Aggressive treatment urged for post-exposure therapy
Aggressive treatment urged for post-exposure therapy
In a recent journal article, the chief of infectious diseases and infection control committee chairman at Catholic Medical Center of Brooklyn and Queens in Jamaica, NY, presents principles on which guidelines for aggressive treatment of health care workers occupationally exposed to HIV were based.1
The hospital’s protocol is similar to the U.S. Public Health Service’s (PHS) recently released provisional recommendations for chemoprophylaxis after occupational HIV exposure. The protocol developed by Aaron Glatt, MD, however, states that employees who incur a needlestick or mucous membrane exposure from a known or potentially HIV-infected source should be evaluated and considered for the following interventions:
• Health care workers should be evaluated immediately either in the employee health service or the emergency department (or by the most readily accessible knowledgeable physician, if neither is available).
• After local wound cleansing and care, general medical evaluation, and HIV screening and counseling, health care workers deemed at risk of occupational HIV seroconversion should be recommended for antiretroviral prophylaxis as soon as possible post-exposure.
While PHS guidelines "recommend" therapy for workers at highest risk and only "offer" treatment to those with lesser-risk exposures — reserving triple-drug therapy for those at higher risk and suggesting single-agent or double therapy for the remainder — Glatt recommends triple therapy for any exposure deemed capable of transmitting HIV. Glatt defines such exposures as all that are not negligible.
"It is very difficult as a practical matter to distinguish among risk exposures, and even if possible, drug resistance still may be present. Finally, why should a health care worker not be recommended optimal therapy’ just because his risk is fortunately lower?" Glatt states.
His preferred prophylaxis regimen is triple-drug combination therapy for four weeks (with dosing adjusted as necessary for renal or hepatic impairment). AZT alone is offered to employees who prefer to take only one drug. If two medications are preferred, AZT and 3TC are used. Informed consent is obtained, regardless of the therapy.
Glatt notes that his hospital’s recommendations are merely suggestions, not mandatory or absolute requirements. All affected employees are referred to a private doctor or to the employee health service for follow-up.
PHS doesn’t recommend routine use of triple-combination therapy for low-risk exposures, mainly because of limited data on the safety and tolerability of the newer drugs.
Glatt’s article outlines the seven basic principles of his facility’s occupational HIV exposure treatment protocol, which was developed in December 1995:
1. Viral load in the index patient affects seroconversion likelihood.
2. Deep or penetrating injuries, especially from hollow needles or visibly contaminated devices, or injuries from procedures involving direct placement into an artery or vein, increase seroconversion risk.
3. Different HIV strains may carry different seroconversion likelihoods.
4. Known or potential HIV resistance alters prophylactic therapy efficacy.
5. Triple-combination antiretroviral therapy generally is superior to monotherapy or double-combination therapy for HIV treatment and for reducing viral load.
6. Zidovudine (AZT, Retrovir) prophylaxis reduces seroconversion risk.
7. Viral replication in a new host is a rapid, dynamic, continuously evolving process.
Reference
1. Glatt AE. Proposed antiretroviral therapy guidelines for prophylaxis of occupationally related HIV seroconversion: A practical approach. Infect Control Hosp Epidemiol 1996; 17:672-674.
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