COMMUNITY (NON-OCCUPATIONAL) BLOOD OR BODILY FLUID EXPOSURE

Transcription

1 COMMUNITY (NON-OCCUPATIONAL) BLOOD OR BODILY FLUID EXPOSURE ALGORITHM 1. Sexual Assault Suspected r reprted sexual assault Cnsult scial wrk fr every case f suspected r reprted sexual assault Inclusin criteria: Patient reprts sexual assault OR Patient s parent/caregiver reprts cncern fr sexual assault N N specific labs r prphylaxis indicated Remainder f medical care based n medical histry, prvider discretin, r patient/family cncern Assess risk f expsure: Has bdily fluid made cntact with a mucsal surface? Yes Obtain labs (see Table 1): Hepatitis B antigen GC/CT urine PCR Hepatitis C antibody HIV 1 and 2 antibody screen Urine pregnancy test Rapid plasma reagin (RPR) Vaginal pathgen screen If starting antiretrvirals (ARVs) fr HIV (see belw), rder CBC and CMP as baseline labs Recmmended prphylaxis fr patients yunger than 12 years (see Table 2): Hepatitis B vaccine fr all expsed patients; HBIG if indicated Call ID and/r CPT t determine need fr prphylaxis against STIs and pregnancy Recmmended prphylaxis fr patients 12 years r lder (see Table 2): Emergency cntraceptin Antibitics fr GC/CT/trichmnas Hepatitis B vaccine fr all expsed patients; HBIG if indicated >72 hurs Hw lng since expsure ccurred? 72 hurs N HIV prphylaxis indicated; if assailant r type f cntact high risk fr HIV, discuss with ID ARVs may be recmmended Cnsider the risks and benefits f ARVs fr HIV prphylaxis (see Table 4). If patient desires ARVs, give first dse in ED AND give starter pack AND prescriptin t take hme Fllw Up: Cmbined Child Prtectin Team/Infectius Disease Clinic held n Thursday mrnings at 8:30am If ARVs are started fr HIV prphylaxis, appintment shuld be made n the Thursday fllwing initial visit Rutine appintment fr all ther sexual assault patients (fr injury healing, mental health resurces, STI testing) shuld be made within 1-2 weeks PCP fllw up fr crdinatin f care, labratry testing, hepatitis B vaccines, mental health supprt Labratry tests are indicated at 6 weeks, 3 mnths, and 6 mnths after expsure (see Table 5) Additinal hepatitis B vaccines are indicated if patient previusly received <3 dses and/r 6 week titer is belw prtective level Page 1 f 16

2 ALGORITHM 2. Needle Stick r Other Bdily Fluid Expsure! If questins abut risk assciated with expsure, cnsult with Infectius Disease (ID) N Needle Stick r Other Bld/Bdily Fluid Expsure Assess risk f expsure: Has a sharp bject cntaminated with bld/bdily fluid punctured the skin, AND/OR Has bld/bdily fluid made cntact with a mucsal surface? Yes Inclusin criteria: Needle sticks/injuries penetrating skin AND/OR Mucsal expsure t bld r bdily fluid (e.g., bites r ingestin) Exclusin criteria: Injuries in which skin was nt brken AND bld/bdily fluids did nt cntact mucus membranes Occupatinal expsures N specific labs r prphylaxis indicated Remainder f medical care based n medical histry, prvider discretin, r patient/family cncern Obtain labs (See Table 1): Hepatitis B antigen Hepatitis C antibody HIV 1 and 2 antibody screen If starting antiretrvirals (ARVs) fr HIV (see belw), rder CBC and CMP as baseline labs Recmmended prphylaxis (See Table 2): Hepatitis B vaccine fr all expsed patients; HBIG if indicated Tetanus vaccine if >5 years since last immunizatin; TIG if indicated Hw lng since expsure >72 hurs ccurred? 72 hurs N HIV prphylaxis indicated; if surce f bdily fluid r type f cntact high risk fr HIV, discuss with ID ARVs may be recmmended Cnsider the risks and benefits f ARVs fr HIV prphylaxis (See Table 4). If patient desires ARVs, give first dse in ED AND give starter pack AND prescriptin t take hme Fllw Up: If ARVs are started fr HIV prphylaxis, schedule appintment with Infectius Disease Clinic within 7 days PCP fllw up fr crdinatin f care, labratry testing, and hepatitis B vaccines - Labratry tests are indicated at 6 weeks, 3 mnths, and 6 mnths after expsure (see Table 5) - Additinal hepatitis B vaccines are indicated if patient previusly received <3 dses and/r 6 week titer is belw prtective level Page 2 f 16

3 TABLE OF CONTENTS Algrithm 1. Sexual Assault Algrithm 2. Needle Stick r Other Bld r Bdily Fluid Expsure Target Ppulatin Backgrund Definitins Initial Evaluatin Sexual Assault Initial Evaluatin Needle Sticks and Other Expsures Clinical Management Labratry Studies Prphylaxis HIV Pst-Expsure Prphylaxis Risk f Transmissin Discharge Planning Checklist Fllw-Up Request Frm Patient Caregiver Educatin References Clinical Imprvement Team TARGET POPULATION: SEXUAL ASSAULT Inclusin Criteria Pediatric patients reprting sexual assault defined as any frced r cerced sexual behavir that ccurs withut cnsent, AND/OR Pediatric patients whse parents reprt cncern fr sexual assault Exclusin Criteria Severe physical trauma necessitating emergent peratin r repair (Must address trauma first, prceed with wrkup and prphylaxis nce stable. Alert CPT and/r ID t pending need fr wrkup and prphylaxis). TARGET POPULATION: NEEDLE STICK INJURY/OTHER BLOOD OR BODILY FLUID EXPOSURE Inclusin Criteria Needle sticks that penetrate the skin, due t discarded needles fund in a cmmunity setting, AND/OR Other injuries that penetrate that skin, due t any sharp bject cntaminated with bld r bdily fluids, AND/OR Mucsal expsure t bld r bdily fluid, such as a bite injury, r ingestin f any material cntaminated with bld r bdy fluid Exclusin Criteria Any injury in which skin was nt brken AND bld/bdily fluids did nt cntact mucus membranes Occupatinal needle sticks r ther injuries r expsures that ccur in a wrkplace setting Page 3 f 16

4 BACKGROUND DEFINITIONS These clinical care recmmendatins are designed t help medical prviders identify, screen, and treat children at-risk f transmissin f infectius agents frm bld r bdily fluid expsure in the cmmunity (including cmmunity needle sticks and sexual expsures). Definitins ARV: Antiretrviral drugs CPT: Child Prtectin Team HIV: Human Immundeficiency Virus ID: Infectius Diseases PEP: Pst-Expsure Prphylaxis STI: Sexually Transmitted Infectin INITIAL EVALUATION: SEXUAL ASSAULT Prir t evaluatin f uncnscius, intxicated, r altered patients, cnsult with CPT. Histry Details f expsure Type f sexual cntact Mucsal surface(s) invlved Patient factrs Pubertal status Vaccinatin status fr hepatitis B Assailant risk factrs Is the assailant knwn t be infected with HIV, hepatitis B, r hepatitis C? Des the assailant agree t be tested fr HIV, hepatitis B, r hepatitis C? Physical Exam Perfrm a cmprehensive physical exam, nting any injuries that culd increase the risk f expsure Exam shuld be perfrmed by a trained prvider INITIAL EVALUATION: NEEDLE STICKS AND OTHER EXPOSURES Histry Details f expsure In what setting was the cntaminated bject r material fund? If needle stick, was bld visible in the syringe? Was the sharp hllw bre r slid? Patient factrs Vaccinatin status fr tetanus Vaccinatin status fr hepatitis B If the surce f bld/bdy fluid is knwn: Is the surce knwn t be infected with HIV, hepatitis B, r hepatitis C? Des the surce agree t be tested fr HIV, hepatitis B, r hepatitis C? Page 4 f 16

5 If the surce f bld/bdy fluid is unknwn: Bld frm discarded needles shuld NOT be tested fr viral infectins. Physical Exam Perfrm a cmprehensive physical exam, nting any injuries Dcument the lcatin and severity f any wunds that penetrated skin. CLINICAL MANAGEMENT Labratry Studies Labs indicated fr: Patients with a bld r bdily fluid expsure f ANY TYPE, including sexual assault Hepatitis B AntiGEN t rule ut infectin prir t current expsure. Hepatitis B antibody is nt indicated, as Hepatitis B vaccinatin is recmmended fr all expsed patients, regardless f antibdy titers 1 Hepatitis C AntiBODY t rule ut infectin prir t current expsure HIV 1 and 2 AntiBODY screen t rule ut infectin prir t current expsure Labs indicated fr: Patients with knwn r suspected ral, vaginal, penile, r anal sexual cntact Gnrrhea/Chlamydia (GC/CT Urine PCR) culture was previusly gld standard, but PCR is sufficiently sensitive t make a diagnsis. Ensure that patient des nt clean their genitals prir t cllecting urine sample. RPR screening test fr syphilis Urine Pregnancy Test t determine whether patient was already pregnant at time f suspected assault, as it wuld be t early t diagnse new pregnancy Vaginal Pathgen Screen screening test fr yeast, bacterial vaginsis, and trichmnas Labs indicated fr: Patients wh will be starting ARVs fr HIV pst-expsure prphylaxis Cmplete Bld Cunt (CBC) with differential t prvide a baseline; if patient is severely neutrpenic, anemic, r thrmbcytpenic, call ID. Cmprehensive Metablic Panel (CMP) t prvide a baseline; if renal functin is abnrmal r liver enzymes are elevated, call ID. TABLE 1: Recmmended Immediate Testing after Expsure Surce # (If available) Expsed Patient Hep B Surface AntiGEN ALL At-Risk Expsures ADD IF Sexual Expsure ADD IF Starting HIV PEP Hep C Ab HIV 1 and 2 Ab screen HIV RNA PCR Chemistry Hld serum + plasma Urine GC/CT PCR* RPR X X X X X X X Preg Test Vaginal pathgen screen CBC with diff X X X X X X X X X X CMP * Perfrmance characteristics f the urine GC/CT PCR have nt been established fr children 13 years f age and yunger. # Surce is defined as the persn whse bld r bdily fluids cntacted the patient. In the case f sexual assault, surce refers t the assailant. In the case f a needle stick, bld frm a syringe shuld never be tested fr infectins. Page 5 f 16

6 Prphylaxis Prphylaxis fr patients with a bld r bdily fluid expsure f ANY TYPE, including sexual assault: HIV cnsider PEP after discussin f risks/benefits (see pages 8-10) Hepatitis B give vaccine t all expsed patients. Give Hep B Immune Glbulin (HBIG) nly if the expsed patient is unvaccinated, has received <3 dses f vaccine, r vaccinatin status is unknwn, AND surce is KNOWN TO BE INFECTED with hepatitis B 1,2. Hepatitis C n prphylaxis is available. Tetanus vaccine is indicated fr needle stick r wund, if mst recent tetanus vaccine was >5 years ag. Give Tetanus Immune Glbulin (TIG) nly if the expsed patient is unvaccinated, has received <3 dses f vaccine, r vaccinatin status is unknwn 3. Prphylaxis against STIs and pregnancy fr pst-pubertal children ( 12 years ld) with knwn r suspected sexual expsure: Gnrrhea all patients 12 years ld with sexual expsure (d nt await results f PCR testing) Weight < 45 kg- Ceftriaxne IV/IM 125 mg nce Weight > 45 kg- Ceftriaxne IV/IM 250 mg nce If renal insufficiency, please cntact ID fr alternative Chlamydia all patients 12 years ld with sexual expsure (d nt await results f PCR testing) Weight < 50 kg- Azithrmycin 20 mg/kg PO nce Weight > 50 kg- Azithrmycin 1000 mg PO nce Trichmnas female patients 12 years ld with psitive vaginal pathgen screen Metrnidazle 2000 mg PO nce Pregnancy female patients with negative pregnancy test, <120 hurs since sexual cntact Ulipristal (Ella ) 30 mg PO nce Prphylaxis against STIs and pregnancy fr pre-pubertal children (< 12 years ld) with knwn r suspected sexual expsure: Call ID and/r CPT fr all sexual assaults in patients less than 12 years f age t determine the need fr STI and/r pregnancy prphylaxis. If prphylaxis is nt administered after discussin with ID and/r CPT, perfrm all screening labs and PCP shuld fllw up n these labs and treat if necessary. Labs can be repeated at 6 weeks pst expsure r sner if symptmatic. Page 6 f 16

7 TABLE 2: Recmmended Prphylaxis fr Expsed Patients Cnditin Ppulatin Indicated Prphylaxis HIV Patient/parent decisin after discussin f risks/benefits HIV PEP regimen PO x4 weeks (see pp. 8-10) Hepatitis B All expsed patients, even if fully vaccinated Hep B vaccine Patients wh are unvaccinated against Hep B, received <3 dses f Hep B vaccine, r vaccinatin status unknwn AND Surce is KNOWN TO BE INFECTED with Hep B Hepatitis C Nne Nne Hep B vaccine PLUS Hep B Immune Glbulin (HBIG) 0.06 ml/kg IM Tetanus Needlestick/Wunds: mre than 5 years since mst recent Tetanus vaccine nly tetanus vaccine Needlestick/Wunds: unvaccinated r <3 dses tetanus vaccine Tetanus vaccine PLUS Tetanus Immune Glbulin (TIG) 250 Units IM Gnrrhea* Sexual Expsure, weight less than 45 kg CefTRIAXne IV/IM 125 mg nce Sexual Expsure, weight greater than 45 kg CefTRIAXne IV/IM 250 mg nce Chlamydia* Sexual Expsure, weight less than 50 kg Azithrmycin PO 20 mg/kg nce Sexual Expsure, weight greater than 50 kg Azithrmycin PO 1000 mg nce Trichmnas* Sexual Expsure, psitive vaginal pathgen screen Metrnidazle PO 2000 mg nce Pregnancy Sexual Expsure (within 120 hurs), negative pregnancy test, patient chice Ulipristal (Ella ) PO 30 mg nce * Fr patients under 12 years f age, call ID and/r CPT t determine the need fr prphylaxis. HIV Pst-Expsure Prphylaxis (PEP) The risk f HIV transmissin varies greatly depending n the particular expsure. Given that each expsure is unique in its risk prfile, a discussin f the risks f transmissin, ptential benefits f PEP, and ptential cmplicatins f PEP with the patient/parents is recmmended using the infrmatin prvided belw. Please call the n-call infectius diseases prvider fr help with PEP recmmendatins. Ptential Benefits f HIV Pst-Expsure Prphylaxis The ptential benefit f HIV PEP depends n the efficacy f the regimen, timing f PEP initiatin after expsure, and adherence t the entire regimen. 1. Efficacy f Regimen: PEP using single-drug therapy fllwing ccupatinal expsure decreases transmissin by 81% 1. Experts nw recmmend the use f a multi-drug regimen with mre ptent antiretrviral agents, which is likely t increase this efficacy. 2. Timing f Expsure: PEP is mst effective when begun as sn as pssible after expsure and becmes less effective as time frm expsure increases. PEP is less likely t be effective 72 hurs after expsure, but the interval after which n benefit is gained is unknwn 1. If >72 hurs have passed since expsure t a surce whse HIV status is unknwn, PEP is nt recmmended; hwever, testing per Table 1 shuld still be cnducted. If >72 hurs have passed since expsure t a surce wh is knwn t be HIV infected, please cntact ID fr recmmendatins n PEP. Page 7 f 16

8 3. Adherence t PEP: The efficacy f PEP depends upn adherence t the entire 28-day curse f medicatin. The mst cmmn reasn fr PEP discntinuatin is side effects. Althugh side effects f PEP regimens are cmmn, they are rarely severe r serius (see Table 3 fr regimen-specific side effects). The side effect prfile f newer antiretrvirals is imprved cmpared with lder drugs. Once-daily regimens als imprve adherence. PEP Drug Regimens All regimens are FOUR WEEKS in duratin. Prescribe 7 days f ndansetrn (Zfran ) with every PEP regimen t ensure tlerability. A. 12 years r lder and weight at least 40 kg: Prescribe bth f the medicatins listed belw: Medicatin Truvada (tenfvir 300 mg/ emtricitabine 200 mg; TDF/FTC) Dlutegravir 50 mg tablet (DTG)* Dse 1 tablet PO nce daily 1 tablet PO nce daily *These medicatins shuld be given with a full meal. Absrptin is impaired by simultaneus administratin f medicatins that cntain plyvalent catins, such as antacids, laxatives, r multivitamins, UNLESS they are taken with fd. B. Yunger than 12 years and/r weight less than 40 kg: Prescribe all three medicatins listed belw: 1. Can swallw pills: Medicatin Strength Weight AM dse PM dse kg 75 mg 75 mg Lamivudine (3TC) 150 mg tablet kg 75 mg 150 mg 25 kg 150 mg 150 mg Zidvudine (AZT, ZDV) 100 mg capsule kg 200 mg 200 mg 30 kg 300 mg 300 mg kg 100 mg 100 mg Raltegravir (RAL)* 100 mg chew tab kg 150 mg 150 mg kg 200 mg 200 mg 40 kg 300 mg 300 mg *These medicatins shuld be given with a full meal. Absrptin is impaired by simultaneus administratin f medicatins that cntain plyvalent catins, such as antacids, laxatives, r multivitamins, UNLESS they are taken with fd. 2. Cannt swallw pills: Medicatin Strength Weight Dse (given BID) Max dse Lamivudine (3TC) 10 mg/ml liquid 40 kg 4 mg/kg/dse 150 mg/dse 4-8 kg 12 mg/kg/dse Zidvudine (AZT, ZDV) 10 mg/ml liquid 9-29 kg 9mg/kg/dse 300 mg/dse 30 kg 300 mg kg 20 mg (1 ml) Raltegravir (RAL)* kg 30 mg (1.5 ml) 100 mg chew tab kg 40 mg (2 ml) disslved in 5 ml water # kg 60 mg (3 ml) kg 80 mg (4 ml) N/A kg 100 mg (5 ml) *These medicatins shuld be given with a full meal. Absrptin is impaired by simultaneus administratin f medicatins that cntain plyvalent catins, such as antacids, laxatives, r multivitamins, UNLESS they are taken with fd. # RAL chew tabs disslve in water after ~15 minutes. The tablet shuld be fully disslved befre administratin. Page 8 f 16

9 TABLE 3. Cmmn Side Effects Experienced with the Recmmended PEP Regimens Intended patients PEP regimen Adverse Effects 12 years and 40 kg Truvada / dlutegravir Cmmn but mild: fatigue, dizziness, insmnia, headache, nausea, diarrhea, liver enzyme elevatin <12 years and/r <40 kg Lamivudine / zidvudine / raltegravir Cmmn but mild: nausea, diarrhea, anemia, neutrpenia, liver enzyme elevatin; headache, insmnia, rash. Rare but severe: muscle pain due t mysitis RISK OF TRANSMISSION Risk f transmissin f HIV r hepatitis B r C is based n the prbability that the surce was infected, the viral lad f an infected surce, and the type f expsure. 1. Prbability surce was infected: a. HIV: As f 2015, the serprevalence f HIV in Clrad is 0.24% (239.2 HIV-infected persns per 100,000 peple) 4. Certain risk grups, including sexual assailants, injecting drug users, and men wh have sex with men have a higher serprevalence. Serprevalence als varies by cunty, with higher rates in Denver metr and El Pas cunties 4. b. Hepatitis B: The Clrad Dept. f Public Health and Envirnment estimates that there are currently abut 16,370 (range f 10,913 t 21,826) peple in Clrad living with chrnic HBV. This estimate is based n the U.S. Census 2015 Clrad ppulatin estimated ppulatin and a natinal published HBV prevalence rate estimate f 0.3% (range f 0.2%-0.4%) 4. c. Hepatitis C: The Clrad Dept. f Public Health and Envirnment estimates that there are currently abut 70,935 (range f 54,566 t 109,131) peple in Clrad living with chrnic, unreslved HCV. This estimate is based n the U.S. Census 2015 Clrad ppulatin estimated ppulatin and a natinal published HCV prevalence rate estimate f 1.3% (range f 1.0% t 2.0) Risk f HIV Transmissin Based n Type f Expsure 1 See Table 4 n the next page. Page 9 f 16

10 TABLE 4. Risk f HIV Transmissin Based n Expsure Type Transmissin Risk per Expsure Type Expsure t a Knwn HIV Psitive Surce Expsure t Cntaminated Sharp Cmments Accidental needle stick Needle-sharing during injectin drug use Sexual Expsures 0.23% (1 per 435) Discarded needles are lw-risk expsures, as HIV is intlerant t envirnmental cnditins. There has never been a reprted case f HIV transmissin frm a discarded needle, as f % (1 per 159) Risk f transmissin frm a needle stick depends n the bre f the needle and depth f penetratin. Discarded small bre needles (i.e. insulin syringes) r slid sharps (i.e., scalpels) with shallw penetratin frm a lw risk ppulatin (i.e., diabetics) wuld be f very lw risk. Newly discarded hllw bre needles with visible bld frm areas frequented by high HIV serprevalent ppulatins (i.e. injecting drug users) wuld be f higher risk. Receptive anal intercurse Receptive vaginal 1.38% (1 per 72) 0.08% Risk f HIV transmissin due t sexual assault r abuse assciated with trauma, bleeding, and tissue injury is significantly higher than that f cnsensual sexual cntact. intercurse (1 per 1,250) Althugh ral sex with intact mucsa is a lw risk transmissin Insertive anal 0.11% event, the presence f ral sres r mucsal injuries increases intercurse (1 per 909) the risk f transmissin. Insertive vaginal 0.04% intercurse (1 per 2,500) Mst experts wuld recmmend PEP in cases f sexual assault r abuse, r sexual cntact with a knwn HIV-psitive surce. Oral sex with Lw risk ejaculatin Mucus Membrane Expsures Oral expsure t bld Nn-intact Skin Expsures Negligible Biting: HIV transmissin frm bites is extremely rare. A bite withut a break in the skin is nt cnsidered an expsure. A bite invlving a high-risk surce with breaks in the skin and bld expsure increases transmissin risk. Kissing/Muth t Muth Resuscitatin: Shuld nt be cnsidered an expsure withut mucsal damage r bld expsure. Saliva cntaminated with bld pses a substantial expsure risk. HIV transmissin by this rute has been reprted. Rare cases f HIV transmissin after nn-intact skin expsure t infected bld have been dcumented, but the risk has nt been quantified. Page 10 f 16

11 DISCHARGE PLANNING CHECKLIST LABS [ ] Obtain prper labratry studies (see Table 1): All Expsures Sexual Expsure Starting HIV PEP [ ] Hep B Surface AntiGEN [ ] GC/CT PCR [ ] CBC with differential [ ] Hep C Antibdy [ ] RPR fr Syphilis [ ] CMP [ ] HIV 1 and 2 Antibdy Screen [ ] Pregnancy Test [ ] Vaginal Pathgen Screen PROPHYLAXIS [ ] Prvide prphylaxis fr Hepatitis B, tetanus, GC/CT, trichmnas, and/r pregnancy as indicated in Table 2. [ ] Discuss risks/benefits f HIV PEP (pp. 8-10). If starting PEP: [ ] Give FIRST DOSE f ARVs in the Emergency Department with ndansetrn (Zfran ) 4mg PO nce. [ ] Call inpatient pharmacy t btain PEP STARTER PACK (Free 7-day supply f ARVs dispensed frm Children s Hspital Clrad pharmacy, intended t bridge patient until fllw-up in ID/CPT clinic.) Patient shuld LEAVE THE ED WITH STARTER PACK in hand. [ ] Write a 7-day PRESCRIPTION FOR ONDANSETRON (Zfran ). [ ] Write a 28-day PRESCRIPTION FOR ARVs. Instruct patient NOT TO FILL PRESCRIPTION unless directed by ID r CPT. Walgreens within CHCO is the preferred pharmacy fr ARV prescriptins. FOLLOW-UP [ ] Schedule fllw up in ID and/r CPT clinics via ne f the fllwing: 1) EPIC in-basket message (link in discharge SmartSet; preferred methd) 2) Fax the PEP Fllw-Up Request Frm t (see attached) Victims f sexual assault n HIV PEP shuld fllw up THIS THURSDAY at 8:30am in cmbined ID/CPT clinic. Victims f sexual assault NOT n HIV PEP shuld fllw up within 2 weeks in CPT clinic. Victims f needle sticks r ther expsures n HIV PEP shuld fllw up within 7 days in ID clinic. (If nt n HIV PEP, these patients shuld fllw up with PCP nly; see guidance belw.) [ ] Ntify Scial Wrk f all cases f cnfirmed r suspected sexual assault. [ ] Cntact Infrmatin: Cnfirm preferred patient cntact infrmatin, including cnfidential cntact number if adlescent sexual assault. List bth in Demgraphics sectin f chart and n PEP Fllw-Up Request Frm, if using. [ ] Give cpy f PATIENT/PARENT EXPOSURE HANDOUT. [ ] PCP Fllw-Up is imprtant fr crdinatin f care, fllw-up labratry testing, vaccines, and mental health supprt. Fllw-up tasks include labs as per Table 5, and vaccines as fllws: HPV vaccines shuld be administered accrding t the rutine 3-dse series. Hepatitis B vaccines may be indicated t cmplete the 3-dse series (see CDC catch-up immunizatin schedule) 2. Indicatins fr additinal Hepatitis B vaccines: Patient determined t be unvaccinated/undervaccinated against hepatitis B prir t the expsure Hepatitis B surface antibdy at 6 weeks is belw the prtective level TABLE 5: Recmmended Fllw-Up Labs RPR Pregnancy Test ALL EXPOSURES SEXUAL EXPOSURES Hep B Surface Hep B Surface Hep C Ab HIV 1 and 2 GC/CT AntiGEN AntiBODY Ab screen PCR 6 Weeks X X X* X X # 3 Mnths X 6 Mnths X $ X $ X X X * Only if did NOT receive prphylaxis against GC/CT during initial visit. # Only if did NOT receive emergency cntraceptin during initial visit. $ Only if 6 week Hep B Surface Antibdy is undetectable. Page 11 f 16

12 COMMUNITY (NON-OCCUPATIONAL) BLOOD AND/OR BODILY FLUID EXPOSURE Pst-Expsure Prphylaxis Clinic Fllw-Up Request: FAX TO: This frm required ONLY if ID r CPT teams were NOT ntified by EPIC in-basket message Patient Name (Last, First): Date f Birth: MR# Patient Weight: Patient Address: Phne #: (H) (C) Preferred Cnfidential Phne # (if adlescent sexual expsure): Insurance: Other ID #: Primary Care Physician: PCP Phne Number: Expsure Date/Time: Brief Descriptin f Expsure: HIV PEP: PEP started? [ ] yes [ ] n If yes, regimen prescribed: Drug Dse First Dse Given in ED [ ] yes [ ] n Starter Pack Given [ ] yes [ ] n 28-Day Prescriptin Given [ ] yes [ ] n [ ] CBC/diff [ ] LFTs [ ] BUN/Cr BUN Cr WBC Hct Plts AST ALT T bili Other Lab Wrk/Prphylaxis: [ ] HIV Antibdy [ ] psitive [ ] negative [ ] pending [ ] STD screen sent (sexual expsures) [ ] RPR [ ] Chlamydia [ ] Gnrrhea [ ] Trichmnas [ ] Prphylaxis given: Drug Dse/Duratin [ ] Pregnancy Screen (sexual expsures) [ ] psitive [ ] negative [ ] Emergency Cntraceptin given [ ] yes [ ] n [ ] Hepatitis Screen Hep B AntiGEN [ ] psitive [ ] negative [ ] pending Hep C AntiBODY [ ] psitive [ ] negative [ ] pending Hepatitis B Vaccine given [ ] yes [ ] n If SOURCE is KNOWN TO BE Hepatitis B psitive: Hepatitis B Immune Glbulin given [ ] yes [ ] n [ ] Tetanus Vaccine [ ] up-t-date [ ] vaccine given [ ] TIG given Treating Prvider Name: Pager #: Date: Time: Page 12 f 16

13 PATIENT CAREGIVER EDUCATION Sexual Assault and Pssible Expsure t Disease: Fr Teen English Spanish Sexual Assault and Pssible Expsure t Disease: Fr Parent f Child English Spanish Needle Sticks and Other Expsure t Bld English Spanish Page 13 f 16

14 REFERENCES 1. Centers fr Disease Cntrl and Preventin, U.S. Department f Health and Human Services. Updated Guidelines fr Antiretrviral Pstexpsure Prphylaxis After Sexual, Injectin Drug Use, r Other Nnccupatinal Expsure t HIV - United States, American Academy f Pediatrics. [Hepatitis B.] In: Kimberlin DW, Brady MT, Jacksn MA, Lng SS, eds. Red Bk: 2015 Reprt f the Cmmittee n Infectius Diseases. 30th ed. Elk Grve Village, IL: American Academy f Pediatrics; 2015:[ ] 3. American Academy f Pediatrics. [Tetanus.] In: Kimberlin DW, Brady MT, Jacksn MA, Lng SS, eds. Red Bk: 2015 Reprt f the Cmmittee n Infectius Diseases. 30th ed. Elk Grve Village, IL: American Academy f Pediatrics; 2015:[ ] 4. Clrad Department f Public Health and Envirnment Data Request System, Nvember Page 14 f 16

15 CLINICAL IMPROVEMENT TEAM MEMBERS Christiana Smith, MD Pediatric Infectius Diseases Betsy McFarland, MD Pediatric Infectius Diseases Heather Heizer, PA Pediatric Infectius Diseases Antnia Chiesa, MD Child Prtectin Team Denise Abd, PhD, NP Child Prtectin Team Bernadette Jhnsn, MD Emergency Medicine Jessica Kraynik, MD Emergency Medicine Jasn Child, PharmD Clinical Pharmacist, Pediatric Infectius Diseases Sarah Nickels, PhD Evidence Based Practice Prject Manager Elise Rlisn, RRT-NPS Prject Manager APPROVED BY Clinical Pathways and Measures Cmmittee April 11, 2017 Antimicrbial Stewardship March 2017 Pharmacy & Therapeutics Cmmittee May 4, 2017, medicatin change apprved n Nvember 2, 2017 Clinical Care Guidelines/Quality MANUAL/DEPARTMENT ORIGINATION DATE June 23, 2014 LAST DATE OF REVIEW OR REVISION May 4, 2017 APPROVED BY Medical Directr, Clinical Effectiveness REVIEW REVISION SCHEDULE Scheduled fr full review n May 4, Clinical pathways are intended fr infrmatinal purpses nly. They are current at the date f publicatin and are reviewed n a regular basis t align with the best available evidence. Sme infrmatin and links may nt be available t external viewers. External viewers are encuraged t cnsult ther available surces if needed t cnfirm and supplement the cntent presented in the clinical pathways. Clinical pathways are nt intended t take the place f a physician s r ther health care prvider s advice, and is nt intended t diagnse, treat, cure r prevent any disease r ther medical cnditin. The infrmatin shuld nt be used in place f a visit, call, cnsultatin r advice f a physician r ther health care prvider. Furthermre, the infrmatin is prvided fr use slely at yur wn risk. CHCO accepts n liability fr the cntent, r fr the cnsequences f any actins taken n the basis f the infrmatin prvided. The infrmatin prvided t yu and the actins taken theref are prvided n an as is basis withut any warranty f any kind, express r implied, frm CHCO. CHCO declares n affiliatin, spnsrship, nr any partnerships with any listed rganizatin, r its respective directrs, fficers, emplyees, agents, cntractrs, affiliates, and representatives. Page 15 f 16

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