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 patient’s room. Threw the needle away before she looked at it carefully. • Patient in that room is HIV infected with VL >750,000. He had complex ARV hx, marked with lots of non-adherence. His current regimen was Combivir, efavirenz. • Nurse was started on Combivir, nevirapine. • Nurse’s 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 <10 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 <750,000 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 <25, 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 person’s 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.