A Brief Synopsis or AFP's "Postexposure Prophylaxis for Common Infectious Diseases"

Postexposure Prophylaxis for Common Infectious Diseases

MAZEN S. BADER, MD, MPH, Hamilton Health Sciences, Hamilton, Ontario, Canada, DAVID S. McKINSEY, MD, University of Kansas School of Medicine, Kansas City, Kansas, and Infectious Disease Associates of Kansas City, Kansas City, Missouri

Am Fam Physician. 2013 Jul 1;88(1):25-32.

http://www.aafp.org/afp/2013/0701/p25.pdf

     Every clinicians' biggest fear is to catch some awful disease from a sick patient. It doesn't stop them from running into the ER during an outbreak, but its still in the back of their minds. The most common and effective prophylaxis is childhood vaccinations. They are available for measles, mumps, rubella, varicella, influenza, hepatitis B, pertussis, among others. In the hospital, standard precautions include regular hand washing, gloves, masks, gowns, isolation precautions and others. This article will focus on what to do if you get exposed to something (post exposure prophylaxis, PEP).
     The first thing that should be done if you think you were exposed to something is to figure out if the patient (source) is really infected. This can be done with culture or serology. Also, the patient may not be infectious even if he or she has the illness. Asking the patient when he or she first got sick, treatment, and current symptoms may help.
     Depending on the patient, PEP for hepatitis B will be different. If the person exposed was unvaccinated, then he or she needs immunoglobulin, followed by vaccination. Those vaccinated with a documented inadequate response will need the immunoglobulin, followed by a vaccine booster. Persons with low risk exposure to HIV would take Truvada or Combivir. High risk exposure persons may take Tenofovir with emtricitabine or Zidovudine with lamivudine, plus Kaletra or Atazanavir.
     Unvaccinated patients who become exposed to hepatitis A should be vaccinated within two weeks. If they are unvaccinated and immunocompromised, they should get immunoglobulin.  For varicella, exposed patients can be vaccinated within five days of exposure. Pregnant or otherwise immunocompromised patients will need immunoglobulin. 
     Persons exposed to rabies who are unvaccinated will need immunoglobulin (IM or around the wound if possible). They will also need to be vaccinated on days 0, 3, 7, 14, and 28. Previously vaccinated persons will need a vaccine on days 0 and 3 if they can prove that they have the antibodies, otherwise they get the shot on days 0, 3, 7, 14 and 28 as well.
     Persons exposed to Step A "necrotizing fasciitis" can get penicillin G plus rifampin, clindamycin, or azithromycin. Persons exposed to meningitis will get cipro, azithromycin, ceftriaxone, or rifampin, for up to two weeks. For pertussis, they can take azithromycin, clarithromycin, erythromycin, or TMP/SMX.  Patients exposed to tetanus who were incompletely vaccinated or not vaccinated will need the vaccine. They can have the immunoglobulin if the wound is dirty. Patients exposed to TB should have a skin test, x-ray, and isoniazid with vitamin B6 if needed. Persons exposed to anthrax will need the vaccine regimen plus cipro or doxycycline. Persons exposed to diphtheria should get the vaccination and penicillin.  
    Exposed patients should be counseled on potential risk and adverse effects of the treatment.