Sexual Assaults and PEP

There is a protocol that can be obtained from Lynda Bell in clinic regarding the care of survivors of sexual assaults. We will sometimes be called to weigh in on HIV PEP alone, as they have a protocol they follow for everything else. However, if you are ever called about what should be done, particularly if a SANE nurse is not available, here are some basics from the protocol.

Baseline laboratory tests should include:

• HIV Antibody testing
• CBC with differential
• LFTs
• BUN/Creatinine
• STD Screen (gonorrhea, chlamydia, syphilis)
• Hepatitis B serology
• Hepatitis C serology
• Pregnancy test

Prophylaxis against the most frequently diagnosed STDs among sexually assaulted women should be administered:

• Ceftriaxone 125mg IM in a single dose [Gonorrhea]
• Metronidazole 2gms orally in a single dose [BV, Trichomoniasis]
• Azithromycin 1gm orally in a single dose OR Doxycycline 100mg orally twice daily for seven days [Chlamydia]

HIV post-exposure prophylaxis is offered within 72 hours of the assault. If the perpetrator's HIV medical history is unknown, the two preferred regimens are:

• NNRTI-based: Efavirenz plus (Lamivudine or Emtricitabine) plus (Zidovudine or Tenofovir)...usually as Sustiva plus Combivir, or Sustiva plus Truvada.
• PI-based: Lopinavir/Ritonavir (Kaletra), plus Zidovudine or Tenofovir...usually as Kaletra plus Combivir, or Kaletra plus Truvada.

I've been advised typically to use the PI-based regimen unless there is another reason they should be avoided. Keep in mind that if the source patient (in the case of needlesticks) is one of OUR HIV clinic patients, we have access to their genotype and med history, and can formulate an appropriate PEP for the victim based on this information (i.e. you wouldn't want to start someone on PEP that their virus would be resistant to).

All sexual assault cases should follow up with a mid-level provider in the ID Clinic, regardless of whether or not they accept PEP. We usually just send a phone message to Lynda Bell with the patient's general information, and she contacts them to set up a follow up within 48 hours or so.

Risk Assessment

Sometimes, you are asked to comment on the risk, given different exposures (assault, blood splashes in the eye, needlestick, etc.). The risk for HIV acquisition per various acts can be found in the MMWR, January 21, 2005). It is also estimated in the Sanford Guide for the treatment of HIV.

Vaccinations in PEP

Hepatitis B: Patients who are unvaccinated prior to the assault should receive the initial Hep B vaccine, and follow up to complete the series. Unless the offender is known to have Acute Hep B, HBIG is not required. Remember, all patients should have serologies drawn.

Tetanus: If the patient has skin abrasions or other wounds and immunization status is greater than 5 years, give Tetanus Toxoid 0.5ml IM. If the patient has never been immunized, also give Hyper-Tetanus 250mcg IM.

Yvonne Carter, MD

Tips for calling an ID consult

General Stuff

Please try to call us with new consults before 1:00 pm, as we go down to the microbiology lab for plate rounds at 1:30, and it's helpful to be able to see their plates, etc. while we're there.

Please don't call us for oral recs on the day of discharge, if at all possible. We don't like to hold up people's exit from the hospital when we tell you they need a PICC line and 2 weeks of bug juice.

HIV Patients

In 2007, the ID division requested from all admitting services that a special HIV consult be called for any and all patients with HIV admitted to UNC, on any team. The purpose of this is to reduce the number of errors in antiretroviral medications prescribed, and so that the clinic providers know their patient is admitted. Unless there's an ID issue you need help with, we'll usually leave a brief note outlining their ARV doses, and then not actively follow the patient. If you want us to follow them, please let us know that up front.

When you call us with one of these, please tell us why they're being admitted, what their most recent CD4 count and viral load are, who their clinic provider is (and if they're not followed here, where they go), and what antiretroviral medications they're taking (if any).

Helpful ID Pearls of Wisdom

The first rule of ID is, don't catch what they have. Don't be ashamed to go dig out a green N95 mask or put on a gown to go talk to a patient, if you don't know what their diagnosis is.

If you stick yourself:

(1) stop whatever you're doing,

(2) wash your hands with soap and water,

(3) call the occupational health clinic, at 966-9119 (or after-hours, 966-7890)

There is no data supporting the use of oral antibacterials for treating a bacteremia in adults - all of them require parenteral therapy, for at least 14d (assuming it's uncomplicated - no endocarditis, indwelling lines, etc.)

Staph aureus in the urine is ALWAYS A BAD THING. It should never be considered a contaminant, and you should call us to help with a general workup for an occult bacteremia.

If you have Staph aureus in the blood, they need an echocardiogram. We're always going to ask for one if you call us with a positive Staph aureus blood culture.

Coag-negative Staph (epidermidis) should always be considered oxacillin/methicillin-resistant (ORSE/MRSE), but doesn't require contact precautions.

For fevers of unknown origin, please make sure you really have no idea where it's coming from - so make sure you have a chest film, urine and blood cultures, and sputum cultures (if appropriate) cooking before you call us.

If you're calling for antibacterial recs, please try to have an idea of what they've been on to-date, when it was started, and the most recent culture data. Microbiology labs at outside hospitals are usually pretty friendly and helpful if you call for data.

If you think your patient has necrotizing fasciitis or a deep-seated tissue infection like pyomyositis, call general surgery FIRST and THEN call us. We'll help with antibacterials, but the treatment is ALWAYS surgical. Clindamycin for the first 72h of true nec fasc may save the patient's life by shutting off bacterial toxin production. Add it if you think they're not doing so hot - and then call us.

For TB rule-outs, you don't have to get sputum samples only from the first-thing-in-the-morning sputum - you can get 3 serial samples, if they're spaced at least 8 hours apart. One bronch sample counts for 3 induced or expectorated sputa.

For questions about contact precautions, etc., we're happy to help - but the best resource is actually hospital epidemiology, whose number is 966-1636. Someone's always on-call for them, too.

New antibacterials

Linezolid is a nasty medication, and shouldn't be used willy-nilly! It can causes a reversible, isolated thrombocytopenia in up to half of patients who receive it, and whole-marrow suppression in up to 25% of those on it. It also has MAOI-like properties, so drug-drug and drug-food interactions are significant - including serotonin syndrome if co-administered with SSRIs, and hypertensive crises if taken with some foods. If you have a question about whether or not to use it for a patient, just call us.

Tigecycline makes people ridiculously nauseous, and that's by far its limiting side effect. It cannot be used for bloodstream infections, since it's static and doesn't concentrate in the blood. Great for tissue, bad for blood.

Daptomycin causes rhabomyolysis, so you need to follow CPKs on patients while on therapy. It can be used for bloodstream infections, but not pneumonias - since lung surfactant inactivates the drug. Great for blood, bad for pneumonias.