Post-Exposure Prophylaxis

Neisseria meningitidis Exposure

• Antimicrobial chemoprophylaxis is recommended for "close contacts" of patients with known disease caused by Neisseria meningitidis. The risk of sporadic meningococcal disease is up to 800 times greater for "close contacts" of patients.
• Prophylaxis should be administered as soon as possible, ideally within 24 h, after the case patient is identified. Antimicrobial agents recommended by the Center for Disease Control and Prevention (CDC) are listed in table.

Blood and Body Fluid Exposure

• The initial management includes cleaning the exposure site and appropriate wound care. There is no evidence to support squeezing of the site, use of caustic materials, or injection of any substance.
• Post-exposure issues include prophylaxis and/or testing for infection with HIV, hepatitis B, and hepatitis C.

  

  Table: Definition of "close contacts" of patients with N. meningitidis disease
  a. Household members b. Day care center contacts c. Anyone directly exposed to the patient�s oral secretions     - kissing     - mouth-to-mouth resuscitation     - endotracheal intubation/ airway management

• Assessment of the risk of HIV includes the evaluation of the source material, the type of exposure, degree of exposure, and the source patient. (Tables 11.17-11.19)
• If the HCW is vaccinated against hepatitis B, then serum antibody titers for HBsAb are measured following an exposure. When the levels are adequate for protection (i.e., >10 mIU ml) no post-exposure prophylaxis is warranted. If the HCW levels fall below 10 mIU/ml, then post-exposure prophylaxis is recommended. (Table 11.20)
• There are no recommendations for post-exposure prophylaxis for hepatitis C. Routine testing includes anti-HCV of the source patient, and both anti-HCV and ALT at baseline and after 6 mo for the exposed HCW.

Table: Antimicrobial prophylaxis against meningococcal disease
Drug	Age	Dose
Ciprofloxacin	>18 yr	500 mg po x 1 dose
Ceftriaxone	Adults	250 mg IM x 1 dose
Ceftriaxone	<15	yr 125 mg IM x 1 dose
Rifampin	<1 mo	5 mg/kg po q 12 h x 4 doses
Rifampin	Children	10 mg/kg po q 12 h x 4 doses
Rifampin	Adults	600 mg po q 12 h x 4 doses
Not recommended for pregnant women.

Table: Risk of infection following percutaneous injury
HIV	0.3%
Hepatitis C	1.8%
Hepatitis B	2-40%

Table: Exposures at risk for the development of HIV
Source Material:	Blood, bloody fluids, or other potentially infectious materials
Type of Exposure:	Mucous membranes, non-intact skin, or percutaneous injury
Degree of Exposure:	Large volume, prolonged contact, or deep penetration
Source Patient:	HIV positive, high viral load
Semen, vaginal secretions, pericardial, cerebrospinal, peritoneal, prophylactic antimicrobials in wound care, synovial and amniotic fluids.

Table: Recommendations for post-exposure prophylaxis for HIV

PEP is not recommended - brief exposure on intact skin PEP may not be warranted - low titer exposure, low volume, non-intact skin or mucous membranes Consider basic regimen - low titer exposure with large volume and/or long duration exposure or less severe percutaneous injury (scratch or solid needle) Recommend basic regimen - high titer exposure, low volume, non-intact skin or mucous membrane Recommend expanded regimen - more severe percutaneous injury (large bore needle, deep injury, visible blood or needle from vessel) regardless of titer: high titer exposure, large volume and/or long duration; or high titer, less severe percutaneous injury (scratch or solid needle)

Table: Post-exposure prophylaxis regimens for HIV
Basic	zidovudine (AZT) 300 mg po BID x 4 wk and lamivudine (3TC) 150 mg po BID 4 wk
Extended	BASIC plus indinavir (Crixivan) 800 mg po q 8 h x 4 wk or nelfinavir (Viracept) 750 mg po TID x 4 wk

Table: Recommended post-exposure prophylaxis - Hepatitis B
Vaccinated HCW:      Serum HbsAb titers >10 mIU/ml                                     <10 mIU/ml	No treatment HBIG 5.0 ml IM and HB vaccine x 1
Unvaccinated HCW	HBIG 5.0 ml IM and HB vaccine x 3 (at 0,1 and 6 mo)
HCW (Health care worker). HBIG (Hepatitis B immunoglobulin). HB (Hepatitis B)

Suggested Reading

1. Centers for Disease Control and Prevention. Control and prevention of meningococcal disease: Recommendations of the Advisory Committee on Immunization Practices. MMWR 1997; 46 (RR-5):1-9.
2. Centers for Disease Control and Prevention. Public health service guidelines for the management of health-care worker exposure to HIV and recommendation for postexposure prophylaxis. MMWR 1998; (RR-7):1-33.
3. Centers for Disease Control and Prevention. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related diseases. MMWR 1998; 47(RR-19):1-38.