  • Zidovudine should be taken in conjunction with lamivudine
    
  • Lamivudine:
    
    • 300 mg PO QD or 150 mg PO BID
      
    • Side effects: GI symptoms, headache, fatigue, neuropathy, congestion, cough (caution with trimethoprim/sulfamethoxazole)
      
  • Combivir (combination zidovudine + lamivudine) (300 mg + 150 mg tab):
    
    • 1 tablet PO BID
      
    • Side effects: See side-effect profiles of zidovudine and lamivudine
      
  • Emtricitabine:
    
    • 200 mg/d PO
      
    • Side effects: Rash, hyperpigmentation
      
    • Emtricitabine must be taken in conjunction with efavirenz and zidovudine
      
  • Tenofovir DF:
    
    • 300 mg/d PO
      
    • Side effects: GI symptoms, headache, fatigue, neuropathy, dizziness
      
    • Tenofovir must be taken in conjunction with efavirenz and emtricitabine
      
  • Didanosine:
    
    • <60 kg 250 mg/d PO as delayed-release
      
    • Side effects: Pancreatitis, GI symptoms, lactic acidosis, neuropathy
      
  • Stavudine:
    
    • 60 kg 40 mg PO BID or
      
    • If wt <60 kg, then 30 mg PO BID
      
    • Side effects: Peripheral neuropathy, GI symptoms, headache, pancreatitis, elevated liver function tests, neutropenia, anemia
      
  • Lopinavir/ritonavir (Kaletra) (200 mg + 50 mg cap):
    
    • 2 capsules PO BID
      
    • Side effects: GI symptoms, hyperlipidemia
      
  • Atazanavir:
    
    • 400 mg/d PO
      
    • If used with tenofovir, then decrease to 300 mg/d PO and add ritonavir 100 mg/d PO
      
    • Side effects: Be wary with medications that prolong PR interval, hyperbilirubinemia
      
  • Fosamprenavir:
    
    • 1,400 mg PO BID
      
    • If used with ritonavir, then decrease to 1,400 mg/d PO or 700 mg PO BID
      
    • Side effects: GI symptoms, rash, drug interactions, depression
      
  • Indinavir:
    
    • 800 mg + ritonavir 100 mg PO BID, in combination with (lamivudine + zidovudine) or (emtricitabine + zidovudine) or(lamivudine + tenofovir) or (emtricitabine + tenofovir);
      
    • If used with ritonavir, then decrease to 800 mg PO BID
      
    • Side effects: Nephrolithiasis, hyperbilirubinemia, GI symptoms
      
  • Saquinavir:
    
    • 1,000 mg + ritonavir 100 mg PO BID
      
    • Side effects: GI symptoms, hepatitis
      
  • Nelfinavir:
    
    • 1,250 mg PO BID
      
    • Side effects: Potential carcinogenic and teratogenic warning, GI symptoms, weakness, rash
      
  • Efavirenz:
    
    • Alternate expanded regimen for HIV postexposure prophylaxis: 600 mg PO in combination with (lamivudine + zidovudine) or(emtricitabine + zidovudine) or (lamivudine + tenofovir) or (emtricitabine + tenofovir)
      
    • Side effects: Stevens–Johnson syndrome, rash, sleep disruption, dizziness, psychiatric, teratogen
      
  • For some of the antiretroviral agents, the oncogenic and teratogenic effects are unknown.
    
  • NRTIs and NtRTIs can result in lactic acidosis with hepatic steatosis.
    
  • All can have serious drug interactions that lead to significant harm or death.
    
• Hepatitis B:
  
  • Hepatitis B immune globulin: 0.06 mL/kg IM
    
  • Hepatitis B virus booster: Unit-dose vial