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Internet
Announcement
In January of 1998, the Hospital Infections Program, the National
Foundation for Infectious Diseases (NFID) and the Public Health Training Network
co-sponsored a videoconference entitled, Putting the Pieces Together: Managing
Occupational Exposures to HIV. NFID is offering this program on videotape.
The 2-hour broadcast provides physicians, nurses, occupational
health professionals, hospital administrators, infection control professionals, and others
who may manage occupational exposures with practical guidelines for managing occupational
HIV exposure. Viewers will learn how to incorporate public health service recommendations
into their own policies and procedures on managing HIV exposure. Topics include potential
occupational risk factors, steps to take if an exposure occurs, available treatments for
the exposure, safety and legal issues, and guidelines for designing proper programs to
manage HIV exposure.
VHS videotapes of the broadcast are available from NFID for $30
each, including shipping and handling. Contact Kip Kantelo, NFID, at (301) 656-0003, fax
(301) 907-0878, or e-mail at kkantelo@aol.com.
Putting
the Pieces Together:
Managing Occupational Exposures to HIV
Satellite Video Conference Agenda
January 15,
1997
1:00-3:30pm EDT
SPEAKERS
Denise M. Cardo, M.D.- Acting Chief, HIV Infections Branch, Hospital
Infections Program, National Center for Infectious Disease (NCID), Centers for Disease
Control and Prevention (CDC), Atlanta, Georgia
Julie L. Gerberding M.D., MPH - Director EPI Center, San Francisco
General Hospital San Francisco, California
Vikas Kapil, DO, MPH - CEO-Medical Director, Premier Mercy Corp.,
Health Services Bloomfield Hills, Michigan
Daniel Riedford, JD. - Office of General Council, CDC, Atlanta,
Georgia
Michael S. Saag, M.D. - Professor of Medicine, University of Alabama,
Birmingham, Alabama
Charles Schable, MS - Chief, HIV Serology Section, HIV Laboratory
Investigations Branch, Division of AIDS, STD, and TB Laboratory Branch, NCID, CDC,
Atlanta, Georgia.
MODERATOR
Bruce Dan, M.D. - Medical Director, Medcast Networks,
Bethesda, Maryland
AGENDA
1) Introduction - Bruce Dan
2) Overview of PHS Recommendations - Denise Cardo
3) Issues in Implementation
Laboratory Testing Considerations - Charles Schable
Legal Considerations - Daniel Riedford
Antiretroviral Medications - Michael Saag
4) Question and Answer Period
5) Approaches to Post Exposure Management
San Francisco General Hospital - Julie Gerberding
Non Hospital -Based Workers - Vikas Kapil
6) Question and Answer Period
Putting
the Pieces Together:
Managing Occupational Exposures to HIV
Satellite
Video Conference
For More Information....
Suggested References (available at your local medical library)
CDC. Public Health Service (PHS) Statement of Management of Occupational Exposures to
HIV and Recommendations for Postexposure Prophylaxis (PEP) MMWR (in press)-copies can
obtained from the National AIDS Clearing House
Armstrong K, Gordon R, Santorella G. Occupational exposures of health care workers to
HIV: stress reactions and counseling interventions. Social Work in Health Care
1995;21(3):61-80
Bell DM, Gerberding JL, eds. Human immunodeficiency virus postexposure management of
healthcare workers (proceedings). Amer J Med 1997;102(suppl 5B).
Cardo DM, Culver DH, Ciesielski CA, et al. A case-control study of HIV seroconversion
in health care workers after percutaneous exposure to HIV-infected blood. NEJM
1997;337(21):1484-1490.
Gerberding JL. Management of occupational exposures to blood-borne viruses. NEJM
1995:332(7):444-450.
Gerberding JL. Prophylaxis for occupational exposure to HIV. Ann Intern Med.
1996;125:497-501
Henderson DK. Postexposure treatment of HIV--taking some risks for safety's sake. NEJM
1997;337(21):1542-43.
Numbers to Remember
National Clinicians' Post-exposure Prophylaxis Hotline (PEP-Line) (888) 448-4911
The HIV Postexposure Prophylaxis Registry (888) PEP-4HIV (737-4448)
The CDC National AIDS Clearing House (800) 458-5231
AIDS Clinical Trials Information Service (800) 874-2572
AIDS Treatment Information Service (800) 448-0440
On the Internet
CDC National Center for Infectious
Disease--Hospital Infections Program
EPI Center -The Epidemiology and
Prevention Interventions Center at UCSF
Antiretroviral Agents
Considerations for their use in HIV PEP
First line agents for HIV PEP
| Drug |
Dose |
Primary Toxicities/Side effects |
Primary Drug Interactions* |
Comments |
| Nucleoside reverse
transcriptase inhibitor (NRTI's) |
| Zidovudine (RETROVIR; ZDV, AZT) |
600 mg qd in divided doses, either 300 mg BID or 200 mg
TID |
Neutropenia and anemia; nausea, fatigue, malaise,
headache, insomnia, asthenia. |
|
Caution should be used if co-administered with bone
marrow suppressive agents or cytotoxic therapy. |
| Lamivudine (EPIVIR™; 3TC) |
150 mg BID |
Headache, abdominal pain, diarrhea and in rare cases,
pancreatitis. Toxicity of ZDV + 3TC when used in combination is approximately equal to
that of ZDV alone. |
|
|
| Zidovudine plus lamivudine (COMBIVIR™)
|
1 Tablet BID; each tablet contains 300 mg zidovudine and
150 mg lamivudine |
Toxicity of ZDV + 3TC when used in combination is
approximately equal to that of ZDV alone. |
|
|
| Protease Inhibitors (PIs) |
| Indinavir (CRIXIVAN) |
800 mg q8h (on an empty stomach, i.e., without food or
with a light meal) |
Nephrolithiasis, crystaluria, hematuria, nausea,
headache, indirect hyperbilirubinemia, elevated liver function tests (LFTs),
hyperglycemia/diabetes. |
No protease inhibitors should be
co-administered with terfenadine (Seldane), astemizole (Hismanal), cisapride (Propulsid),
triazolam and midazolam. Rifampin should not be administered with PIs. Cytochrome P450
metabolism inhibitors like ketoconazole may increase PI plasma concentrations; dose
reduction of the PI is only indicated for indinavir. Ergot alkaloid preparations should
not be used in combination with PIs. If Rifabutin is used
concomitantly, rifabutin dose should be reduced due to inhibition of rifabutin metabolism
(With concomitant indinavir or nelfinavir use, reduce rifabutin dose by 50%.)
Serum levels of PIs may be increased when multiple PIs are
used in combination. These agents should be co-administered with expert consultation.
|
Incidence of nephrolithiasis may be reduced by consuming
large quantities of water (i.e., drinking six 8 oz glasses of water [total 48 oz ]
throughout the day). |
| Nelfinavir (VIRACEPT™) |
750 mg TID (with meals or a light snack) |
Diarrhea; hyperglycemia/diabetes. |
Diarrhea usually can be controlled with over-the-counter
(OTC) anti-diarrheal agents, e.g., loperamide.
If oral contraceptives are being used, alternative or
additional contraceptive measures should be used while taking nelfinavir. |
Adapted from "PHS Statement on
the Management of Occupational Exposures to HIV and Recommendations for PEP"(in
press)
* See package insert for other contraindications and
possible drug interactions.
Other antiretroviral agents used for treatment of
HIV that may be considered for PEP in special circumstances
| Drug |
Dose |
Primary Toxicities/Side effects |
Primary Drug Interactions* |
Comments |
| Nucleoside reverse
transcriptase inhibitor (NRTI's) |
| Zalcitabine (HIVID, ddC) |
0.75 mg q8h |
Stomatitis, peripheral neuropathy. |
Do not co-administer ddC with ddI or d4T due
to the potential for enhanced periperal neuropathy. |
Peripheral neuropathy from ddC, ddI, or d4T
is usually after prolonged exposure.
If using ddI, to avoid potential drug interactions, give
concomitant medications 2 hours after ddI dosing. |
| Didanosine (VIDEX, ddI) |
200 mg BID; < 60 kg 125 mg BID; should be taken on an
empty stomach |
Pancreatitis, peripheral neuropathy, nausea, diarrhea. |
| Stavudine (ZERIT™, d4t) |
40 mg BID; < 60 kg, 30 BID |
Peripheral neuropathy. |
| Protease Inhibitors (PIs) |
| Ritonavir (NORVIR™) |
600 mg BID; dose escalation recommended (300 mg BID for 1
day, 400 mg BID for 2 days, 500 mg BID for 1 day, then 600 mg BID for duration of regimen) |
Nausea, emesis, diarrhea, circumoral paresthesia, taste
alteration, increased cholesterol, and triglycerides, hyperglycemia/diabetes, increased
LFT's. |
No protease inhibitors should be
co-administered with terfenadine (Seldane), astemizole (Hismanal), cisapride (Propulsid),
triazolam or midazolam. Rifampin should not be administered with PIs. Cytochrome P450
metabolism inhibitors like ketoconazole may increase protease inhibitor plasma
concentrations. Ergot alkaloid preparations should not be used in combination with Pis.
Rifabutin should not be coadministered with either saquinavir (due to
reduction of saquinavir serum concentrations) or ritonavir (due to increased rifabutin
concentrations).
Serum levels of protease inhibitors may be increased when
multiple protease inhibitors are used in combination. These agents should be
co-administered with expert consultation |
Ritonavir also should not be used with various
antiarrhythmics and certain sedative/hypnotics. Ritonavir also has potential interactions
with certain analgesics, antibiotics, antidepressants, anti-emetics, antifungals, calcium
channel blockers, and others. If oral
contraceptives are being used, alternative or additional contraceptive measures should be
used while taking ritonavir . |
| Saquinavir (INVIRASE™) (hard gel formuation)
Saquinavir (FORTOVASE™ )
(soft gel formulation) |
600 mg TID with fatty meals
1200 mg TID within 2 hours of a meal |
Diarrhea, headache, hyperglycemia/diabetes, increased
LFT's and triglycerides. |
|
| Drug |
Dose |
Primary Toxicities/Side effects |
Primary Drug Interactions* |
Comments |
| Non-nucleoside reverse
transcriptase inhibitors (NNRTIs) |
|
| Nevirapine (VIRAMUNE) |
200 mg BID (200 mg qd first 2 weeks) |
Rash (including rare cases of Stevens- Johnson sydrome),
fever, nausea, headache, increased LFTs. |
Nevirapine induces hepatic cytochrome CYP3A isoforms;
however, drug interaction studies with drugs metabolized by this enzyme have not been
conducted. Careful monitoring is therefore recommended if nevirapine is co-administered
with other drugs metabolized by |
Oral contraceptives may be less effective during
concomitant use with nevirapine.
Dose escalation of nevirapine is recommended. |
| Delavirdine (RESCRIPTOR) |
400 mg TID |
Rash (including rare cases of Stevens- Johnson sydrome),
nausea, increased LFTs. |
Delavirdine inhibits hepatic cytochrome CYP3A
isoforms. Should not be co-administered with terfenadine (Seldane),
astemizole (Hismanal), cisapride (Propulsid), triazolam, midazolam, nifedipine,
anticonvulsants, amphetamines, rifabutin, or rifampin. Delavirdine may increase protease
inhibitor levels.
This agent should be used in combination with expert
consultation. |
Antacids and ddI decrease absorption of delavirdine and
should be separated by 2 hours . |
Percutaneous
Injuries
Stage of HIV Infection in Source Patient
| Characteristics of Injury |
Asymptomatic - Known low titer |
Symptomatic - AIDS |
Acute Infection - Pre-terminal AIDS
- Known high titer |
| Superficial Injury |
Offer |
Recommend |
Strongly Encourage |
| Visibly bloody device uses in artery or vein |
Recommend |
Recommend |
Strongly Encourage |
| Deep/IM exposure actual injection |
Strongly Encourage |
Strongly Encourage |
Strongly Encourage |
Mucosal Exposures
Stage of HIV Infection in Source
Patient
| Characteristics of Injury |
Asymptomatic - Known low titer |
Symptomatic - AIDS |
Acute Infection - Pre-terminal AIDS
- Known high titer |
| Small volume, brief duration |
Offer |
Offer |
Offer |
| Large volume OR long duration |
Recommend |
Recommend |
Recommend |
| Large volume AND long duration |
Recommend |
Recommend |
Strongly Encourage |
Partner Acknowledgement
This conference is sponsored by:
- the Centers for Disease Control and Prevention (CDC),
- the National Foundation for Infectious Diseases (NFID), and
- the Public Health Training Network (PHTN)
NFID's sponsorship is underwritten through unrestricted education grants from:
- Agouron Pharmaceuticals, Inc.,
- Glaxo Wellcome, Inc.
- Merck & Co., and
- Pharmacia & Upjohn, Inc.
This page last reviewed: October 24, 2001
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