Cases from the PEPline A

1
Cases from the PEPline A

• Male paramedic splashed with large volume of
  bloody amniotic fluid onto open ulcers on his
  arms. Washed arms approximately one hour later.
  He has diabetes, hypertension, hyperlipidemia,
  GERD, peripheral neuropathy and history of kidney
  stones.
• Source is HIV without any treatment during this
  pregnancy.
• Paramedic started on AZT, 3TC and indinavir.Two
  days later he complains of overwhelming nausea
  and vomiting.

2
Cases from the PEPline A

• Assess injury Large volume exposure to skin with
  compromised integrity.
• Assess source Known HIV, likely Class II (high
  viral load), but virus also likely wild-type.
• Recommend management Manage symptoms using
  anti-emetics and consider pro-motility agent for
  diabetic gastroparesis. Consider other regimens
  AZT/3TC (wild type virus in source),
  AZT/3TC/Nelfinavir, AZT/3TC/RTV/SQV, AZT/3TC/EFV.
  Consider drug interactions.

3
Cases from the PEPline - B

• Doctor stuck with needle used to inject
  lidocaine. Not visibly bloody, superficial stick.
  Concern about pus on the needle.
• Source patient denied any risks, married for
  20yrs, rural area of the Northeast.
• Rapid HIV test (SUDS) run immediately showed
  positive result

4
Cases from the PEPline - B

• Doctor started promptly on AZT, 3TC and
  indinavir, but complained of severe nausea and
  vomiting and had family history of kidney stones.
  
• Three days later, source patient Hepatitis B and
  C serologies both came back positive.Western Blot
  confirmation of HIV ELISA still pending.

5
Cases from the PEPline - B

• Assess injury Less severe
• Assess source Potentially HIV, although
  asymptomatic and virus likely wild-type.
• Recommend management Continue PEP, but consider
  stopping indinavir, or changing to nelfinavir,
  especially if toxicity limits ability to complete
  regimen.

6
Cases from the PEPline - B

• Follow-up
• Doctor completed 28 day course of AZT, 3TC and
  indinavir.
• Significant side effects included nausea, fatigue
  and acute anemia (Hgb 8), but no kidney stones.
• 6 week follow up serologies all negative.
• Source patient Western Blot positive, viral load
  50,000.

7
Cases from the PEPline - C

• Medical resident called the PEPline in the middle
  of the night unable to sleep.
• She had had a needlestick 6 weeks earlier while
  inserting an IV into a pregnant woman who was
  HIV- early in pregnancy and HIV- after the
  exposure.

8
Cases from the PEPline - C

• Assess injury More severe.
• Assess source Not HIV infected.
• Recommend management Manage emotional crisis
  normalize her reaction, help identify fears,
  clarify difference between rational concern and
  fear-driven anxiety, strategize about getting
  support.

9
Cases from the PEPline-D

• Nurse stuck with a needle found on the floor of a
  patients room. Threw the needle away before she
  looked at it carefully.
• Patient in that room is HIV infected with VL
  gt750,000. He had complex ARV hx, marked with lots
  of non-adherence. His current regimen was
  Combivir, efavirenz.
• Nurse was started on Combivir, nevirapine.
• Nurses husband (in infectious disease)
  recommended changing to AZT, d4T and Kaletra.

10
D, continued

• Assess injury No characteristics of the needle
  available. Stick not deep.
• Assess source Unknown source. Consider how
  likely it is that needle came from HIV source.
• Recommend management If it is likely that this
  needle was used on an HIV patient recently, a
  full course of PEP is recommended, with choice of
  drugs taking into account possible resistance.
  Kaletra may maintain activity against resistant
  virus, but AZT and d4T not recommended in
  combination because of clinical and in vitro
  antagonism.

11
Cases from the PEPline -E

• A pathologist stuck while suturing the body of a
  person who died 24 hr ago. Stick superficial and
  needle not visible bloody.
• The source died of lymphoma, nothing else is
  known about him.
• The MDs Hep B Sab titers were lt10 two years after
  vaccination.

12
Cases from the PEPline - E

• Assess injury Less severe.
• Assess source HIV status unknown. No known risk
  factors. HIV can be recovered from cadavers, but
  infectiousness not characterized.
• Recommend management Consider 2 drug PEP,
  toxicities may outweigh benefits. HBV booster now
  and recheck titers.

13
Cases from the PEPline - F

• Nurse stuck with catheter used to insert IV for
  woman in labor. Stick was deep.
• Source is known Hepatitis B S Ag and Hepatitis C
  infected.
• Nurse is in good health with adequate Hepatitis B
  titers.

14
Cases from the PEPline - F

• Assess injury high risk
• Assess source high risk based on history of IV
  drug use and known BBP infection.
• Recommend management Offer PEP for HIV, but
  benefits probably outweigh toxicities. Two drugs
  likely adequate, since source virus would be wild
  type. Follow closely for HCV. RN is HBV protected.

15
Cases from the PEPline - G

• Resident stuck superficially with suture needle
  in the OR. Needle not bloody. She is 8 wks
  pregnant.
• Source known HIV, not on meds. Died of GI bleed,
  cause not HIV related. VL and CD4 unknown.

16
Cases from the PEPline - G

• Assess injury Low risk
• Assess source Thought to be asymptomatic from
  HIV (Class I), but VL unknown. Virus likely wild
  type.
• Recommend management Recommend 2 drug HIV PEP,
  consider a third drug. Include counseling about
  risks of ARVs and HIV seroconversion in pregnancy.

17
Cases from the PEPline - H

• Medical student administering PPD got superficial
  stick. She is 18 wks pregnant.
• Source is homeless crack-cocaine user. Tested
  HIV- 2 months ago.
• Student started on AZT, 3TC, nelfinavir.

18
Cases from the PEPline - H

• Assess injury Less severe
• Assess source Recently HIV-, but may have
  ongoing risk behavior.
• Recommend management Consider 2 drug HIV PEP,
  consider no PEP.

19
Cases from the PEPline - I

• Nurse in pediatrics practice stuck with needle
  from immunization room sharps box. Needle not
  visibly bloody, stick superficial.
• No known HIV patients in practice. Last
  immunizations done the day before.
• Nurse is 13 weeks pregnant.

20
Cases from the PEPline - I

• Assess injury Less severe
• Assess source Statistically very unlikely to be
  a needle from an HIV source. At least 12 hours
  since use.
• Recommend management Given low risk nature of
  the exposure, improbability of viable HIV in
  needle, and pregnancy of HCW, PEP probably not
  warranted.

21
Cases from the PEPline - J

• Phlebotomist stuck with vacutainer needle while
  transferring blood. Wearing gloves. Deep stick.
• Source is HIV, and Hepatitis C . Started on
  AZT, ddI and nelfinavir one month ago when VL
  lt750,000 and CD4 73. His doctor thinks adherence
  is good.
• Three months before starting new regimen,
  genotype while on d4T, 3TC, efavirenz had shown
  resistance to 3TC, all NNRTIs.

22
Cases from the PEPline - J

• Assess injury More severe
• Assess source Probably Class II, with resistant
  virus.
• Recommend management Recommend expanded (3 drug)
  regimen for HIV PEP. 3TC likely ineffective.
  Protease inhibitor resistance unlikely to have
  developed during one month of therapy. Consider
  AZT, ddI, nelfinavir (same as source regimen), as
  option most likely to combine effectiveness with
  tolerability. Follow closely for Hepatitis C
  seroconversion.

23
Cases from the PEPline - K

• 36 yo nurse stuck after starting an IV on a
  patient with advanced HIV and HCV infection.
  Source off treatment with history of resistance
  to 3TC.
• Nurse started immediately on AZT, 3TC, indinavir,
  but indinavir changed to nevirapine after 3 days
  because of nausea.
• 15 days later nurse presents with rash, fever to
  103, palpable cervical adenopathy.

24
Cases from the PEPline - K

• Laboratory data
• WBC 1.5 with 30 eosinophils
• Transaminases in the 300s, bilirubin and alkaline
  phosphatase both elevated.
• PEP stopped, 5 days later, viral load lt25, liver
  function tests normalizing.

25
Cases from the PEPline - L

• Nurse stuck with a suture needle in the OR Stick
  not deep, but needle visible bloody.
• Source is married 36 yo woman, never previously
  tested for BBPs, undergoing cholecystectomy.
  Clinician reports low prevalence area.

26
Cases from the PEPline - L

• Assess injury Less severe, except visible blood
  on device.
• Assess source No history of testing, but very
  unlikely to be HIV infected.
• Recommend management Generally no PEP warranted,
  but consider basic (2 drug) PEP based on exposed
  persons preference.

27
Cases from the PEPline - M

• Nurse stuck while pushing morphine into IV port
  for ICU patient. No blood in the line.
• Source is prison inmate who denies any risk
  factors.

28
Cases from the PEPline - M

• Assess injury No infectious body fluid involved,
  therefore no risk of BBP transmission.
• Assess source Denies risk factors or recent
  testing.
• Recommend management PEP not recommended.

29
Cases from the PEPline - N

• Garbage collector stuck with needle from the
  trash in a residential neighborhood. Stick was
  deep, but needle never recovered.
• Area with relatively high prevalence of viral
  hepatitis, as well as HIV, among IV drug users.

30
Cases from the PEPline - N

• Assess injury More severe based on deep injury.
• Assess source Unknown, although high prevalence
  area.
• Recommend management Consider basic (2 drug) PEP
  for HIV. Initiate Hepatitis B vaccination series,
  consider HBIG X 1.

31
Cases from the PEPline - O

• Four year old child stuck with needle found on
  the floor of the pharmacy.
• Caller not sure if needle was even used. Pharmacy
  not thought to serve HIV clientele or IV drug
  users.

32
Cases from the PEPline - O

• Assess injury Less severe
• Assess source Needle unlikely to be used on HIV
  source, and exposed to environmental conditions.
• Recommend management Consider basic (2 drug)
  PEP, but toxicities likely to outweigh potential
  benefits.

33
Cases from the PEPline - P

• Nurse stuck after giving insulin injection 3 days
  ago. Stick not deep. Nurse in good health.
• Source ELISA now positive, she admits to a
  history of heterosexual promiscuity.

34
Cases from the PEPLine - P

• Assess injury Less severe
• Assess source Preliminary positive HIV result
  with recent high risk behavior, however
  asymptomatic for HIV, so likely Class I.
• Recommend management Recommend PEP - basic (2
  drug) regimen, but with option of adding a
  protease inhibitor until test results can be
  confirmed and, if necessary, viral load assessed.
  Efficacy of PEP delayed beyond 3 days is not
  known, but some experts recommend more aggressive
  treatment for significant injuries, when there is
  a delay in initiation of treatment.

35
Cases from the PEPline - Q

• Security guard stuck outside of ER by a needle
  just used by someone to inject drugs. Needle
  visible bloody and used in vein, but stick not
  deep. Guard has history of kidney stones.
• Source claims to be HIV and Hepatitis C infected.
  Consented to testing in the ER.

36
Cases from the PEPline - Q

• Assess injury More severe
• Assess source High risk, could be HIV Class II.
• Recommend management Recommend expanded (3 drug)
  regimen, based on source report of HIV status,
  and severity of the injury. Prefer nelfinavir as
  third drug over indinavir, since guard has
  history of kidney stones. HBIG and Hepatitis B
  vaccination warranted if guard is not previously
  vaccinated.