BLOOD BORNE PATHOGEN EXPOSURE Management – What you need to know about Needlesticks and Splashes - PowerPoint PPT Presentation

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BLOOD BORNE PATHOGEN EXPOSURE Management – What you need to know about Needlesticks and Splashes

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  1. BLOOD BORNE PATHOGEN EXPOSURE Management – What you need to know about Needlesticks and Splashes Amy J. Behrman, MD Occupational Medicine Dept of Emergency Medicine University of Pennsylvania

  2. EPIDEMIOLOGY OF EXPOSURES • Blood and Body Fluid Exposures (BFEs) are common • 33 events/year/100 beds in the US • Most are preventable • Assess the situation prior to procedure • Dispose of sharps safely at the bedside • Never Never Never Recap • Help your colleagues and trainees

  3. EPIDEMIOLOGY OF EXPOSURES • EXPOSURE RATES ARE HIGHEST AMONG HCW who do the most procedures • NURSES • OR STAFF • EMERGENCY DEPARTMENT STAFF • HOUSE OFFICERS

  4. HEPATITIS B • Percutaneous transmission rate 2-40% for unimmunized HCW • e Antigen correlates with viral titer and replication • Exposure to e antigen-positive or high titer blood carries highest risk

  5. HEPATITIS B • Shed in many body fluids • Multiple transmission modes • Percutaneous • Mucous Membrane/Broken Skin splash • Bite • Long Term Sequelae

  6. HEPATITIS B • Vaccine Preventable • Vaccine is safe, effective, recombinant • Available free to all HCWs per OSHA • Universally recommended (AAP) • Minimal Side Effects • >95% immune after 3 doses • Long term protection

  7. HEPATITIS B Vaccine • Follow-up testing to detect non-responders is crucial. • Booster series may be helpful. • HBIG: Post-exposure prophylaxis is effective for non-responders. • Non-responders should be evaluated for chronic HBV infection

  8. HEPATITIS C • Prevalent in many patient populations • Long term sequelae • The most common bloodborne pathogen at HUP and PMC • Shed in blood, semen, vaginal fluid • “Splash” transmission documented • Nosocomial infectivity between HBV and HIV

  9. HEPATITIS C • No Vaccine • No Post-exposure prophylaxis • Prompt Reporting and Follow-up are crucial to identify infections early • Early rx may improve outcomes in acute infection • PCR-based testing facilitates management in high-risk situations

  10. HIV • More complex exposure management • Percutaneous transmission rate .3% • Post-exposure prophylaxis (PEP) with anti-retrovirals is effective • PEP effectiveness is greatest if started early • Immediate Reporting and Prompt Follow-up is crucial to preventing infection

  11. HIV • Counseling and PEP are available 24 hours/day at HUP and PMC • Starter Packs of Anti-Retrovirals are available in EDs and OM sites • It is your responsibility to report any BFEs in person as soon as possible • It is your responsibility to facilitate reporting for trainees and colleagues • It is your responsibility to assist in source patient testing

  12. HIV • Current first-line PEP consists of Combivir or Combivir and Kaletra www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm • Modified per source status and resistances • 4 week regimen for known HIV exposures • Follow-up for toxicity • 6-9 months follow-up testing

  13. HIV • The source patient with unknown HIV status • Most common scenario • HCWs may choose to treat pending source patient test results • Usually 2 drug regimen • Source patient testing requires cooperation between Occupational Medicine and the Source Patient’s Physicians

  14. HIV • Source patient testing must be done in conformance with hospital policy and state law. • http://uphsxnet.uphs.upenn.edu/hupinfpl/inf_pdfs/appendix_practice%20guidelines.pdf • http://uphsxnet.uphs.upenn.edu/hupadmpl/1_12_33.pdf • Source patient testing is successful > 95% of the time at HUP and PMC.

  15. BBPs and HCWs • KNOW WHERE TO GO • HUP • DAYS: OCC MED – 1 SILVERSTEIN • NIGHTS/EVENINGS/WEEKENDS – ED • 215-662-2367 or 215-662-2358 • PMC DAYS: • OCC MED • NIGHTS/EVENINGS/WEEKENDS – ED • 215-662-8278 • 24 Hour Consult Coverage is available • HUP: Occupational Med On Call 215-524-8864 • PMC: Infectious DiseaseOn Call

  16. BBPs and HCWs • FOLLOW-UP IS CRUCIAL • Follow-up is based on CDC Guidelines: www.cdc.gov/mmwr/PDF/rr/rr5011.pdf www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm • Follow-up is customized for each exposure based on the BBPs involved, the likelihood of drug resistance, and the HCW medical history

  17. BBPs and HCWs • WE NEED YOUR HELP TO TEST SOURCE PATIENTS • HBV Surface Antigen and HCV Antibody • HIV Antibody (which always requires written consent from patient or proxy) • “Rapid” HIV is available when appropriate with OM approval • Requires charted source patient consent • Specimens sent directly to Microbiology Lab

  18. BBPs and HCWs - Goals • Start anti-HIV prophylaxis (PEP) within 1-2 hours if appropriate. • Occupational Medicine follow-up on next business day to ensure: • F/U Testing for HCW • F/U for Source Patient Testing • Drug safety monitoring (if appropriate) • Immunization review