A 36-year-old woman comes to the emergency department due to 4 weeks of weight gain, shortness of breath, and headaches. Her symptoms have become progressively more severe, and now she has shortness of breath with mild activity. The patient has had HIV for several years but refused antiretroviral treatment until recently. Her most recent CD4 count was 220/mm³. The patient smokes a pack of cigarettes daily and drinks 2 or 3 beers most evenings. She has a history of intravenous heroin use but quit several years ago. Temperature is 36.8 C (98.2 F), blood pressure is 184/100 mm Hg, pulse is 78/min, and respirations are 14/min. Physical examination shows moist mucous membranes, rales at the bilateral lung bases, and normal first and second heart sounds. The abdomen is soft and nontender. Anasarca is present. The remainder of the examination is normal. A urine sample appears cloudy on gross inspection. Laboratory results are as follows: During preparation for the microscopic examination of the patient's urine, the laboratory technician inadvertently splashes a small amount of urine into her eye. Besides generously flushing the technician's eyes with water, what is the most appropriate next step in management of this occupational exposure?

Question

Quizplus · Accepted Answer

Explanation: The transmission of HIV to health care personnel (HCP) is rare; fewer than 100 confirmed cases have been documented in the United States since the beginning of the epidemic. However, all potential exposures should be evaluated to determine whether postexposure prophylaxis (PEP) with 3-drug antiretroviral therapy is required. Generally, PEP is offered to patients with any risk of occupational transmission as guided by exposure type and body fluid involved. HCP with the following occupational exposures are at risk for acquiring HIV: Percutaneous injury from a contaminated needlestick or sharp object (eg, scalpel) Mucous membrane (eg, eyes) or nonintact skin exposure to infected body fluids However, these exposure types put HCP at risk only when the following fluids are involved: High risk: Blood, fluids contaminated with visible blood, semen, and vaginal secretions Possible risk: Cerebrospinal, synovial, pleural, pericardial, and amniotic fluids Body fluids such as urine, feces, tears, and vomitus are considered noninfectious if no visible blood is present. This laboratory technician had a mucous membrane exposure putting her at risk of acquiring HIV. However, she was exposed to a body fluid (urine with no red blood cells) that is considered noninfectious. As such, she does not require PEP; treatment with eye irrigation, counseling, and reassurance is sufficient. (Choice B) This patient on antiretroviral therapy likely has a suppressed viral load, which reduces the risk of transmission. However, the source patient's viral load does not influence the need for PEP. In addition, PEP should not be delayed for laboratory testing in patients who require it; PEP is most effective if initiated within 1-2 hours of exposure. (Choices C, D, and E) Most PEP recommendations involve 3-drug antiretroviral therapy for 4 weeks. Monotherapy and more extended treatment are not advised. This patient with nonbloody urine exposure to her eyes does not require PEP. Educational objective: The occupational transmission of HIV to healthcare personnel can occur during percutaneous, mucous membrane, or nonintact skin exposure to an HIV-infected body fluid. The body fluids at highest risk are blood and fluids with visible blood. Nonbloody urine, feces, vomitus, and tears are considered noninfectious; exposure to these fluids does not require postexposure prophylaxis.

A 36-Year-Old Woman Comes to the Emergency Department Due to 4