Approach
Immediate wound care
Sharp Injury:
- Encourage wound to bleed
- Do not suck the puncture wound
- Wash thoroughly (soap & running water) then disinfect with alcohol ± Betadine
- Document neurovascular status
- Check tetanus status
Bites and scratches:
- Encourage area to bleed & wash with soap & 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
This protocol should be used to assess the need for a HIV-PEP starter-pack (held in ED resusc.) which should be dispensed and administered to patient if warranted.
CUH:
- Please refer for PEP follow up via iCM
Elsewhere:
- Please send a referral letter to the ID secretary via FAX (021 4921343)
- A yellow prescription should be written and sent to pharmacy via internal post
Initial Mx
Assessment for HIV post occupational/non occupational exposure
Step 1 - Assess risk of exposure
Step 2: Assess risk of source
Nightclub needlestick
In 2021 several patients presented following needle stick injuries in bars/nightclubs. These are very low risk patients and, in general (source unknown), should not be considered for PEP but require usual hepatitis management.
Decision table for HIV PEP
| PEP for HIV Exposures |
Known HIV+ source | Unknown source status |
| High risk exposure | Emtricitabine/Tenofovir + Raltegravir* |
Consider PEP |
| Moderate risk exposure | Emtricitabine/Tenofovir + Raltegravir* |
Consider PEP |
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 Hep B PEP or emergency contraception
- Advise against unprotected sexual intercourse until specialist assessment
- Organise follow up before the patient leaves the ED. In CUH this is via an iCM referral
* 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
| 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 |
| 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 |
| Semen/Blood splash to non-intact skin, eye or mouth | Considered | Not recommended | Not recommended | Not recommended |
| PEP for HIV Sexual exposures | Management |
|---|---|
| Red box exposure | Emtricitabine/Tenofovir + 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
- Administer tetanus toxoid if indicated
- Organise follow up before the patient leaves the department (In CUH, via iCM)
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 Immunoglobulin 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 Immunoglobulin to patients where the source is unknown
Hepatitis B virus prescribing details
Hepatitis vaccine
Engerix B 1mL IM (deltoid) or B Vax IM (deltoid).
Will need x2 further injections to complete the course (GP).
Hep B Immunoglobulin (HBIG)
Hepacect CP (0.16-0.20 mL/Kg)
Infuse at reate of 0.1 mL/kg/hr.
In CUH
Hep B HBIG is sourced from Blood Bank @22537.
Hep B vaccines are located in Clean utility fridge ED (or Pharmacy Dept if stock depleated in ED).
CUH ED Discharge/follow up for patients for PEP or PEPSE
If you examine/review a patient and decide that a PEP pack is required, you must:
- Complete a referral on iCM to the HIV clinic. This will ensure the patient is reviewed by ID and will facilitate the supply of a further 3 weeks of medicines if they are required
- For staff members or following occupational injury, follow-up should be organised with Occupational Health
- Please write a prescription and leave in the Resusc DDA press when you are taking the 7 day pack
- Do not give a prescription to the patient (they cannot access these meds. in the community)
- Print/provide an Information leaflet
Appendices
| 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 |
Links
- Truvada Isentress Patient Information leaflet
- Obtaining consent for HIV testing
- CUH HIV PEP prescription checklist
- CUH Occupational Health staff exposure to body fluids report form
- Print version CUH PEP protocol
- CUH PEP referrals are via iCM
- PEPSE patient information
- HPSC EMI and PEP page
- HPSC EMI Guideline (only 113 pages)
- HPSC EMI Summary (4 pages)
- Hepatect IgG Information
- Hepatect CP SPC
- HPSC EMIToolkit - Hepatect
- Patient in CUH should be informed about relevant procedures and the relevant consent for a photograph to be taken, consent for surgery and consent for tissue retention