A 24-year-old health care worker comes to the employee health clinic due to a needlestick injury. He sustained a percutaneous injury while drawing blood from an HIV-positive patient. The source patient's most recent CD4 count is 90/µL and viral load is 300,000 copies/mL. What is the most appropriate next step in management of the health care worker's exposure to HIV?

Question

A 24-year-old health care worker comes to the employee health clinic due to a needlestick injury.  He sustained a percutaneous injury while drawing blood from an HIV-positive patient.  The source patient's most recent CD4 count is 90/µL and viral load is 300,000 copies/mL.  What is the most appropriate next step in management of the health care worker's exposure to HIV?

Quizplus · Accepted Answer

11ec25c8_d1b2_9064_bc81_21c22a10e678_MD0003_00 The risk of HIV seroconversion following occupational needlestick exposure is low (<0.5%) and is seen primarily with hollow-bore (eg, phlebotomy) as opposed to solid (eg, suture) needle use. Nevertheless, HIV post-exposure prophylaxis (PEP) is recommended following any exposure to blood or potentially contaminated body fluids from an HIV-positive source patient via percutaneous exposure or exposure to mucous membranes or nonintact skin. If the HIV status of the source patient is unknown but the patient has risk factors for HIV, prophylactic therapy should be initiated while awaiting results of HIV testing. The exposed health care worker should have HIV testing immediately to establish baseline serologic status; testing should be repeated at 6 weeks, 3 months, and 6 months. In addition to obtaining baseline serological studies, PEP should be started urgently, preferably in the first few hours following exposure (Choice D). If possible, workers should be relieved of duties immediately to initiate PEP (eg, operating room personnel should scrub out of the procedure). Standard PEP consists of triple-drug therapy (Table) (Choice C). Tenofovir-emtricitabine with raltegravir is preferred due to a low side effect profile and few drug-to-drug interactions. PEP should be continued for 4 weeks. (Choice A) PEP must be initiated as soon as possible and should not await the results of HIV serology. If the exposed worker's baseline HIV test is positive, suggesting established infection, the decision to continue PEP may be revisited at that time. (Choice E) Knowing drug resistance of the source strain may be helpful for PEP drug selection. However, PEP is most effective when started as soon as possible and should not be delayed for resistance testing. Educational objective: Postexposure HIV prophylaxis with 3-drug antiretroviral therapy for 4 weeks is recommended following high-risk occupational exposure to blood or body fluids from an HIV-infected individual. Therapy should be started as soon as possible, preferably in the first few hours. References: Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. (http://www.ncbi.nlm.nih.gov/pubmed/23917901)

A 24-Year-Old Health Care Worker Comes to the Employee Health