PEP under pressure: Needlestick starts clock
Serious exposure prompts flurry of activity
The challenge of rapidly providing HIV postexposure prophylaxis (PEP) could scarcely have unfolded in a more dramatic scenario than it did last year for an infection control professional at a small community hospital.
It was a Friday afternoon and Jeannie Sanborn, RN, BS, CIC, an ICP at Heywood Hospital in Gardner, MA, was covering calls for the hospital employee health department. The situation about to occur was so serious she would have been called in shortly anyway, says Sanborn, who presented the case recently in San Diego at the annual conference of the Association for Professionals in Infection Control and Epidemiology.
"I got the call - I remember exactly - it was five after two," she tells Hospital Infection Control.
Sanborn was advised that a nurse had suffered a serious needlestick after administering pain medication to an end-stage AIDS patient who was also infected with hepatitis C and B viruses.
"When they told me the source, my heart sank a little bit," she says. "I don't see this every day, and this was by far the most significant exposure that I had experienced in 14 years in infection control."
Sanborn quickly alerted the pharmacy that PEP drugs would be needed, picked up the patient's chart, and walked the injured nurse to the emergency room to begin counseling and follow-up. However, after a clinical consultation with colleagues, another problem became apparent.
Alternative regimen not available
There was concern that the source patient had been noncompliant with HIV medications, meaning the nurse may been exposed to a mutant or resistant strain of HIV. Thus, a PEP regimen comprising different medications than those given to the patient would likely have the best chance of thwarting HIV transmission to the nurse. Such an alternative regimen was not immediately available because the hospital stocked a standard three-drug regimen for PEP.
"We got on the phone and started calling other hospitals and pharmacies," Sanborn says. The antiretroviral drugs needed were soon found at an area supermarket pharmacy.
Thus even as the window of opportunity was narrowing, quick action and clinical teamwork resulted in delivery of an alternative PEP regimen to the exposed worker shortly beyond the two-hour mark. Fortunately, the exposed nurse was immunized for HBV, but only continued testing will reveal if HIV or HCV were transmitted.
"Six months down the road, all her test results are negative, and we will retest again at one year," Sanborn says.
The Centers for Disease Control and Prevention recently amended the suggested two-hour window for optimal PEP delivery to a more general "as soon as possible" approach in its revised guidelines, which also recommend using alternative regimens if a resistant strain is suspected.1 (See related story, p. 101.)
Though the hospital was able to respond to the needlestick in a timely manner, the system has since been streamlined in a fashion that reflects the kind of preparedness recommended in the new CDC guidelines, Sanborn says. For example, the hospital now has on hand a regularly updated list of the PEP drugs stocked by area pharmacies and hospitals, she noted. That was considered a more cost-effective option for a small hospital than stocking a large inventory of antiretroviral agents that may be outdated before they are ever needed, she says.
24-hour beeper coverage established
In addition, PEP kits were assembled containing a three-day supply of zidovudine, lamivudine, and indinavir to avoid the "infection control nightmare" of a late Friday night exposure at the beginning of a three-day holiday weekend, she adds. Also, patient information materials including explanation of the various PEP drugs and the protocol for administration were made available in the emergency department. The hospital protocol calls for exposed workers to contact employee health during regular hours, but to report directly to the emergency room on nights and weekends, she says. In addition, 24-hour beeper coverage was established with the infection control clinicians, and all emergency department physicians were educated regarding the recommendations for treatment.
"The policy is to beep me, the chairman of the infection control committee, and our infectious disease consultant," Sanborn says.
Education efforts also included a hospital presentation on PEP, says Sanborn, noting the nurse who had the needlestick has been very open and has received much support from colleagues.
"She has labeled us guardian angels," Sanborn says. "At her six-month check-up she presented me with an angel."
The case also underscores the need for needle safety designs on prefilled medication syringes, but Sanborn says she has yet to find any on the market.
Reference
1. Centers for Disease Control and Prevention. Public Health Service guidelines for the management of health-care worker exposures to HIV and recommendations for postexposure prophylaxis. MMWR 1998; 47(No. RR-7):1-33.
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