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Virology > Post-exposure prophylaxis > Flashcards

Post-exposure prophylaxis Flashcards

1
Q

When talking of BBV, what viruses are common in UK?

A

HBV
HCV
HIV

Technically any virus including HTLV, WNV could be transmitted

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2
Q

BBVs spread through contact with blood and other body fluids, such as semen and
breast milk. Unless there is blood contamination there is no, or very low, risk (depending
on the virus) from contact with saliva, sweat, urine, faeces, vomit or sputum.

What are methods of transmission of BBVs?

A

sharps - needles/ accidental

sexual

open wounds/ splashing mucus membranes/ human bites - less common

Whether contact will lead to viral transmission depends on:

  • route of exposure,
  • the type of virus
  • how much of the virus the carrier has in their body
  • immune status of the exposed person
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3
Q

What is risk of HBV transmission through the following injuries:

puncture injury

bite

splashing

A

puncture injury - up to 30%

bite - limited cases, evidence suggests low risk

splashing - limited cases, lower risk than puncture injury/ bite. Even lower risk if it is saliva/ urine, as lower viral load

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4
Q

What is risk of HCV transmission through the following injuries:

puncture injury

bite

splashing

A

puncture injury - 1%-3%

bite - limited cases, evidence suggests low risk

splashing - limited cases, lower risk than puncture injury/ bite. No history of cases of transmission with saliva/ urine

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5
Q

What is risk of HIV transmission through the following injuries:

puncture injury

bite

splashing

A

puncture injury - 0.3%

bite - no previous cases

splashing - 0.1% if splash blood onto open wound. No evidence of salivary transmission

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6
Q

What should healthcare workers do to reduce risk of needlestick?

A

PPE
Clean up body fluids
Cover breaks in skin
Vaccination - HBV

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7
Q

After needlestick, what is next step in first aid?

A

Bleed/ wash/ cover wound

Inform line manager

If a bite - need to consider other infections (not BBV)

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8
Q

Following needlestick, risk assessment must be carried out by A+E/ occupational health.

What is risk assessment based on?

Injury
Source
Recipient

A

Percutaneous -

  • Needle gauge
  • Superficial/ deep injury
  • Contaminated fresh blood present
  • Gloves worn - single/ double

Mucocutaneous -

  • area of exposure
  • skin breaks
  • cotaminated fresh blood present
  • approx volume of blood

Source -
BBV staus
viral load if on treatment

Recipient -
HBV vaccination status
Medical conditions including pregnancy

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9
Q

If deemed low risk - then to contact occupational health at earliest opportunity.

Following high-risk needlestick (bites, puncture). baseline tests are taken for storage. This can later be tested for BBV serology from patient, if source found to be positive.

HBV Ag
HCV Ab
HIV Ag/ Ab
Select blood and body fluid exposure on ICE.

Requires consent form from patient.
If not willing to consent - inform Workplace Health and Wellbeing.
If unable to consent, can complete consent form in patients best interests

What post-exposure prophylaxis may given?

A

HBV immunisation - given within 24 hours usually. Effective up to 7 days.
Give dose at day zero, 1 month, 2 months if not previously vaccinated. May need booster at 12 months.
Previously vaccinated - give booster dose if last dose >1 year ago

HBIG can be given in rare cases, if patient is known to be non-responder to previous vaccine

HIV PEP (truvada + raltegravir) can be given within 72 hours, but usually only under specialist advice if high risk e.g if there has been significant trauma/ blood contamination

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10
Q

Following high-risk needlestick injury, what advice is given to patient

A

Offer counselling/ time off work

Avoid blood donation/ sex

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11
Q

After high risk needlestick, and initial tests are negative for BBV transmission, when is next testing done?

A

4- 6 weeks
HBsAg
HepC RNA
HIV Ag/Ab test

3 months
HBsAg
HepC Ab - add Ag/ PCR if high risk
HIV Ag/Ab test - if negative no further testing

6 months
HBsAg
HepC Ab

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12
Q

NNUH needlestick policy.

Immediate management - bleed/ wash/ cover
Report to person in charge - datix

What is next step?

A

0830-1700 contact Workplace Health and Wellbeing

Out of hours - contact site manager.
High risk - refer A+E
Low risk - wait to refer to Workplace Health and Wellbeing

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13
Q

NNUH needlestick policy.

Immediate management - bleed/ wash/ cover

Report to person in charge - datix

Contact Workplace Health and Wellbeing/ A+E depending on time of incident

What is next step?

A

If low risk - Workplace Health and Wellbeing at earliest opportunity

If high risk - assess if needs HBV/ HIV prophylaxis.

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14
Q

NNUH needlestick policy.

Immediate management - bleed/ wash/ cover

Report to person in charge - datix

Contact Workplace Health and Wellbeing/ A+E depending on time of incident

Assess if prophylaxis required.

What is next step?

A

Follow up

Staff member -
- follow up with Workplace Health and Wellbeing

If not a patient/ staff member -

  • follow up with employer occupational health
  • their occupational health can contact NNUH Workplace Health and Wellbeing

Give advice about blood donation/ sex

Offer counselling

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15
Q

HIV post-exposure prophylaxis.

When is PEP indicated?

A

Not recommended

  • HIV negative/ low risk source
  • if exposed to non-infectious body fluids - urine, vomit, saliva & faeces which are not visibly blood stained
  • blood exposure on unbroken skin
  • bite causing broken skin
  • high risk blood exposure, with no HIV history
  • HIV positive on ART - if viral RNA <200

Recommended

  • blood exposure in confirmed HIV unless viral RNA <200 (including blood on mucocutaneous surface)
  • blood exposure in high risk HIV - e.g IVDU, MSM, sex workers, African

PEP not given lightly due to side effects

If patient <16 or pregnant, then discuss with paeds/ gynaecology

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16
Q

What drugs are included in HIV PEP?

A

Taken for 28 days

Turvada (tenofovir 300mg/ emtricitabine 200mg) one tablet OD

Raltegravir 400mg, one tablet BD

17
Q

HBV post-exposure prophylaxis.

Non-significant exposure, with ongoing risk

  • Unvaccinated
  • Partially vaccinated
  • Fully vaccinated
  • Vaccine non-responder (anti-HBs <10mIU/ml 2 months after innoculation)
A
  • Unvaccinated - initiate HepB vaccination
  • Partially vaccinated - complete HepB vaccination
  • Fully vaccinated - reassure, no prophlyaxis
  • Vaccine non-responder - consider HepB booster, no HBIG
18
Q

HBV post-exposure prophylaxis.

Significant exposure, source negative

  • Unvaccinated
  • Partially vaccinated
  • Fully vaccinated
  • Vaccine non-responder (anti-HBs <10mIU/ml 2 months after innoculation)
A
  • Unvaccinated- consider HepB vaccine
  • Partially vaccinated - complete course Hep B vaccine
  • Fully vaccinated - reassure, no prophylaxis
  • Vaccine non-responder - consider HepB booster, no HBIG
19
Q

HBV post-exposure prophylaxis.

Significant exposure, source HBV positive

  • Unvaccinated
  • Partially vaccinated
  • Fully vaccinated
  • Vaccine non-responder (anti-HBs <10mIU/ml 2 months after innoculation)
A
  • Unvaccinated - HepB accelerated course, plus HBIG with first dose
  • Partially vaccinated - one dose of HepB vaccine and complete course
  • Fully vaccinated - one dose HepB vaccine if last dose >1 year ago
  • Vaccine non-responder - one dose of HepB vaccine, HBIG at first dose, then one month later
20
Q

HBV post-exposure prophylaxis.

Significant exposure, source HBV status unknown.
Very similar to HBV positive treatment

  • Unvaccinated
  • Partially vaccinated
  • Fully vaccinated
  • Vaccine non-responder (anti-HBs <10mIU/ml 2 months after innoculation)
A
  • Unvaccinated - HepB accelerated course (no HBIG)
  • Partially vaccinated - one dose of HepB vaccine and complete course
  • Fully vaccinated - one dose HepB vaccine if last dose >1 year ago
  • Vaccine non-responder - one dose of HepB vaccine, HBIG at first dose, then one month later
21
Q

What are side effects of HIV PEP?

A

Diarrhoeal illness - offer loperamide/ domperidone

Serious -
Convulsions
Hepatitis
Liver failure
Bone marrow failure
22
Q

Which diseases have immunoglobulin available as PEP?

A

HAV - within 14 days of contact

HBV - within 4 days of contact

Measles - within 6 days of contact

Rabies - to wound ASAP

Varicella - within 10 days of contact

Clostridium tetani - ASAP

Clostridium botulism - anti-toxin

Corynebacteroum diptheria - anti-toxin

HBIG/ VZIG/ HRIG/ HTIG have specific pooled immunoglobulin.

Other more common infections e.g measles/ HAV, normal human immunoglobulin will have high enough antibodies to provide protection

23
Q

Antimicrobials can be used as PEP in certain conditions

What is PEP for these conditions?

GAS

TB

Varicella

A

GAS - Household contacts

  • Pen V 10 days
  • Azithromycin 3 days

TB - rifampicin/ isoniazid 3 months

Varicella - Household contact who is immunosuppressed/ pregnant and not eligble VZIG. aciclovir from day 10 of contact until day 21

24
Q

Antimicrobials can be used as PEP in certain conditions

What is PEP for these conditions?

Bordetella pertussis

Influenza A+B

Meningococcal

A

Bordetella pertussis - Household contacts. azithromycin/ clarithromycin

Influenza A+B - oseltamavir/ zanamivir 10 days

Meningococcal - Household contacts

  • ciprofloxacin single dose
  • rifampicin 2 days
  • azithroymcin single dose
  • ceftriaxone single dose
25
Q

28 week pregnant exposed to child who developed chickenpox 2 days ago. No previous history of chickenpox. VZ IgG shows 90mIU/ml

What is next step in management

A

Cut off is 100mIU/ml pregnant patient
150 mIU/ml immunosupressed patient

Aciclovir 800mg 4x for days 7-14

26
Q

Student in Thailand bitten by stray dog. Not previously immunised against rabies. Returns UK two days later with healing wound

What is next step in management when returns to UK

A

Administer rabies immunoglobulin to wound, and give second dose of rabies of vaccination

Rabies vaccination schedule day 0, 3, 7, 21 if never had before

Routine rabies vaccination schedule at days 0, 7, 28

27
Q

Unbooked pregnant woman presents in advanced labour.

What is most important blood test?

A

HIV Ag/Ab
HBsAg

They both have time dependent treatments -

ART needs given intrapartum to reduce risk transmission
HIV will need C-section

HBV vaccine needs given to child within 24 hours
HBIG needs given ASAP if mother high infectivity

28
Q

How soon does HBIG need to be given if indicated?

A

ASAP

Up to 7 days in green book

29
Q

Source patient is HIV positive, involved in mucosal splash injury

Which body fluids are not considered infectious?

A

Fluids that are not considered infectious (unless they contain blood)

faeces
nasal secretions
saliva
gastric secretions
sputum
sweat
tears
urine
vomit

30
Q

Body fluids implicated in the transmission of HIV are: blood, semen, vaginal secretions and other body fluids contaminated with visible blood.

What other body fluids are considered potentially infectious?

A

Other body fluids that could be potentially infectious are

cerebrospinal fluid
synovial
pleural
peritoneal
pericardial
amniotic fluid

Virology (56 decks)

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