Didactic Series. Updated Post-Exposure Prophylaxis (PEP) Guidelines. Daniel Lee, MD UCSD Medical Center, Owen Clinic January 9, 2014

Transcription

1 Didactic Series Updated Post-Exposure Prophylaxis (PEP) Guidelines Daniel Lee, MD UCSD Medical Center, Owen Clinic January 9, 2014 ACCREDITATION STATEMENT: University of California, San Diego School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The University of California, San Diego School of Medicine designates this educational activity for a maximum of one credit per hour AMA PRA Category 1 Credits. Physicians should only claim credit commensurate with the extent of their participation in the activity. 1

2 Learning Objectives 1) Knowledge of updated (2013) PEP guidelines 2) Able to manage post-exposure prophylaxis to HIV 3) Know how to obtain expert consultation on PEP 2

3 Occupational Risk Exposure Exposure = infectious body fluid + portal of entry Infectious body fluid Blood Cerebrospinal, synovial, pleural, pericardial, peritoneal or amniotic fluids Semen or vaginal fluids Portal of entry percutaneous, mucous membrane or non intact skin Most exposures do not cause infection 3

4 Poll 1: A 39-year-old female nurse has a needle stick injury on her right thumb. The source patient has documented HIV infection. What is the estimated risk of infection? 1)0.09% 2)0.3% 3)1% 4)3% 5)Unsure 4

5 Occupational Transmission 1) Source is HIV infected 2) HBV- Needle stick: 1% - 31% 3) HCV- Needle stick: 1.8% 5

6 Preventing Occupational Transmission Do you have access to a written safety & exposure plan? Do you know who to contact in case of exposure? Have you received HBV series & immune? Do you always follow Universal Precautions? 6

7 Exposure to Potentially Infectious Material Needle stick, cut or fluid contact with non-intact skin Wash area with soap and water Eyes Irrigate with commercially prepared isotonic solution in eye wash stations Or irrigate with saline solution or water Nose or mouth Flush with water CDC does not recommend use of caustic solutions (e.g. bleach) or injection of antiseptics Contact supervisor & seek medical treatment 7

8 OCCUPATIONAL PEP 2013 GUIDELINES

9 Source: Kuhar DT, et al. Infect Control Hosp Epidemiol. 2013;34:

10 Case History: HIV Exposure in a Health Care Worker A 39-year-old female nurse has a needle stick injury on her left thumb. The site bled for about 2 minutes after the injury. The source patient has documented HIV infection, has never taken antiretroviral medications, and most current lab studies showed HIV RNA level of 2,350 copies/ml and CD4 count of 658 cells/mm 3. Poll 2: Based on USPHS 2013 Guidelines, what is recommended? 1) 2 drugs: Tenofovir-emtricitabine 2) 3 drugs: Efavirenz-tenofovir-emtricitabine (Atripla) 3) 3 drugs: Tenofovir-emtricitabine + Raltegravir 4) 3 drugs: Tenofovir-emtricitabine + Darunavir + ritonavir 5)Unsure Adapted from slide by David Spach, MD

11 2013 USPHS Occupational PEP Guidelines Number of Antiretroviral Medications to Use As less toxic and better-tolerated medications for the treatment of HIV infection are now available the PHS working group recommends prescribing 3 (or more) tolerable drugs as PEP for all occupational exposures to HIV. Source: Kuhar DT, et al. Infect Control Hosp Epidemiol. 2013;34:

12 2013 USPHS Occupational PEP Guidelines Recommended Antiretroviral Regimens for Occupational PEP (28-Day Duration) Preferred Regimen INSTI NNRTI Pill Burden Raltegravir (Isentress) 400 mg twice daily Tenofovir-Emtricitabine (Truvada) 1 pill daily Source: Kuhar DT, et al. Infect Control Hosp Epidemiol. 2013;34: Slide by David Spach, MD 12

13 Case History HIV Exposure in a Health Care Worker A 32-year-old physician has a needle stick injury on her hand that involves an HIV-infected patient. The source patient is taking tenofovir-emtricitabine-efavirenz (Atripla) and had an undetectable HIV RNA level 3 months prior. Poll 3: Based on USPHS 2013 Guidelines, would you recommend antiretroviral PEP for this physician? 1) No 2) Yes 3) Unsure 13 Slide by David Spach, MD

14 2013 USPHS Occupational PEP Guidelines PEP when Source Patient has Undetectable HIV RNA Level Exposure to a source patient with an undetectable serum viral load does not eliminate the possibility of HIV transmission or the need for PEP and follow-up testing. While the risk of transmission from an occupational exposure to a source patient with an undetectable serum viral load is thought to be very low, PEP should still be offered. Source: Kuhar DT, et al. Infect Control Hosp Epidemiol. 2013;34:

15 Source Patient HIV Testing If possible, determine the HIV status of exposure source patient to guide appropriate use of PEP For sources whose HIV status is unknown, rapid HIV testing facilitates decisions about need to initiate or continue PEP 4th-generation HIV Ag/Ab tests allow identification of most HIV infections during the window period PEP initiation should not be delayed while waiting for HIV test results If the source is found to be HIV negative, PEP should be discontinued, and no follow-up HIV testing for HCP is needed 15

16 2013 USPHS Occupational PEP Guidelines Situations for Which Expert Consultation Advised 1) Delayed exposure report (eg. longer than 72 hours) 2) Unknown source (eg. needle in sharps disposal) 3) Known or suspected pregnancy in exposed person 4) Exposed person breast-feeding 5) Known or suspected ARV drug resistance in source patient 6) Serious medical illness in exposed persons 7) Toxicity occurring in exposed person taking PEP regimen 16 Source: Kuhar DT, et al. Infect Control Hosp Epidemiol. 2013;34:

17 Free Hotline & Consultation 17

18 2013 USPHS Occupational PEP Guidelines Baseline and Follow-Up for Occupational PEP Early Reevaluation after Exposure (within 72 hours) Baseline and Follow-up HIV Testing - Baseline HIV testing - Follow-up HIV testing 6, 12, and 24 weeks after exposure - Follow-up HIV testing at 6 and 16 weeks if 4 th generation assay* used Baseline and Follow-up Laboratory Testing - Baseline renal and hepatic function tests - Follow-up renal and hepatic function tests at 2 weeks *4 th generation combination assay = HIV p24 antigen-hiv antibody test Source: Kuhar DT, et al. Infect Control Hosp Epidemiol. 2013;34: Slide by David Spach, MD 18

19 References 1) Centers for Disease Control and Prevention. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for Postexposure Prophylaxis. MMWR 2005;54(No. RR-9):2 2) Kuhar DT, Henderson DK, Struble KA, Heneine W, Thomas V, Cheever LW, Gomaa A, Panlilio AL. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infection control and hospital epidemiology: the official journal of the Society of Hospital Epidemiologists of America. 2013;34(9): ) 19