From: Dr. A. R. Pazare
Date: 22 May 2008
Time: 12:28 PM +0530
Post Exposure Prophylaxis
Protocol at KEM hospital: Dr. A. R. Pazare
Professor of medicine
• Put finger under running water • Wash injured part with soap & water
• Never squeeze
• Wash mucous membrane with saline
• Report immediately to MICU & he will receive 2 days medicine
• Take PEP drugs irrespective of patients status
• Report next day to ART center (Room no. 222, 2nd floor main hospital building) for further management
• Detailed history form will be filled at Medicine dept.
• Basal Elisa of HCW is advised.
• HCW also advised to convinced for sending Elisa of the patients
• After assessment
basic regime (Stavudine + lamivudine) or expanded regime (Basic +
efavirenz) advised. When Efavirenz is not tolerated then Indinavir is advised.
• Drugs are continued for 28 days.
• HCW is advised to get his 3 month & 9 month follow up Elisa
Rationale for PEP:
There is a 0.3% risk of transmission of HIV after percutaneous exposure
to HIV infected blood. (Bell, Am J. Med 1997) While risk after mucus
membrane exposure is 0.09% (Ippolito, Arch int Med 1993). Risk due to
contact with non-intact skin is less than mucus membrane exposure.
(Fahey, Am J. Med 1991) And risk due to fluid or tissue other than HIV
infected blood is less than blood exposure. (Henderson Ann Int med
1990). Till now 56 definite & 138 possible HCWs became positive
after occupational exposure. (CDC,2000 report)
All HIV exposure will not cause infection. CTL response seen in
most persons may be taken as exposure marker & AZT blunts CTL
response & hence it might inhibit early HIV infection. (D’Amico,
ICHE 1999)
Tenofovir administered 48 hrs before, 4 hrs after & at 24
hrs in SIV inoculated macaque & continued for 4 weeks. Non of
animal turned positive when drug was administered 48 hrs before, 4 hrs
after exposure. All animals turned positive when drug was not given or
started after 24 hrs. Few animals turned positive when drug was given
for 3- 10 days only (Tsai J.virol 1998). Human studies: AZT reduces
MTCT by 67%. (Sperling, NEJM 1996) AZT + 3TC before delivery reduces
MTCT by 50% at labour by 37% (Saba J. CDC 1999)
Type of injury: • Pinprick • Scalpel injury • Mucus membrane exposure • Skin
contact (hands & face) • Sexual exposure
High viral load
Low Viral load
• Frank blood
• Bloody fluid
• Semen
• Vaginal secretion
• CSF
• Amniotic fluid • Stool
• Saliva
• Milk
• Sweats
• Tears
• Urine
HCWs exposed to the secretions containing high viral load must
received PEP & PEP may be deferred in HCWs exposed to the
secretions containing low viral load.
When to start:
It should be started as early as possible & Preferably within 1
hrs. Benefit may be given up to 72 hrs. There is no use of PEP after 72
hrs. It may be given to HCWs who received exposure form HIV positive
patients or from the patients whose HIV status not known. There is
debate about staring PEP in HCWs who has exposure form HIV negative
patients.
Basic Regime:
1. Stavudine +Lamivudine
2. AZT +Lamivudine
3. DDI+ Stavudine
Regime-1 Stavudine 30 mg (when weight of HCW < 60 kg) or 40
mg (when weight of HCW > 60 kg) + lamivudine 150mg BD for 4 weeks
Advantage
Disadvantage
• Well tolerated
• Good adherence
• Least toxic
• BD doses • ? Teratogenecity
• Source patient virus may be resistant
Regime-2 -AZT300mg + lamivudine + 150mg BD for 4 weeks
Advantage
Disadvantage
• Extensively used
• Control trials available
• No serious side effect
• Side effect are manageable
• safe in pregnancy • Anemia & GI upset is common
• ? Teratogenecity
• Source patient virus may be resistant
Regime-3 - Stavudine 30/40mg BD+ DDI 250 mg (when weight of HCW
< 60 kg) & 400mg (when weight of HCW > 60 kg) OD for 4 weeks
Advantage
Disadvantage
• Effective
• Less chance of resistance • Unpalatable
• Serious side effect like Pancreatitis (fatal)
• Low adherence
• ? Teratogenecity
• Interfere with absorption of other drugs
Expanded regimes: This regime is given to the HCW who got bold
pinprick from HIV positive or strongly suspected HIV positive patient.
Blood from Positive or suspected positive patients expose to mucus
membrane of HCWs then also expanded regime is advised. Any drug from
expanded group is added to regime 1 to 3
NRTI & NNRTI
Protease Inhibitors (PI)
• Abicavir • Delavirdine
• Efavirenz • Indinavir(PI)
• Nelfinavir(PI)
• Ritonavir (PI)
• Saquinavir (PI)
• Amprenavir (PI)
• Lopinavir/Ritonavir (PI)
NEVIRAPINE IS NOT ADVISED AS PEP BECAUSE IT CAN CAUSE SEVERE HEPATITIS WHOSE CD4 COUNT IS NORMAL.
Efavirenz : It is preferred due to single night dose (600mg)
hence has a good adherence. It has some side effect in the form of
Insomnia, Dizziness Steven-Johnson syndrome & teratogenecity.
Dizziness is sometimes troublesome & may hamper day activity.
PI- (almost all PI but we prefer Indinavir): It is a Potent HIV
inhibitor but has large pill load & have serious side effects like
Neprolithiasis, Teratogenecity or Drug interaction.
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