Isolation Guidelines and Bloodborne
Pathogen Exposures: HIV Post
Exposure Prophylaxis with Rapid HIV
Testing of Source; Mucous
Membrane Exposures
Gonzalo Bearman MD,MPH
Assistant Professor of Medicine
Associate Hospital Epidemiologist
Outline
•
•
•
•
•
Isolation categories
Bloodborne pathogens lists
Exposure types
Risk of transmission based on exposure
VCUHS data of occupational bloodborne
pathogen exposures
• PPE: for mucous membrane exposures
• PEP and Rapid HIV Testing- new protocol
Goal of Isolation
• Prevent transmission of microorganisms from
infected or colonized patients to other patients,
hospital visitors, and healthcare workers
Types of Isolation Precautions
Transmission-based
Transmission-basedPrecautions
Precautions
-for
-forpatients
patientswith
withdocumented
documentedor
orsuspected
suspectedinfections
infections
-3
-3Types:
Types:
airborne,
airborne,droplet
dropletand
andcontact
contact
Standard
StandardPrecautions
Precautions
-Apply
-Applyto
toall
allPatients
Patients
--Replace
--ReplaceUniversal
UniversalPrecautions
Precautions
Standard Precautions
• Used for all patients
• Must wear gloves when touching:
–
–
–
–
Blood
All body fluids
Nonintact skin
Mucous membranes
• Wash hands immediately after glove
removal and between patients
Standard Precautions
• Masks, eye protection, face shield:
– Wear during activities likely to generate splashes or
sprays
• Gowns
– Protect skin and soiling of clothing
– Wear during activities likely to generate splashes or
sprays
• Sharps
– Avoid recapping of needles
– Avoid removing needles from syringes by hand
– Place used sharps in puncture –resistant containers
Airborne Precautions
• Designed to prevent airborne transmission of
droplet nuclei or dust particles containing
infectious agents
• For patient with documented or suspected:
–
–
–
–
Measles
Tuberculosis (primary or lanryngeal)
Varicella (airborne + contact)
Zoster (disseminated or immunocompromised patient;
(airborne and contact)
– SARS (Contact+airborne)
Airborne Precautions
• Room:
– Negative pressure
– Private
– Door kept closed
• Mask
– Orange ‘duckbill’ mask required to enter room
Empiric Use of Airborne
Isolation
• Vesicular rash (airborne+contact)
• Maculopapular rash with coryza and fever
• Cough + fever + upper lobe pulmonary
infiltrate
• Cough + fever + any infiltrate + HIV
infection
Droplet Precautions
• Designed to prevent droplet (larger particle)
transmission of infectious agents when the patient
talks, coughs, or sneezes
• For documented or suspected:
– Adenovirus (droplet+contact)
– Group A step pharyngitis, pneumonia, scarler fever (in
infants, young children)
– H. Influenza meningitis, epiglottitis
– Infleunza, Mumps, Rubella
– Meningococcal infections
Empiric Use of Droplet
Precautions
• Meningitis
• Petechial/ecchymotic rash and fever
• Paroxysmal or severe persistent cough
during periods of pertussis activity
Contact Precautions
• Used to prevent transmission of
epidemiologically important organisms
from an infected or colonized patient
through direct (touching patient) or indirect
(touching surfaces or objects in the patient’s
environment) contact
Contact Precautions
• For suspected or documented:
–
–
–
–
–
–
–
–
–
Adenovirus (contact+droplet)
Infectious diarrhea in diapered/incontinent patients
Group A strep wound infections
MDR bacteria (MRSA,VRE)
Viral conjunctivitis
Lice, scabies
RSV infection
Varicella (Contact+airborne)
Zoster (disseminated or immunocompromised;
contact+ airbrone
– SARS (Contact+airborne)
Blood and Body Fluid Exposures
Potential Bloodborne Pathogens
•
•
•
Human Immunodeficiency Virus (HIV)
Hepatitis Viruses
As well as agents that cause...
o
o
o
o
o
o
o
o
o
o
Babesiosis
Brucellosis
Leptospirosis
Creutzfeldt -Jakob Disease
HTLV-1 Infections
Arboviral Infections
Malaria
Relapsing Fever
Viral Hemorrhagic Fever
Syphilis
Transmission of these agents in the workplace
can occur through the following routes:
•Parenteral exposure - The pathogen is
introduced directly into the body through a break in the
skin, needlestick, or througha cut with a contaminated
instrument or glass.
•Mucous membrane exposure - Exposure
through contact of a mucous membrane in the eye,
nose or mouth.
Risk of Infection after Contact with Infected Blood
Percutaneous exposure:
Prospective studies of several thousand HCWs indicate that the risk of
seroconversion:
HIV-infected blood is approximately 0.3%.
Hepatitis B depends on the e antigen (e Ag) status of the patient.
If the patient's blood is positive for the e Ag
the risk of transmission -30% or about 100 times that of HIV.
HCV infection is 3% to 10% or about 10 times the risk following a single exposure to
HIV-infected blood.
Risk of Infection after Contact with Infected
Blood
• Mucous Membrane Exposure:
– Risk of HIV Transmission
• 0.09 % risk of transmission after a mucous membrane
exposure to HIV infected blood.
– Hepatitis B and C
• Risk of transmission not well documented
• Presumed to be less than in percutaneous injury
– Although the risk of transmission associated with
mucous membrane exposures is less, it is not
negligible
VCUHS
Exposure Type
Count
% total
BBF-Mucous
Membrane
(Splash)
103
29%
BBFNeedlestick/Sharp
255
71%
358
100%
Roughly
Roughly1/3
1/3of
ofall
allemployee
employeebloodborne
bloodbornepathogen
pathogenexposures
exposuresat
atVCUHS
VCUHSare
are
Mucous
Membrane
Mucous Membrane
Mucous Membrane Exposures
Can be Prevented!!!!!!
• PPE: Masks, faceshields / goggles
– MUST BE WORN IN ANY PROCEDURE OR
PATIENT CARE ACTIVITY THAT POSES A RISK
OF BLOOD OR BODY FLUID
SPLASH/SPLATTER/AEROSOLIZATION.
– The include:
• Phlebotomy and blood cultures
• Suctioning of gastric or respiratory secretions
• Removal of medical devices
– CVC, ET tubes, Foley catheters, IV lines
Personal Protective Equipment
PPE
PPEincludes
includes
masks,
masks,masks
masks
with
faceshields
with faceshields
and
andgoggles
goggles
PPE
PPEequipment
equipment
can
canbe
befound
foundinin
isolation
isolationcarts,
carts,
and
wall
mounted
and wall mounted
PPE
PPEstorage
storageunits
units
Reveal:Rapid HIV Test
MedMira Laboratories
• Rapid HIV test performed on patient serum
– HIV antibody test
• SENSITIVITY: 99.8%
– All positive tests are confirmed by western blot
• Processing time for the test (upon receipt by the
laboratory) is about 20-30 minutes.
– It is critical that the the source blood be drawn
immediately and delivered to the laboratory in
an expeditious manner
D id a p e rc u ta n e o u s o r M M
e x p o s u re o c c u r th a t c a rrie s
s ig n ific a n t ris k o f tra n s m is s io n
o f H IV ?
P E P n o t in d ic a te d ;
n o fo llo w -u p n e e d e d
N O
Y es
H a v e fe w e r th a n 3 6 h o u rs
e la p s e d s in c e th e e x p o s u re
o c c u rre d ?
Y e s : P ro c e e d w ith R a p id
H IV T e s tin g
N O
S a m p le m u s t b e o b ta in e d S T A T (s e r u m
s e p a r a to r ) a n d s e n t v ia p n e u m a tic tu b e to
Im m u n o lo g y L a b
Is th e s o u rc e p a tie n t H IV
in fe c te d a s d e te rm in e d b y
ra p id te s tin g ?
P E P T eam
th e la b .
P E P n o t o p tim a l b u t
s h o u ld b e c o n s id e re d . If
c o n s id e re d - p ro c e e d w ith
ra p id H IV te s tin g o f
s o u rc e a n d fo llo w
a lg o rith m a c c o rd in g ly .
P E P n o t in d ic a te d ;
n o fo llo w -u p n e e d e d
N O
M e m b e r w ill b e n o tifie d o f b o th P O S I T I V E a n d N E G A T I V E r e s u lts b y
I n itia te H A A R T (I F S O U R C E I S P O S I T I V E - 3 D R U G S A R E P R
T H E S E A R E S T A N D IN G O R D E R S :
• R e c o m m e n d e d re g im e n : z id o v u d in e 3 0 0 m g p o b id + la m iv u d in e 1 5
(o r C o m b iv ir 1 b id )
P L U S
N e lfin a v ir 1 2 5 0 m g p o b id w ith fo o d
• P e rfo rm b a s e lin e c o n fid e n tia l H IV te s tin g o f th e e x p o s e d h e a lth c a re
h o u rs o f in itia tin g H A A R T
• R e fe r to E m p lo y e e h e a lth fo r a d d itio n a l m a n a g e m e n t: H A A R T , H e p
S o u rc e p a tie n t’s s e ro lo g ic te s t is
c o n firm e d H IV n e g a tiv e a n d th e re is n o
e v id e n c e o f a c u te re tro v ira l s y n d ro m e in
th e s o u rc e p a tie n t.
S to p P E P
E F E R R E D )
0 m g p o b id
w o rk e r w ith in 7 2
a titis B a n d C
S o u rc e p a tie n t’s s e ro lo g ic te s t is c o n firm e d
H IV p o s itiv e o r in d e te rm in a te , o r s e ro lo g y
is u n a b le to b e o b ta in e d .
C o n tin u e P E P fo r 4 w e e k s
Conclusion-1
• Mucous membrane blood and body fluid
exposures are known risk factors for the
transmission of HIV and Hepatitis B/C
• Of all blood and body fluid exposures at VCUHS;
mucous membrane exposure account for 30%
nearly every year.
• PPE (masks, faceshields or goggles) must be worn
when a patient care activity poses a risk of BBF
splash, spray or aerosolization.
Conclusion-2
• New PEP protocol
– Rapid HIV testing will now be employed
• Processing time is about 20-30minutes upon receipt
of the source patient’s blood
• Blood must be obtained from the source in an
expeditious manner
• Rapid HIV test results will be reported back to the
PEP member
– Standing orders for Antiretrovirals; 3 regimen
HAART