Post Exposure Prophylaxis

(Needle-stick, bites etc.)



Immediate wound care

Sharp Injury:

  • Encourage wound to bleed. Do not suck the puncture wound.
  • Wash thoroughly (soap and running water) the disinfect with alcohol ± Betadine.
  • Document neurovascular status.
  • Check tetanus status.

Bites and scratches:

  • Encourage area to bleed and wash with soap and cold water.
  • Do not use a nail-brush. The wound should be covered.

Splashes

  • Wash with soap and cold water. Contaminated clothing should be removed.
  • Eyes: Wash eyes with cold tap water.
  • Mouth: Rinse thoroughly with cold water.

For bites, as above plus wound care incl.

  • Thorough wound cleaning as soon as possible.
  • Wound closure only for large defects (cosmesis) - may require general anaesthesia.
  • Antibiotics - Co-amoxiclav or clarithromycin) for 1 to 3 days. Add metronidazole in severe injury.
  • Consider x-ray for tooth fragments.
  • Complete body fluid exposure forms as for needle stick injury.

Triage/Initial Management

If a patient presents to ED Triage for PEP Mon-Fri 9am-4.30pm, the triage nurse should contact ID CNS (087 6996272) or ID SpR (bleep 203).

Outside of these hours this protocol should be used to assess the need for a HIV-PEP starter-pack (held in ED pharmacy) which should be dispensed and administered to patient if warranted.


Assessment for HIV post occupational/non occupational exposure

Step 1 - Assess risk of exposure

Step 2: Assess risk of source

Assess Risk of Source

High Risk Source:

Known HIV+, HCV + or HepB sAg+

Moderate Risk Source:

Unknown source in High Risk environment e.g. discarded needle in public place, prison

Unknown person with probable risk factors for infection but actual status unknown

Low Risk Source:

Unknown source in low risk environment e.g. nursing home

Decision table for HIV PEP

Decision table for HIV PEP
PEP for HIV
Exposures
Known HIV+ source Unknown source status
High risk exposure Truvada +
Raltegravir*
Consider PEP
Moderate risk exposure Truvada +
Raltegravir*
Consider PEP

* In the case of a known HIV-positive source, the case should be discussed with the ID SpR or consultant.

Don't forget!

  • Take baseline bloods: FBC, U&E, LFTs, HIV screen, Hep C Ab, Hep B sAg, cAb and sAb.
  • Administer tetanus toxoid if indicated.
  • Consider if Hep B PEP or emergency contraception is indicated.
  • Advise against unprotected sexual intercourse until specialist assessment.
  • Organise follow up before the patient leaves the department.

* In the case of a known HIV-positive source, the case should be discussed with the ID SpR or consultant.


Assessment for HIV PEP following sexual exposure

Only for patients presenting within 72hrs of exposure)

Step 1 : assess risk of exposure
Exposure risk after sex
  Source known HIV positive

HIV status unknown,

Source high risk for HIV+

HIV status unknown
Source low risk for HIV

Exposure Viral load detectable Viral load undetectable
Receptive anal sex Recommended Recommended Recommended Considered
Insertive anal sex Recommended Not recommended Considered Not recommended
Receptive vaginal sex Recommended Not recommended Considered Not recommended
Insertive vaginal sex Recommended Not recommended Considered Not recommended
Fellatio sex with ejaculation Consider Not recommended Not recommended Not recommended
Fellatio without ejaculation Not recommended Not recommended Not recommended Not recommended
Semen splash to eye Consider Not recommended Not recommended Not recommended
Cunnilingus Not Recommended Not Recommended Not recommended Not recommended
Sharing of injecting equipment Recommended Not recommended Consider Not recommended
Human bites Consider in very limited circumstances Not recommended Not recommended Not recommended
Needlestick from discarded needle in community     Consider in very limited circumstances (above) Not recommended
Needlestick direct from source Recommended Not recommended Consider Not recommended
Blood splash to non-intact skin, eye or mouth Considered Not recommended Not recommended Not recommended
Decision table for HIV PEPSE
PEP for HIV Sexual exposures Management
Red box exposure Truvada + Raltegravir
Yellow box exposure Consider PEP

Don't forget

  • Take baseline bloods: FBC, U&E, LFTs, HIV screen, Hep C Ab, Hep B sAg, cAb and sAb.
  • Consider if Hepatitis B PEP or emergency contraception is indicated.
  • Advise against unprotected sexual intercourse until specialist assessment.
  • Organise follow up before the patient leaves the department.

Potential hepatitis B exposure

PEP for Hepatitis B virus

  • The vaccine is relatively safe, including in pregnancy – it is unnecessary if the patient has been adequately vaccinated.
  • Hepatitis B Immunoglobulin (Hepatect) is produced from blood donors, and treated to inactivate virus present. There is a risk of contamination e.g. other unknown viruses, CJD etc.
  • Hepatitis B IgG should only be prescribed when the source is known to be HepB sAg positive.
  • The prevalence of Hepatitis B in Ireland is too low to warrant giving Hepatitis B IgG to patients where the source is unknown. The prevalence of Hepatitis B core Ab positivity in blood donors in Ireland is 0.51%, increasing to 6% in prisoner/ IVDU populations. However the prevalence of chronic active infection with Hepatitis BsAg positivity is substantially less.

Hepatitis B virus prescribing details


PEP for hepatitis C virus

PEP for hepatitis C virus is not available. Regular monitoring in follow up period could show seroconversion. In this case early referral to ID/hepatology is warranted for consideration of early treatment. The estimated risk of transmission in healthcare workers exposed to HCV-infected blood is 1-3%.


Discharge and follow up for patients presenting to CUH ED for PEP or PEPSE

Outside of normal working hours this protocol should be used to assess the need for a PEP starter pack which should be dispensed and administered to patient if warranted. Follow-up with Infectious Diseases is extremely important and should be arranged as detailed below prior to the patient leaving the Department. Patients will be seen in the next ID clinic. For staff members following occupational injury, follow-up should be organised with Occupational Health.

To arrange follow-up with ID prior to patient’s discharge from ED:

  • Call the phone of the ID Dept (021 4922795) and leave voice-mail with patient’s name, MRN, and brief case details, stating that patient should be booked into next clinic.
  • Send overview referral letter to ID secretary via FAX (021-4921343) or delivering the letter in person to the ID office (not to rely on internal post).
  • Referral should be either a Narrative Letter or the PEP proforma in appendix 1 ONLY (NB, NOT the EMI toolkit proforma).
  • Patients should be given the contact details of the ID CNS (087 6996272) as a direct contact person in the ID department and should be advised to call them during working hours for counselling issues or questions due to medications/side effects.
  • Print Patient Information Leaflet (Appendix 2) and provide to patient.
  • Ensure that an up-to-date patient phone number is included in the referral.

Appendices

Figure 1: Estimated Risk of HIV Transmission per Exposure from Source known to be HIV Positive
Type of exposure Estimated risk per exposure
Blood transfusion 1 in 1
IVDU sharing needles 1 in 150
Occupational needles-tick
(known HIV pos+ve patient)
1 in 300
Mucous membrane exposure 1 in 1,000
Receptive anal sex Up to 1 in 30
Insertive anal sex Up to 1 in 1,000
Receptive oral sex Up to 1 in 2,500
Insertive vaginal sex Up to 1 in 1,000
Receptive vaginal sex Up to 1 in 500


Content by Dr Íomhar O' Sullivan 25/02/2004. Reviewed by Dr ÍOS 13/06/2005, 04/09/2005. Reviewed by Dr Jim Clair 14/08/2007. Last review Dr ÍOS 4/12/18.