0071643192.pdf

INFECTIOUS DISEASE

POSTEXPOSURE PROPHYLAXIS (PEP)

A 28-year-old surgical intern presents after being stuck with a bloody

18G needle while placing a femoral line. The patient has known AIDS

with a high viral load. What is the HIV transmission risk and what treatment

should be initiated?

High-risk source; high-risk exposure. Although the transmission rate is probably

<1% for this exposure, should recommend expanded HIV PEP regimen with first

dose given as soon as possible. Confirm Hep B vaccination.

■ Needlestick injuries are associated with risk for bacterial infections, hepati-

tis B, hepatitis C, and HIV.

Occupational Exposure

HIV TRANSMISSIONRISK

■ Greatly reduced by universal precautions

■ Majority of occupational seroconversions are percutaneous.

■ Occasionally mucocutaneous

■ No confirmed HIV seroconversions to date with a suture needle

■ See Table 8.6 for HIV transmission rates.

■ See Table 8.7 for risk stratification.

TREATMENT

■ Tetanus immunization; see “Special Wound Infections”

■ Hepatitis B PEP for nonvaccinated exposed individuals (see below)

■ No current PEP is available for Hepatitis C, but testing of source and patient

should be conducted to document if patient converts.

■ HIV PEP

■ Consider source patient testing if not known.

■ Depends on patient agreement and state law

■ Rapid HIV

■ Hepatitis panel

■ Consider RPR or other tests given clinical scenario.

TABLE 8.6. Risk for HIV Transmission by Route (per Episode)

TYPE EXPOSURE ESTIMATEDRISK(%)

Occupational Percutaneous 0.3

Mucocutaneous 0.09

Nonoccupational Needle-sharing injection drug 0.7

(assumes no condom use) Receptive anal intercourse 0.5

Receptive penile-vaginal intercourse 0.1

Insertive anal intercourse 0.07

Insertive penile-vaginal intercourse 0.05

Receptive oral (male) intercourse 0.01

Insertive oral (male) intercourse 0.005

Exposure of bodily fluids onto

intact skin is not a risk for HIV

transmission.