Health care workers are often exposed to the blood and body fluids of HIV-infected patients or patients at high risk of harboring the HIV virus.
Emergency-department-based studies have demonstrated that substantial numbers of patients continue to have unsuspected HIV infection and that HIV seropositivity cannot be accurately predicted, even with the aid of risk factors assessment.9 Universal precautions should be practiced, and all contacts with blood or body fluids should be considered potentially infectious. Universal precautions include gloves, gown, mask, and eye protection for any situation with the potential for exposure by splash, spray, touch, puncture, or immersion. These measures are also indicated for all emergency department procedures, including examination of bleeding patients, chest tube placement, central line placement, suturing, wound care, and lumbar puncture. 32
The risk of acquiring HIV through occupational exposure is low. The likelihood of contracting AIDS after a parenteral exposure has been estimated at 0.32 percent; for mucocutaneous exposure, risk is considered to be at least one-tenth of that. Approximately 80 percent of documented occupational exposure cases have resulted from hollow-bore needle-stick injuries. As of December 1997, the CDC had documented 54 cases of HIV seroconversion following occupational exposure.
Guidelines for PEP of health care workers following an occupational exposure are based on a recent case-control study of needle-stick injuries from an HIV-infected source (which included 33 cases who seroconverted and 739 control subjects). This study reported that AZT prophylaxis was associated with a 79 percent reduction in disease transmission.33 PEP recommendations for health workers are based on exposure category, and PEP should be administered in consultation with an infectious disease specialist. The highest-risk injuries are deep punctures and injuries caused by large-bore hollow needles. PEP should be initiated as quickly as possible, preferably within 1 to 2 h. The interval after which there is no benefit for starting PEP is not known, although animal studies suggest little benefit if started 24-36 hours after exposure. Antiretroviral therapy can be given for patients presenting more than 36 h after exposure, depending on the risk of transmission. Treatment regimens vary by type of exposure. All include AZT and lamivudine (3TC); indinavir (Crixivan) or nelfinavir (Viracept) is added for high-risk exposures. PEP should probably be given for 4 weeks. However, GI and constitutional side effects can be considerable.
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