1998 CDC Recommendations for Postexposure Prophylaxis in Health Care Workers

 

Material to which exposure may occur:

(1) blood

(2) bloody fluid

(3) other potentially infectious material:

(3a) semen

(3b) vaginal secretions

(3c) cerebrospinal fluid

(3d) synovial fluid

(3e) pleural fluid

(3f) peritoneal fluid

(3g) pericardial fluid

(3h) amniotic fluid

(3i) tissue

 

Step 1: Determine Exposure Code

 

If the source of exposure is not one of the following, then no post-exposure is probably not required:

(1) blood

(2) bloody fluid

(3) other potentially infectious material (OPIM, body fluid, etc as listed above)

(4) an instrument contaminated with one of these substances

 

Other potentially infectious material:

(1) Exposures should be evaluated on a case-by-case basis.

(2) In general, these body substances are considered a low risk for transmission in health-care settings.

(3) Any unprotected contact to concentrated HIV in a research laboratory or a production facility is considered an occupational exposure that requires clinical evaluation to determine the need for post-exposure prophylaxis.

 

Blood or bloody fluid on intact skin only:

(1) This is not normally considered a risk for HIV transmission.

(2) If the exposure was to a higher volume exposure (extensive area of skin was exposed, or there was prolonged contact with blood), then risk for HIV transmission should be considered.

 

Other Exposures to Blood or Bloody Fluids	Extent of Exposure	Exposure Code
Mucous membrane or skin with compromised integrity	volume small (few drops, short duration)	1
	volume large (several drops, major blood splash, and/or longer duration of several minutes or more)	2
Percutaneous exposure	less severe (solid needle, superficial scratch)	2
	more severe (large bore hollow needle, deep puncture, visible blood on device, needle used in source patient’s artery or vein)	3

 

Skin integrity is considered compromised if one or more of the following is present:

(1) chapped skin

(2) dermatitis

(3) abrasion

(4) open wound.

 

Determine the HIV Status Code

 

HIV status of exposure source		HIV status code
HIV negative	no post-exposure prophylaxis required	NA
Status unknown or source unknown		“unknown”
HIV positive	lower titer exposure (asymptomatic, high CD4 count)	1
	higher titer exposure (advanced AIDS, primary HIV infection, high or increasing viral load, or low CD4 count)	2

 

HIV negative: If there is

(1) laboratory documentation of a negative HIV antibody, HIV PCR, or HIV p24 antigen test on a specimen collected at or near the time of exposure, AND

(2) no clinical evidence of a recent retroviral-like illness.

 

HIV positive: if there has been either

(1) a positive laboratory result for HIV antibody, HIV PCR, or HIV p24 antigen; OR

(2) physician diagnosed AIDS.

 

Determine the Post-Exposure Prophylaxis Recommendation

 

Exposure Code	HIV Status Code	Post-Exposure Prophylaxis (PEP) Recommendation
1	1	PEP may not be warranted. Exposure type does not pose a known risk for HIV transmission. Whether the risk for drug toxicity outweighs the benefit of PEP should be decided by the exposed health care worker and the treating clinician.
1	2	Consider basic regimen. Exposure type poses a negligible risk for HIV transmission. A high HIV titer in the source may justify consideration of PEP. Whether the risk for drug toxicity outweighs the benefit of PEP should be decided by the exposed health care worker and treating clinician.
2	1	Recommend basic regimen. Most HIV exposures are in this category; no increased risk for HIV transmission has been observed but use of PEP is appropriate.
2	2	Recommend expanded regimen. Exposure type represents an increased HIV transmission risk.
3	1 or 2	Recommend expanded regimen. Exposure type represents an increased HIV transmission risk.
2 or 3	unknown	If the source, or, in the case of an unknown source, the setting where the exposure occurred suggests a possible risk of HIV exposure, then consider PEP basic regimen

 

Basic regimen:

(1) 4 weeks of zidovudine (600 mg per day in 2-3 divided doses), and

(2) lamivudine (150 mg twice daily)

 

Expanded regimen:

(1) 4 weeks of zidovudine (600 mg per day in 2-3 divided doses), and

(2) lamivudine (150 mg twice daily)

(3) either indinavir (800 mg every 8 hours), or nelfinavir (750 mg three times a day)