0071643192.pdf

INFECTIOUS DISEASE

TABLE 8.9. Nonoccupational HIV Post-Substantial-Risk Exposure Treatment Guidelines

TIMECOURSE SOURCE=UNKNOWNHIV STATUS SOURCE=KNOWNHIV+

<72 hours Case-by-case determination 28-day course of HAART (three-drug

regimen), start ASAP

>72 hours No HAART recommended No HAART recommended

Patients with a known

response to Hep B vaccination

(ie,HBsAg positive) are

considered protectedand do

not require Hep B PEP

following a possible exposure.

■ HIV prophylaxis nonoccupational algorithm

■ Negligible exposure risk

■ Urine, nasal secretions, saliva, sweat, or tears not visibly contami-

nated with blood

■ HIV Postexposure Prophylaxis not recommended

■ Substantial exposure risk

■ Exposure of vagina, rectum, eye, mouth or other mucous mem-

brane, nonintact skin, or percutaneous contact

■ Blood, semen, vaginal secretions, rectal secretions, breast milk, or

any body fluid visibly contaminated with blood

■ See Table 8.9 for treatment guidelines.

Hepatitis B

Health care workers in the United States are required to receive Hepatitis B

vaccination. For this reason, health care workers generally do not need to receive

PEP to prevent Hep B transmission following possible exposure. Nonvaccinated

individuals and those known not to have responded to vaccination with a high-

risk exposure should receive:

■ Hepatitis B immunoglobulin (HBIG)

■ Hepatitis B vaccination: Usually given as three doses over 4–6 months with

first dose given with HBIG in different site

■ Individuals who have been vaccinated but who did not receive postvaccine

testing to confirm the presence of the HBsAg should receive a vaccine booster.

SPECIAL WOUND INFECTIONS

An 80-year-old male presents with pain and stiffness in his masseter mus-

cles 1 week after stepping on a rusty nail. Muscle rigidity has progressed to

his neck, torso, and upper extremities. What treatment needs to be initiated

before wound debridement?

Tetanus immunoglobulin.

Tetanus

■ The spore-forming, anaerobic, Gram-positive rod Clostridium tetani

■ Ubiquitous in soil, dust, and animal feces

■ Risk factors

■ IV drug users

■ Temperate climates (Texas, Florida, California)

■ Elderly (>60 years old)