วันพุธที่ 11 กรกฎาคม พ.ศ. 2555

Occupational HIV/HBV/HCV exposure

ประเมิน risk 2 อย่างดังนี้

Risk for HIV infection: percutaneous injury (0.3%), contact of mucous membrane (0.09%) with blood, tissue, body fluids (CSF, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, amniotic fluid); not include feces, nasal secretions, saliva, sputum, sweat, tears, urine, vomitus

Risk of seroconversion: symptomatic HIV, AIDS, acute seroconversion, known high viral load(>1500 copies/ml), large-bore hollow needle, deep puncture, visible blood on device, needle used in patient’s artery/vein

Investigation:

Source: AntiHIV, HBsAg, AntiHCV; CD4 count, HIV viral load

Exposure: AntiHIV (0, 6wk, 12wk, 6mt), HBsAg, AntiHBs, AntiHCV(0, 4-6mt), HCV RNA (4-6wk)(not recommended direct viral assey: HIVp24 antigen, HIV riboneucleic acid); CBC, BUN, Cr, ALT, UPT, BS if on PI, UA + LDH if on IDV (0, q 2wk)

Management

1. HIV exposure: evaluate risk and start PEP within 1-2 hr

Percutaneous exposure: > 3 drug regimen; 2 drug regimen in low risk of seroconversion; no PEP or consider 2 drug regimen (if HIV-infected is likely) in unknown source/unknown HIV status

Mucous membrane or nonintact skin exposure: 2 drug regimen; 3 drug regimen in large volume + risk of seroconversion; no PEP or 2 drug regimen (if HIV-infected is likely) in unknown source/unknown HIV status with large volume

Basic regimen
• AZT + 3TC(Combivir) or FTC
• TDF + 3TC or FTC (Truvada)
• 3TC + d4T or ddI
• FTC + d4T or ddI

Expanded regimen add
• Lopinavir/ritonavir (Kaletra®; LPV/RTV)
• Atazanavir (Reyataz®; ATV) + ritonavir
• Fosamprenavir (Lexiva®; FOSAPV) +/- ritonavir
• Indinavir (Crixivan®; IDV) +/- ritonavir
• Saquinavir (Invirase®; SQV) + ritonavir
• Nelfinavir (Viracept®; NFV)
• Efavirenz (Sustiva®; EFV) if PI resistance is suspected

Dosing
 AZT(Zidovudine)(100,300): 300 mg bid/200 mg tid, with food
 3TC(Lamivudine)(150,300): 300 mg od/150 mg bid
 Combivir(300/150): one tablet twice daily
 FTC(emtricitabine): 200 mg (one capsule) od
 d4T(Stavudine) 40mg bid
 ddI(Didanosine) 200 mg bid/400 mg od for >60 kg and 125 mg bid/250 mg od if < 60 kg on empty stomach
 LPV/RTV: 400/100 mg = 3 capsules bid with food
 EFV 600 mg od hs

**Drug interaction with PI(-navir): rifampicin, BZD, -statin, ergot derivative, pimozide, fluticasone, St. john’s wort, garlic

**Drug interaction with EFV: voriconazole, BZD, ergot derivative, cisapride, St. john’s wort, garlic

Expert consultation esp.delayed (> 24–36 hours) exposure report, unknown source, known/suspected pregnancy, breastfeeding, resistance of the source virus to antiretroviral agents, toxicity of the initial PEP regimen

2. HBIG (0.06 ml /kg IM) + vaccination if known source HBV infected or high risk source + unvaccinated or nonresponser (AntiHBs < 10 mIU/mL) HBV vaccine; vaccine booster in unknown response HBV vaccine + unknown source; repeat AntiHBs 1-2 mo after last dose of vaccine

3. HCV: PEP not recommended, advise for prevent 2nd transmission

Disposition:

• Advised to prevent secondary transmission, especially during the first 6–12 weeks postexposure

• Informed regarding possible drug toxicities, possible drug interactions

• F/U in 72 hours postexposure, esp. after additional information about the exposure or source person becomes available

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