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Standard Precautions and
Post Exposure Prophylaxis
Unit 17
HIV Care and ART: A Course for
Healthcare Professionals
Learning Objectives
 Describe the basic principles and procedures of
standard precautions
 Identify the risks of HIV, HCV, and HBV
seroconversion following accidental
occupational exposures
 List the management steps of occupational
exposure
 Describe the principles of HIV post-exposure
prophylaxis
2
Case study
 Abebech is a 32 year-old nurse. She came to the ART
clinic after she sustained a needle stick while providing
an injection to a hospitalized patient. She thinks that the
patient is HIV positive and she is requesting HIV postexposure prophylaxis
 What measures are important for preventing this
problem in the future?
 What further information is needed to manage this
patient?
3
Occupational Exposure Risk
Estimated Pathogen-Specific
Seroconversion Rate Per Exposure for
Occupational Needlestick Injury
5
.
AETC http://depts.washington.edu/hivaids
Type of Exposure Involved in Transmission
of HIV to Health Care Workers
AETC http://depts.washington.edu/hivaids
6
Source of HIV Involved in HIV Transmission
to Health Care Worker
AETC http://depts.washington.edu/hivaids
7
Risk Factors for HIV Transmission with
Occupational Exposure to HIV-Infected Blood
Odds Ratio
Confidence
Interval
Deep Injury
15
6.0-41
Visibly Bloody Device
6.2
2.2-21
Device Used in Artery or Vein
4.3
1.7-12
Terminally Ill Source Patient
5.6
2.0-16
Use of Zidovudine for PEP
0.19
0.06-0.52
Risk Factor
P<0.01 for all associations
8
Other Possible Risk Factors
 Hollow bore vs solid bore
 No documented cases to date of seroconversion from suture
needles
 Glove use
 50% decrease in volume of blood transmitted
 Mucous membrane exposure
9
HIV in the Environment
 How long does HIV live outside the body?
 HIV does not survive well in the environment
 When HIV-infected blood or body fluids dry, the
theoretical risk of environmental transmission is
essentially zero
 No reports of environmental transmission
10
Standard Precautions
Standard Precautions
 Definition
 Standards developed to prevent exposure and
transmission of disease in occupational setting
 Provide guidance for the safe handling of infectious
material
 Formerly referred to as Universal Precautions.
“Universal” means everyone, everywhere, always
12
Components of Standard Precautions
 Hand washing – Key step in limiting nosocomial
spread of disease
 Use protective barriers when indicated
 Gloves: mucus membranes, body fluids, broken skin
 Goggles: procedures
 Gowns/masks: procedures
13
Components of Standard Precautions (2)
 Sharps and waste - handle with gloves and
dispose in designated containers






Needles
Scalpels
Suture material
Bandages
Dressings
Anything contaminated with any body fluid
14
Rules to Follow While Disposing Sharps
 Do not recap needles!
 Put containers within arms reach
 Use adequate light source when treating
patients
 Wear heavy-duty gloves when transporting
sharps
 Incinerate used needles to a sufficient
temperature to melt
 Keep sharps out of reach of children
15
Components of Standard Precautions (3)
 Re-usable instruments - must be thoroughly
disinfected
 Speculums
 Surgical tools
 Thermometers
 Immunizations
 Hepatitis A and B
16
Recommended Antiseptic Solutions
 Ethyl alcohol, 70%
 Chlorhexidine, 2-4% (e.g. Hibtane, Hibiscrub)
 Chlorhexidine gluconate and cetrimide, at least
2% (e.g. Savlon*)
 Iodine tincture, 3%
 Iodophores, 7.5-10% (e.g. Betadine)
 Chlorozylenol in alcohol, 0.5-3.75%, (e.g.
Dettol*)
*Use undiluted
17
Recommended Disinfectants
 Chlorine, 0.5% (Barkina)
 Sedex and Ghion brands contain 5% Chlorine, dilute
for use
 Glutaraldehyde, 2-4% (e.g. Cidex)
 Formaldehyde, 8%
 Hydrogen peroxide, 6%
 Soak the instrument for 20 minutes after
decontamination and cleaning
18
Management of Occupational
Exposure
Wound Care
 Gently wash wounds with soap and water (don’t
scrub vigorously)
 Allow wounds to bleed freely
 Irrigate exposed mucosal surfaces with sterile
saline
20
Post Exposure Prophylaxis
 Definition:
 Use of therapeutic agent to prevent establishment of
infection following exposure to pathogen
 Roles in Occupational Exposure:
 HIV prevention
 HBV prevention
21
HIV PEP for Occupational Exposure
 Overview





Limited data (animal)
Better to err on side of treatment
Exposed patient must be tested for HIV prior to PEP
Start immediately after exposure
Duration 28 days
22
Decision-making Tools for PEP
 Source code (SC)
 Risk assessment of the source patient
 SC 1, SC 2, SC Unknown
 Exposure code (EC)
 Risk assessment of exposure type
 EC 1, EC 2, EC 3
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Step 1: Does This Patient
Need HIV PEP?
Source patient
HIV -
HIV +
Unknown /
Unwilling to
get tested*
High background risk
No PEP
PEP
Low background risk
No PEP
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*CDC recom: usually PEP unnecessary; consider use if source patient is high risk
Step 2: Determine HIV Status Code of
Source (HIV SC)
HIV Negative
HIV Positive
Asymptomatic/high CD4
= HIV SC 1
No PEP
HIV Status Unknown
or Source Unknown
= HIV SC Unknown
Advanced disease,
primary infection or low
CD4 =HIV SC 2
25
Step 3: Type of Exposure: Determine the
Exposure Code
Exposure on
Mucous membrane or
broken skin
Determine
Volume
Few drops, short
duration,
SMALL = EC 1
Several drops/long
duration/major
blood splash
LARGE = EC 2
Exposure on
Intact Skin
No PEP
Percutaneous
Exposure
Determine Severity
Solid, superficial
Scratch
LESS SEVERE = EC 2
Hollow needle, deep
Puncture
MORE SEVERE = EC 3
26
Step 4: Determine PEP Regimen
HIV SC
EC
PEP Recommendation
1
1
PEP may not be warranted
2
1
Consider basic regimen
1
2
Recommend basic regimen
2
2
Expanded regimen recommended
1 or 2
3
Expanded regimen recommended
Unknown
If EC is 2 or 3 and a risk exists, consider PEP basic
regimen
27
Step 4: Determine PEP Regimen (2)
Exposure Type
Source Infection Status
HIV+ Class 1
HIV+ Class 2
Less Severe
Basic (2 Drugs)
Expanded (3 Drugs)
More Severe
Expanded (3 Drugs)
Expanded (3 Drugs)
 Less Severe: Solid needle, superficial injury
 More Severe: Large-bore hollow needle, deep punture,
visible blood on device, or needle used in patient's artery
or vein
 HIV Class 1: Asymptomatic or HIV RNA less than 1500
copies/ml
 HIV Class 2: Symptomatic HIV infection, AIDS, acute
seroconversion, or known high HIV RNA
28
HIV Post Exposure Prophylaxis
 2 drug regimen
 Zidovudine plus lamivudine (combivir)
 Stavudine plus Lamivudine
 Tenofovir plus lamivudine
 3 drug regimen




LPV/r or Indinivr or Nelfinavir plus NRTI backbone
Efavirez plus NRTI backbone
Consider resistance potential of source patient
Don’t use NVP (hepatotoxicity)
29
HIV PEP - When to Start
 As soon as possible!
 U.S. Public Health Service Guidelines recommends
prompt initiation of PEP (within hours of exposure),
but does not rule out consideration of PEP even if
more than 36 hours have elapsed since the exposure
 Animal data show no benefit when treatment is
delayed 24-36 hours
 Most experts use 72 hour window limit
30
The Early Stages of HIV Infection
Cell free
HIV
CD40—CD40
T-cell
Immature Dendritic
cell
Skin or
mucosa
PEP
24 hours
1.
Burst of HIV
replication
Via lymphatics or
circulation
HIV co-receptors,
CD4 + chemokine
receptor CC5
48 hours
2.
Selective of
macrophagetropic HIV
3.
Mature Dendritic
cell in regional LN
undergoes a single
replication, which
transfers HIV to Tcell
31
HIV PEP - When to Stop
 Timing is unclear
 Animal studies suggest better efficacy with 28
days of PEP when compared with shorter
duration of therapy
32
Current PEP Policy in Ethiopia
 Emphasis is on standard precautions
 Individual ART programs may access and
distribute PEP free of charge
33
Case Study 1
 27 year-old female nurse presents to OPD for
evaluation of needle stick injury 2 days ago from
a diabetic lancet
 Source patient (SP): 35 year-old male, HIV+
 Discussion:
 What do we need to know about the source patient
and exposure in order to manage this nurse?
 Would you offer her PEP? If so, which agents?
34
Additional Information
 The SP has been taking AZT/3TC/NVP (1st
regimen) for one year.
 He was WHO stage II prior to starting ART, and
is currently in good health
 The SP’s most recent CD4 count was 200; his
initial CD4 before starting ART was 180
 Viral load 2 months ago was 60,000
 How does this information influence the choice of
PEP regimen?
35
Case Study 1 - Questions





What is her risk for contracting HIV?
What factors influence this risk?
Is it too late to start PEP?
Which regimen(s) should be considered?
What follow-up should be arranged?
36
Case Study 1: PEP Options
 Source patient’s high-level viremia despite
HAART suggests that he is either not taking his
medications, or that he has developed
resistance to his regimen
 Resistance assay is not performed in Ethiopia –
therefore must reason around patterns of
anticipated resistance to SP’s regimen
 If resistance has developed, would suspect
resistance to lamivudine and zidovudine
 May have NNRTI cross resistance as well
37
Case Study 1: PEP Options
 High viral load of source patient would warrant
use of a three drug PEP regimen
 One reasonable PEP regimen: didanosine +
tenofovir + lopinavir/ritonavir
38
Case Study 2
 24 year-old dental technician splashed in the
eye during dental procedure 3 hours ago
 Source patient: 33 year-old male, co-infected
with HIV and HCV
 What else do you need to know?
39
Which Fluids are Potentially
Infectious for HIV?




Blood?
Saliva?
Sweat?
Feces?




Spinal fluid?
Pleural fluid?
Pus?
Urine?
40
Which Fluids are Potentially
Infectious for HIV? (2)




Blood
Saliva
Sweat
Feces




Spinal fluid
Pleural fluid
Pus
Urine
41
Case Study 2 – cont.
 Saliva was visibly bloody - in fact, it was mostly
blood that splashed her
 She rinsed out her eye immediately
 Source patient has never taken antiretrovirals,
has a CD4 count of “about 500” and a viral load
of 20,000 last time it was checked.
 The exposed patient is 8 weeks pregnant
42
Case Study 2 – Questions
 Discuss:
 What are your PEP recommendations?
 How does her pregnancy affect your decision
making?
43
PEP in Pregnancy
 Most antiretrovirals class B or C in pregnancy
 Antiretroviral Pregnancy Registry has not detected
increased teratogenic risk for ARVs in general, nor
specifically for AZT and 3TC, in the first trimester1
 Avoid efavirenz (anencephaly in monkeys), amprenavir
(ossification defects in rabbits), and, in late term,
indinavir (hyperbilirubinemia)
 Avoid combination d4T and ddI
 Theoretically higher risk of vertical transmission with
primary HIV infection
44
Case Study 2 - cont.
 The patient starts AZT/3TC/Nelfinavir
 3 days later she calls complaining of headache,
congestion, an itchy rash, and URI symptoms
 What further information is needed for managing this
patient?
45
Case 2 – cont.
 Exam:
 VS: T 99.0 R 14 P 78 BP 134/76
 Gen - alert, tired-appearing, no acute distress
 HEENT - hyperemic nasal mucosa with frontal sinus
tenderness; pharynx is also red
 Neck - 3 cm. left ant cervical lymph node
 Lungs, cardiac, abdomen: normal
 Neuro: normal
 Skin: urticarial rash on trunk and legs; no ulcerations
46
Case 2 – Questions
 What is the most likely diagnosis?
 How would you manage this patient?
47
Primary HIV Infection
 Flu-like or mono-like illness often accompanied
by a rash1
 Onset typically 2-6 weeks following exposure,
but high variability
 Symptoms generally resolve spontaneously in 13 wks (corresponding with VL reduction)
 Treatment of PHI with antiretroviral therapy may
have significant long-term benefit3
48
1 mil
HIV
RNA
100,000
+
_
10,000
Ab
1,000
100
HIV-1 Antibodies
HIV RNA
PHI: Diagnostic Testing
Exposure
Symptoms
10
0
7
14
21
Days
28
Image courtesy of The Center for AIDS Information & Advocacy, www.centerforaids.org
49
Could She Have Primary HIV Infection?
 Primary HIV Infection less likely
 Only three days since the exposure
 Presence of nasal congestion
 Rash is urticarial
 However, would not be unreasonable to check
an HIV viral load to rule out PHI
50
Follow-up HIV Testing
 CDC recommendations: HIV Ab testing at 6
weeks, 3 months, 6 months following exposure
 Extended HIV Ab testing at 12 months
recommended if health care worker contracts
HCV from a source patient co-infected with HIV
and HCV
 VL testing not recommended unless Primary HIV
Infection (PHI) suspected
MMWR June 29, 2001 / 50(RR11);1-42.
51
Key Points
 Standard precautions should be implemented and
practiced by all healthcare providers
 The most important infection control method is
handwashing
 Proper handling of sharps is critical for reducing
occupational exposure to blood borne pathogens
 Risk of HIV seroconversion after occupational exposure
varies depending on source patient and exposure
circumstance
 When indicated, PEP should be employed immediately
(within hours)
52