Post-exposure prophylaxis

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Post-exposure prophylaxis
Other namesPost-exposure prevention

Post-exposure prophylaxis, also known as post-exposure prevention (PEP), is any

preventive medical treatment started after exposure to a pathogen
in order to prevent the infection from occurring.

It should be contrasted with pre-exposure prophylaxis, which is used before the patient has been exposed to the infective agent.

COVID-19

In 2021, the US

emergency use authorization (EUA) to bamlanivimab/etesevimab for post-exposure prophylaxis against COVID-19.[1] However, due to its reduced effectiveness against Omicron variants of the SARS-CoV-2 virus, it is no longer recommended for this purpose.[2]

Ensitrelvir is being studied for its potential use as post-exposure prophylaxis against COVID-19.[3][4][5]

Rabies

PEP is commonly and very effectively used to prevent the onset of

immunoglobulin.[7] Rabies vaccine is given to both humans and animals who have been potentially exposed to rabies.[8]

Tetanus

immunoglobulin (also called tetanus antibodies or tetanus antitoxin[9]). It can be given as intravenous therapy or by intramuscular injection.[citation needed
]

The guidelines for such events in the United States for non-pregnant people 11 years and older are as follows:[10]

Vaccination status Clean, minor wounds All other wounds
Unknown or fewer than three doses of tetanus toxoid containing vaccine
Tdap
and recommend catch-up vaccination
immunoglobulin
Three or more doses of tetanus toxoid containing vaccine AND less than 5 years since last dose No indication No indication
Three or more doses of tetanus toxoid containing vaccine AND 5–10 years since last dose No indication Tdap preferred (if not yet received) or Td
Three or more doses of tetanus toxoid containing vaccine AND more than 10 years since last dose Tdap preferred (if not yet received) or Td Tdap preferred (if not yet received) or Td

HIV

tenofovir, and raltegravir

History

AIDS in 1987. Healthcare workers would occasionally be exposed to HIV during work. Some people[who?] thought to try giving health care workers AZT to prevent seroconversion. This practice dramatically decreased the incidence of seroconversion among health workers when done under certain conditions.[11]

Later the questions arose of whether to give HIV treatment after known exposure or high risk of exposure. Early data from preclinical studies established the efficacy of AZT in preventing transmission of HIV infection.[12] AZT was also seen to reduce maternal-infant transmission of HIV in a randomized controlled trial, suggesting AZT's post-exposure prophylaxis (PEP) use.[13] Subsequent data show combination antiretroviral therapy is significantly superior than AZT in reducing perinatal transmission rates.[14] In addition, AZT is generally no longer recommended due to poor tolerance resulting in high rates of patient noncompliance.[citation needed]

Non-occupational exposures include cases when a condom breaks while a person with HIV has sex with an HIV-negative person in a single incidence, or in the case of unprotected sex with an anonymous partner, or in the case of a non-habitual incident of sharing a syringe for injection drug use. Evidence suggests that PEP also reduces the risk of HIV infection in these cases.[15] In 2005, the US DHHS released the first recommendations for non-occupational PEP (nPEP) use to lower risk of HIV infection after exposures. The recommendations were replaced with an updated guideline in 2016.[16]

Occupational exposures include needlestick injury of health care professionals from an HIV-infected source. In 2012, the US DHHS included guidelines on occupational PEP (oPEP) use for individuals with HIV exposures occurring in health care settings.[17]

Since taking HIV-attacking medications shortly after exposure was proven to reduce the risk of contracting HIV, this led to research into pre-exposure prophylaxis by taking medication before a potential exposure to HIV occurred.[18]

A report from early 2013 revealed that a female baby born with the HIV virus displayed no sign of the virus two years after high doses of three antiretroviral drugs were administered within 30 hours of her birth. The findings of the case were presented at the 2013 Conference on Retroviruses and Opportunistic Infections in Atlanta, U.S. and the baby is from Mississippi, U.S. The baby—known as the "Mississippi baby"—was considered to be the first child to be "functionally cured" of HIV.[19] However, HIV re-emerged in the child as of July 2014.[20]

Risk evaluation

Initiation of post-exposure prophylaxis with the use of

sexually transmitted diseases, testing for hepatitis B and C (nPEP is also effective against hepatitis B), and pregnancy tests for women of childbearing potential.[16]

Risk factors for developing HIV includes exposure of

HIV positive partner is considered risky, but sharing sex toys, spitting and biting considered to be negligible risks for initiating post-exposure prophylaxis. The highest non-sexual risk is blood transfusion and the highest sexual contact risk is receptive anal intercourse. The timing of exposure does not affect the risk of developing HIV, but it does alter whether post-exposure prophylaxis will be recommended. Exposures that occurred 72 hours or less to beginning treatment are eligible for post-exposure prophylaxis. If the exposure occurred over 73 hours prior to treatment initiation, post-exposure prophylaxis is not indicated.[16]

Testing

Initial HIV testing: Before initiating PEP after potential

HIV2 antigens and antibodies in the blood using a rapid diagnostic test. PEP should only be started if rapid diagnostic test reveals no HIV infection present or if tests results are not available. However, if HIV infection is already present then PEP should not be started. HIV test should be repeated four to six weeks and three months after exposure.[16]

People may experience signs and symptoms of

acute HIV infection, including fever, fatigue, myalgia, and skin rash, while taking PEP. CDC recommends seeking medical attention for evaluation if these signs and symptoms occur during or after the month of PEP. If follow-up laboratory antibody tests reveal HIV infection, HIV treatment specialists should be sought out and PEP should not be discontinued until person is evaluated and treatment plan is established.[16]

STI and HBV testing: People with potential exposure to HIV are also at risk of acquiring

NAAT) for gonorrhea and chlamydia and blood tests for syphilis. PEP is also active against HBV infections so discontinuation of medication can cause the reactivation of HBV, though rare. Health care providers must monitor HBV status closely.[16]

Follow up testing:

renal function, and hematologic parameters should be monitored.[16]

Treatment

In the case of

CDC recommends PEP for any HIV-negative person who has recently been exposed to HIV for any reason.[21]

To be most effective, treatment should begin within an hour of exposure.[22] After 72 hours PEP is much less effective, and may not be effective at all.[21] Prophylactic treatment for HIV typically lasts four weeks.[21][23]

While there is compelling data to suggest that PEP after HIV exposure is effective, there have been cases where it has failed. Failure has often been attributed to the delay in receiving treatment (greater than 72 hours post-exposure), the level of exposure, and/or the duration of treatment (lack of adherence to the 28-day regimen). In addition, since the time and level of non-occupational exposures are self-reported, there is no absolute data on the administration timeframe to which PEP would be efficacious. The standard antibody window period begins after the last day of PEP treatment. People who received PEP are typically advised to get an antibody test at 6 months post-exposure as well as the standard 3 month test.[21]

The antiretroviral regimen used in PEP is the same as the standard

fatigue, diarrhea, headache, nausea and vomiting.[21]

People at high risk for re-exposure due to unprotected intercourse or other behavioral factors should be given PrEP, which would begin immediately after the completion of the nPEP treatment course. Inversely, if a medically adherent patient is already on PrEP upon non-occupational exposure, nPEP treatment is not necessary.[16]

Hepatitis A

For exposure to

immunoglobulin (HNIG) and/or hepatitis A vaccine may be used as PEP depending on the clinical situation.[25][26]

Hepatitis B

If the person exposed is an HBsAg positive source (a known responder to HBV vaccine) then if exposed to hepatitis B a booster dose should be given. If they are in the process of being vaccinated or are a non-responder they need to have hepatitis B immune globulin (HBIG) and the vaccine. For known non-responders HBIG and the vaccine should be given whilst those in the process of being vaccinated should have an accelerated course of HBV vaccine.[citation needed][27]

Hepatitis C

Persons exposed to hepatitis C should be tested monthly with PCR, and if seroconversion occurs then treatment with interferon, or possibly ribavirin.[citation needed]

Anthrax

A 60-day course of oral ciprofloxacin should be given when exposure to anthrax is suspected.[28]

Lyme disease

A single 200 milligram oral dose of doxycycline may be used within 3 days of a deer tick bite in a high risk area (such as New England), if the tick was attached for at least 36 hours.[29][30][31]

Monkeypox and Smallpox

The smallpox vaccine decreases the incidence of infection with

monkeypox and smallpox and the risk of severe illness even when administered after exposure. The CDC advises "that smallpox vaccine be given within 4 days from the date of exposure to prevent onset of the disease but should be offered up to 14 days post-exposure"; the NHS concurs with this but also urges to vaccinate as soon as possible after exposure.[32]

See also

References

  1. ^ Research, Center for Drug Evaluation and (16 September 2021). "FDA authorizes bamlanivimab and etesevimab monoclonal antibody therapy for post-exposure prophylaxis (prevention) for COVID-19". FDA. Archived from the original on 17 September 2021. Retrieved 24 April 2022.
  2. ^ "Prevention of SARS-CoV-2". NIH. 20 December 2023. Retrieved 27 January 2024.
  3. ^ Cosdon, Nina (31 March 2023). "Ensitrelvir: A COVID-19 Antiviral That Remains Effective Against New Variants". ContagionLive. Archived from the original on 31 October 2023. Retrieved 28 October 2023.
  4. ^ "Shionogi presses on with Xocova research following Japanese approval". The Pharma Letter. 16 February 2023. Archived from the original on 28 October 2023. Retrieved 28 October 2023.
  5. ^ "Studies Currently Enrolling". University of Kansas Medical Center. Archived from the original on 28 October 2023. Retrieved 28 October 2023. SCORPIO-PEP is a 28-day study to assess the prevention of COVID-19 infection in those who have been exposed through household contact.
  6. ^ "Rabies". www.who.int. World Health Organization. Archived from the original on 2019-05-09. Retrieved 2019-06-16.
  7. ^ "Rabies: Guide for post-exposure prophylaxis". World Health Organization. Archived from the original on June 27, 2004. Retrieved 2013-05-28.
  8. PMID 6095272
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  9. ^ "Tetanus antitoxin | biochemistry | Britannica". www.britannica.com. Retrieved 2023-11-08.
  10. ^ "Tetanus" Archived 2008-03-06 at the Wayback Machine, from the Centers for Disease Control and Prevention. Page last updated August 12, 2013.
  11. PMID 9366579
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  12. PMID 1995734
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  13. S2CID 13457499
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  14. PMID 12063373
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  15. PMID 9091810
    .
  16. ^ a b c d e f g h i "Updated Guidelines for Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV— United States, 2016" (PDF). Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Archived (PDF) from the original on November 20, 2016. Retrieved June 24, 2016.
  17. S2CID 17032413. Archived
    from the original on 2019-06-23. Retrieved 2018-11-04.
  18. PMID 29229609
    .
  19. ^ Saundra Young (4 March 2013). "Researchers: Toddler cured of HIV". CNN. Archived from the original on 19 May 2013. Retrieved 4 July 2013.
  20. ^ National Institute of Allergy and Infectious Diseases (10 July 2014). ""Mississippi Baby" Now Has Detectable HIV, Researchers Find". NIH. Archived from the original on 9 September 2016. Retrieved 12 August 2014.
  21. ^
    Centers for Disease Control. Archived
    from the original on 14 April 2011. Retrieved 7 July 2011.
  22. PMID 10895754
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  23. ^ "HIV/AIDS Bureau - HIV Care Pocket Guide 2006 - Occupational HIV Postexposure Prophylaxis (PEP)". Archived from the original on 2008-03-11. Retrieved 2008-03-05.
  24. ^ "Archived copy" (PDF). Archived from the original (PDF) on 2021-06-07. Retrieved 2021-06-07.{{cite web}}: CS1 maint: archived copy as title (link)
  25. ^ "Hepatitis A Questions and Answers for Health Professionals". CDC. November 9, 2018. Archived from the original on March 6, 2016. Retrieved December 9, 2018.
  26. PMID 28910270
    .
  27. ^ "Post-exposure Prophylaxis Hepatitis B". conditions.health.qld.gov.au. Archived from the original on 2022-03-04. Retrieved 2022-05-25.
  28. ^ "Prevention - Anthrax - CDC". www.cdc.gov. 9 January 2019. Archived from the original on 10 December 2018. Retrieved 9 December 2018.
  29. ^ "Tick Bite Prophylaxis". Centers for Disease Control and Prevention. 30 May 2019. Archived from the original on 26 May 2021. Retrieved 20 May 2021.
  30. PMID 34749665
    .
  31. PMID 33251700
    . We recommend that prophylactic antibiotic therapy be given only to adults and children within 72 hours of removal of an identified high-risk tick bite, but not for bites that are equivocal risk or low risk (strong recommendation, high-quality evidence). comment: If a tick bite cannot be classified with a high level of certainty as a high-risk bite, a wait-and-watch approach is recommended. A tick bite is considered to be high-risk only if it meets the following three criteria: the tick bite was from (a) an identified Ixodes spp. vector species, (b) it occurred in a highly endemic area, and (c) the tick was attached for ≥36 hour
  32. ^ "Recommendations for the use of pre and post exposure vaccination during a monkeypox incident" (PDF). assets.publishing.service.gov.uk. 17 June 2022. Archived (PDF) from the original on 3 July 2022. Retrieved 9 July 2022. Vaccination should be administered as soon as possible and within 4 days after an identified exposure to prevent or attenuate infection.

Further reading

External links
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