A 51-year-old executive with a history of cocaine abuse and peptic ulcer disease is scheduled to undergo a routine colonoscopy at an outpatient surgical center. While preparing for the procedure, a staff nurse accidentally suffers a needlestick injury while placing an intravenous peripheral line on the patient. The physician in charge of the case notifies the appropriate administrators and orders immediate laboratory testing for infectious disease, including HIV and hepatitis B and C. When informed, the patient becomes very upset and refuses to give blood for testing as he does not want to be tested for HIV. He insists that he is at very low risk and testing would be unnecessary. Which of the following would be the most appropriate next step?

Question

A 51-year-old executive with a history of cocaine abuse and peptic ulcer disease is scheduled to undergo a routine colonoscopy at an outpatient surgical center.  While preparing for the procedure, a staff nurse accidentally suffers a needlestick injury while placing an intravenous peripheral line on the patient.  The physician in charge of the case notifies the appropriate administrators and orders immediate laboratory testing for infectious disease, including HIV and hepatitis B and C.  When informed, the patient becomes very upset and refuses to give blood for testing as he does not want to be tested for HIV.  He insists that he is at very low risk and testing would be unnecessary.  Which of the following would be the most appropriate next step?

Quizplus · Accepted Answer

Explanation: HIV testing is a highly sensitive issue for many patients. In cases involving occupational exposure of a health care worker (via needlestick or other means), patients should undergo HIV testing to protect the health of the exposed individual. When patients refuse HIV testing, physicians must make decisions in the absence of information. Laws regulating whether a patient can be tested for HIV without consent following occupational exposure vary depending on location. HIV post-exposure prophylaxis should be implemented as the immediate first step when the patient refuses testing, testing results are pending, or HIV status of the patient is unknown. HIV post-exposure prophylaxis consists of 2 or 3 antiretroviral medications. It significantly decreases the rate of transmission following exposure and should be implemented immediately following suspected exposure, as efficacy decreases over the course of hours. HIV prophylaxis can be discontinued following receipt of a negative test result from the source patient, but it must be continued if the patient continues to decline testing. (Choices A and D) Although monitoring and serial testing of the nurse and interviewing the patient regarding his potential risk factors would be helpful, the most important next step involves initiating post-exposure prophylaxis immediately to reduce the risk of HIV transmission. (Choice C) Although testing following occupational exposure is strongly recommended, laws are inconsistent regarding testing a patient against his/her will. (Choice E) Offering the patient the option to be tested without knowing the results creates further ethical dilemmas for the physician as the patient may unknowingly infect other contacts if unaware of HIV status. This option also further delays post-exposure prophylaxis. Educational objective: Testing a patient for HIV following an occupational exposure is highly recommended to avoid unnecessary HIV prophylaxis. When a patient refuses testing following occupational exposure, the first step is to administer HIV post-exposure prophylaxis medication to the health care worker immediately. References: Unconsented HIV testing in cases of occupational exposure: ethics, law, and policy. (http://www.ncbi.nlm.nih.gov/pubmed/22994417) Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. (CDC statement 2013 http://stacks.cdc.gov/view/cdc/20711) (http://www.ncbi.nlm.nih.gov/pubmed/16195697)

A 51-Year-Old Executive with a History of Cocaine Abuse and Peptic