nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1

OSHA BLOOD-BORNE PATHOGENS

STANDARD: MANAGEMENT OF

EXPOSURE TO BLOOD-BORNE PATHOGENS

Dana Bartlett, BSN, MSN, MA, CSPI

Dana Bartlett is a professional nurse and author.

His clinical experience includes 16 years of ICU

and ER experience and over 20 years of as a

poison control center information specialist. Dana has published numerous CE and

journal articles, written NCLEX material and textbook chapters, and done editing and

reviewing for publishers such as Elsevier, Lippincott, and Thieme. He has written

widely on the subject of toxicology and was recently named a contributing editor,

toxicology section, for Critical Care Nurse journal. He is currently employed at the

Connecticut Poison Control Center and is actively involved in lecturing and mentoring

nurses, emergency medical residents and pharmacy students.

Abstract

Healthcare workers are continuously exposed to hazards of blood-

borne pathogen transmission. Many bacteria and viruses may be

transmitted to healthcare workers by needlesticks, sharps injury, or

splash contact. Hepatitis B, hepatitis C, and the human

immunodeficiency virus (HIV) account for the greatest number of

exposures and infections. Important aspects of the Occupational

Safety and Health Administration (OSHA) standard and information on

the management of exposure to blood-borne pathogens are discussed.

Policy Statement

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 2

This activity has been planned and implemented in accordance with

the policies of NurseCe4Less.com and the continuing nursing education

requirements of the American Nurses Credentialing Center's

Commission on Accreditation for registered nurses. It is the policy of

NurseCe4Less.com to ensure objectivity, transparency, and best

practice in clinical education for all continuing nursing education (CNE)

activities.

Continuing Education Credit Designation

This educational activity is credited for 1.5 hours. Nurses may only

claim credit commensurate with the credit awarded for completion of

this course activity.

Statement of Learning Need

Front-line healthcare workers need to know OSHA safety protocol to

prevent and to report exposure to blood-borne pathogens, in addition

to initial interventions for exposure.

Course Purpose

To provide health clinicians with basic knowledge of OSHA

recommendations for exposure to blood-borne pathogens.

Target Audience

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 3

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses

and Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Dana Bartlett, BSN, MSN, MA, CSPI, William S. Cook, PhD,

Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC –

all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.

1. The majority of occupational exposures to blood-borne pathogens are

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 4

a. percutaneous. b. air-borne.

c. cutaneous. d. percutaneous and cutaneous together.

2. The most common blood-borne pathogens in occupational

exposures are:

a. Hepatitis B, hepatitis D, and MRSA. b. Hepatitis C, HIV, and tuberculosis.

c. Hepatitis B, hepatitis C, and HIV. d. Hepatitis E, HIV, and gram-negative bacteria.

3. The risk of HIV transmission after a percutaneous exposure

is approximately:

a. 3.0%.

b. 0.3%. c. 30%.

d. 13%

4. True or False: Infection with a blood-borne pathogen can occur after contact with a contaminated surface.

a. True

b. False

5. The first step in managing an exposure to a blood-borne pathogen is:

a. Testing of the source patient. b. Notifying the employee health department.

c. Testing of the affected healthcare professional. d. Perform basic wound care or flush the affected area.

Introduction

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 5

Exposure to blood-borne pathogens is a serious, ongoing hazard for

healthcare workers and the Occupational Safety and Health

Administration (OSHA) developed a standard that was designed to

protect at-risk employees: the blood-borne pathogens standard, which

is identified by the Code of Federal Regulations number CFR

1910.1030.1 The standard was amended in 2001 to include the

Needlestick Safety and Prevention Act, and CFR 1910.1030 provides:

• Definitions of risk situations.

• Recommendations for the prevention of exposures to blood-

borne pathogens

• Recommendations for the management of exposures to blood-

borne pathogens.

Nurses have considerable risk for exposure to blood-borne pathogens,

and they are required to have a basic knowledge of, and comply with,

the recommendations of the OSHA blood-borne pathogens standard.

This module will review important aspects of the standard and provide

information on the management of exposure to blood-borne

pathogens.

Epidemiology Of Exposures To Blood-Borne Pathogens

Many bacteria and viruses can be, and have been transmitted to

healthcare workers by needlesticks, sharps injury, or splash contact,2

but hepatitis B, hepatitis C, and the human immunodeficiency virus

(HIV) account for the greatest number of exposures and infections.2

The majority of occupational exposures to and infections from these

viruses are caused by percutaneous injury.3 The term percutaneous

injury refers to any puncture of the surface of the skin such as a

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6

needlestick and a sharps injury, the latter being a puncture of the skin

from a scalpel, a trochar, or any other medical device or instrument.

The exact incidence of needlesticks, sharps injuries, and splash

exposures is not known, but it is clear they are a common occurrence,

as seen by the following reports:

• The Centers for Disease Control and Prevention (CDC) has

estimated that in the United States there are 385,000

needlesticks every year.4

• The Exposure Prevention and Information Network (EPInet)

noted in their 2011 report that the number of needlestick

injuries was 19.46 per 100 occupied beds.5

• Karmon, et al. (2013) surveyed healthcare workers in an urban

hospital and they found that in the previous year 9.4% of

nurses, physicians, and other employees had a needlestick, a

sharps injury, or a splash contact with blood or potentially

infectious body fluid.6

• Henderson (2012) estimated that almost 1 of every 10

healthcare workers in the United States has a needlestick

exposure each year.7

• Under-reporting of needlestick injuries, sharps injuries, and

splash contacts with potentially infectious fluids is not

unusual.8-12 The CDC has estimated that 50% or more of these

incidents are not reported.4

Health clinicians work in a wide variety of patient care areas, i.e.,

emergency room (ER), intensive care unit (ICU), and operating room

(OR), they frequently use needles and handle sharps, and they are

often exposed to blood and body fluids. These factors increase their

risk for exposure and needlesticks, sharps injuries, and splash

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 7

exposures, all of which occur more often to nurses than to other

healthcare workers.12-15

Risk Of Infection After Occupational Exposure

The risk of infection after an occupational exposure to a blood-borne

pathogen depends on many factors7,16,17 and the viral load of the

source (the patient) is probably the most critical of these.7 Infection is

least likely from a splash contact (cutaneous exposure), and it is most

likely from a deep puncture by a large-gauge, hollow bore needle that

contains a large amount of blood that has a high viral load.

Simultaneous transmission of several blood-borne pathogens from a

needlestick has been reported.18

Table Risk 1: Factors for Infection after Exposure to a Blood-borne

Pathogen6,7,16

Amount of blood injected

Availability/efficacy of post-exposure prophylaxis

Depth of the injury

Health status of the source person

Hollow bore needle

Immune system competency

Placement of the injuring device in an artery or a vein

Prevalence of the pathogen in the population

The pathogen

Type of injury, i.e., puncture wound versus splash contact

Viral load

Visible blood on a needle or sharp

The risk of infection after a percutaneous exposure to HIV has been

estimated to be 0.32%7 and the risk for infection after a mucous

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 8

membrane exposure to HIV has been estimated to be 0.03%-

0.09%.16,19,20 No transmission of HIV through intact skin has been

documented. All known sero-conversions from occupational exposure

to HIV have occurred after exposure to blood, bloody fluids, or viral

cultures.19 Semen, vaginal fluids, and body fluids visibly contaminated

with blood can transmit HIV; and, amniotic fluid, cerebrospinal fluid,

pericardial fluid, peritoneal fluid, pleural, and synovial fluid are

potentially HIV-infected. Feces, gastrointestinal fluids, nasal

secretions, saliva, sputum, sweat, tears, urine, and vomitus are not

considered to be HIV infectious unless they contain blood.

The risk for transmission after exposure to fluids or tissues other than

HIV-infected blood has not been quantified but is probably quite low.21

In most reported instances involving transmission of HIV, the

needlestick injury occurred within seconds or minutes after the needle

was withdrawn from the source patient.22 The CDC surveyed

occupational exposures to HIV that occurred in the years 1981-2010

and found 57 cases of documented HIV sero-conversion; and, 84.2%

of these were percutaneous exposures and in greater than 90% of the

cases there were non-occupational risk factors for HIV exposure.23

The risk of infection after percutaneous exposure to hepatitis B has

been estimated to be between 6%-62%16,19,24 and is especially high if

the source is positive for hepatitis B surface antigen (HbsAg) and

hepatitis B e antigen (HbeAg).16 Infection in healthcare workers with

hepatitis B who have not had a needlestick or other percutaneous

exposure could be due to exposure to the virus through an abrasion, a

burn, a scratch, or a mucous membrane,25 and in approximately two-

thirds of all people infected with hepatitis B, no needlestick was

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 9

identified.26 Hepatitis B surface antigen is found in other body fluids

aside from blood such as bile, breast milk, cerebrospinal fluid, feces,

nasopharyngeal washings, saliva, semen, sweat, and synovial fluid.

However, these fluids contain low levels of the virus and exposure to

them would not be likely to cause hepatitis B infection.25

The risk for infection after percutaneous exposure to hepatitis C has

been estimated to be approximately 1.8%, the reported range being

0-10%.27-29 Approximately 39% of all hepatitis C infections in

healthcare workers are considered to be occupational.28 Infection with

hepatitis C after mucous membrane exposure is considered to be

unlikely, but infection after conjunctival or ocular exposure has been

reported.30-32 Hepatitis C virus has been found in ascites, menstrual

fluid, saliva, semen, spinal fluid, and urine. These fluids have a much

lower hepatitis C viral content than blood and transmission of the virus

from these fluids has not been reported but if they were contaminated

with blood or if there was a large exposure, transmission and infection

could occur.33

Learning Break:

Blood-borne pathogens can contaminate surfaces and persist in the

environment and contact with these contaminated surfaces can

cause infection. Hepatitis B and HIV in dried blood can remain on

surfaces for a week34,35 and hepatitis B is capable of causing

infection during that time.34 Hepatitis C also can survive outside

the body on environmental surfaces36 and it can remain infective at

room temperatures on surfaces for up to six weeks.37

How Do Exposures To Blood-borne Pathogens Occur?

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 10

Needlestick injuries and other exposures to blood-borne

pathogens are usually caused by human error. These errors

can involve personal and organizational issues, and factors such as

poor staffing, a relative lack of nursing experience, long hours at work,

stress and fatigue, and poor or improper use of equipment have been

identified as causes of needlestick injuries.38-42 The most common

situations that are involved in needlestick injuries and other exposures

to blood-born pathogens are listed in Table 2.

Table 2: At-Risk Situations for Needle-stick Injuries

Accessing an IV line

Cleanup

Collision with another nurse or another healthcare worker

Manipulating the needle while it is in a patient

Passing a needle or a sharp

Poor or improper disposal technique

Puncturing skin with a needle or a sharp

Suturing

Recapping needles

Transferring blood from one container to another

Equipment that must be manipulated after or during use such as

disposable syringes, IV catheter stylettes, needles attached to

tubing such as winged infusion sets and suture needles

Acute care, ER, ICU, or OR settings

The OSHA Blood-Borne Pathogens Standard

The OSHA blood-borne pathogens standard is both general and specific

in its recommendations. Some sections provide detailed guidance while

others provide basic direction. For example, the standard states that

employers must provide hand-washing facilities but if providing these

is not possible the employer must provide either an appropriate

antiseptic hand cleaner or antiseptic towelettes. The standard,

however, does not specify what type of hand cleaners or towelettes. A

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 11

fact sheet that provides a short overview of the standard is available

at this link: http://www.osha.gov/OshDoc/data_BloodborneFacts/bbfact01.pdf.

There are other fact sheets on the OSHA website that address topics

such as the standard’s recommendations on hand washing and the

recommendations for the safe use of needles and sharps.

Learning Break:

The blood-borne pathogen standard was amended in 2001 to include the

Needlestick Safety and Prevention Act that was passed by Congress in

2000. This Act amended standard CFR 1910.1030 in order to require

employers to: 1) maintain a sharps injury log, and 2) involve non-

managerial personnel in the decision-making process of selecting safer

needle devices. The Act also added language to the blood-borne

pathogens standard that redefined engineering controls as "controls (i.e.,

sharps disposal containers, self-sheathing needles, safer medical devices,

such as sharps with engineered sharps injury protections and needleless

systems) that isolate or remove the blood-borne pathogens hazard from

the workplace."

Another helpful OSHA resource that has detailed information about the

standard is: Most Frequently Asked Questions Concerning the Blood-

Borne Pathogens Standard. It is available at this link:

https://www.osha.gov/pls/oshaweb/owadisp.show_document%3Fp_table=INTERPRE

TATIONS%26p_id=21010.

OSHA Blood-Borne Pathogen Standard: Definitions

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 12

Familiarity with definitions used by the OSHA blood-borne pathogens

standard can help increase understanding of and compliance with the

standard. The definitions provided here are essentially the same as

those found in the standard.

Blood-borne pathogens:

Pathogenic microorganisms that are present in human blood and can

cause disease in humans. These pathogens include, but are not limited

to, hepatitis B virus and HIV.

Contaminated:

Contamination involves the presence, or the reasonably anticipated

presence, of blood or other potentially infectious materials on an item

or surface.

Exposure:

Eye, mouth, other mucous membrane, non-intact skin, or parenteral

contact with blood or other potentially infectious materials that results

from the performance of an employee’s duties.

Other potentially infectious material: 1) semen, vaginal secretions,

cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid,

peritoneal fluid, amniotic fluid, saliva in dental procedures, any body

fluid that is visibly contaminated with blood, and all body fluids in

situations where it is difficult or impossible to differentiate between

body fluids; 2) Any unfixed tissue or organ (other than intact skin)

from a human (living or dead); 3) HIV-containing cell or tissue

cultures, organ cultures, and HIV- or hepatitis B virus-containing

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 13

culture medium or other solutions; and, 4) blood, organs, or other

tissues from experimental animals infected with HIV or hepatitis B

virus.

Compliance With The Blood-Borne Pathogens Standard:

Employers And Employees

Adherence to the OSHA blood-borne pathogen standard is mandatory

for all hospitals and healthcare facilities. To be in compliance with the

standard employers must establish a written plan for controlling

exposure to blood-borne pathogens. This plan should include 1) an

assessment of risk situations, 2) a determination of which employees

are at risk and when they are at risk, and 3) specific actions the

employer will use to control and manage exposure to blood-borne

pathogens. The plan must be reviewed and updated annually and it

must be accessible to all employees, as outlined below.

• Implement standard precautions, ensure that employees know

how to use standard precautions, and ensure they use standard

precautions.

• Provide personal protective equipment (PPE) at no cost to all

employees who need it.

• Provide initial training and annual training on blood-borne

pathogens to all employees. This training should include 1) a

review of the OSHA Blood-borne pathogens standard, 2)

information on the risks of exposures and how exposures

happen, 3) information on how to prevent exposures to blood-

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 14

borne pathogens, and 4) information on the benefits and risk of

vaccination against hepatitis B.

• Use engineering controls to control risk:

Engineering controls that control the risk of exposure to blood-

borne pathogens would include providing sharps disposal boxes,

using safe medical devices, using needles that do not need to be

re-capped, providing proper waste disposal containers, and using

appropriate signs to warn of danger and to instruct employees

on the proper use of equipment.

• Use work practice controls:

The employer must have a plan or plans in place for the proper

handling and disposal of blood and other specimens, the proper

handling and disposal of contaminated waste, and for the proper

cleaning and decontamination of equipment, patient rooms, and

patient care areas.

• Offer vaccination against hepatitis B to all employees who may

be reasonably expected to have an occupational exposure to the

hepatitis B virus.

• Have a plan to handle employee exposure to blood-borne

pathogens. This plan should include provisions for immediate

care (i.e., evaluation, first aid, laboratory screening tests, post-

exposure prophylactic medications) and follow-up care.

Nurses must comply with the requirements of the blood-borne

pathogens standard. The ones that address needlestick injuries and

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 15

exposure to a blood-borne pathogen will be discussed separately.

Other requirements of standard 1910.1030 that apply to nurses and

the practice of nursing:

• Understanding and following the engineering and work practice

controls established by the employer such as proper waste

disposal and adhering to the employer’s safety and sanitary

rules.

• Using PPE correctly:

The employee is required to wear the appropriate PPE. The PPE

must be removed immediately upon removing the work area, or

as soon as possible, and it must be placed in a container

specifically designated for the purpose of receiving contaminated

waste.

• Proper handling of blood and other body fluids.

• Understanding and using Universal Precautions

• Proper use of medical equipment; i.e., do not bend, break, or re-

cap needles. Do not re-use disposable medical equipment.

• Proper disposal of contaminated/potentially contaminated

medical equipment.

• Disposable gloves:

Disposable gloves must be discarded as soon as possible after

they have become contaminated, punctured, or torn. Gloves are

not required to be worn when giving an injection as long as hand

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 16

contact with blood or other potentially infectious material is not

reasonably expected.

• Hand washing:

Employees must wash their hands immediately after removing

gloves or as soon as possible after removing gloves. Employees

must wash their hands after contact with blood or other

potentially infectious material and before and after performing

patient care. If hand washing with soap and running water is not

possible, the employee must use either an antiseptic hand

cleaner with clean cloth or paper towels or antiseptic towelettes.

After using an antiseptic hand cleaner or a towelette, the

employees must wash their hands with soap and running water

as soon as feasible.

• Food and drink storage:

Food and drink should not be stored in refrigerators, cabinets,

etc., where blood or other potentially infectious material will be

stored.

• Bagging specimens:

Double-bagging specimens is required if the outside of the

specimen container is contaminated or if the specimen could

puncture the primary container.

Managing Exposures To Blood-Borne Pathogens

Managing exposures to blood-borne pathogens involves three steps:

1) initial care of the exposed person, 2) reporting the exposure and

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 17

investigating the circumstances, and 3) post-exposure prophylaxis, if

needed.

Table 3: Managing Exposures to Blood-Borne Pathogens

Initial Care ↓

Reporting the Exposure/Investigating the Circumstances ↓

Post-Exposure Prophylaxis

Initial care of the exposed person involves basic wound care. The first

step in managing an exposure to a blood-borne pathogen is to clean

the exposed area.19 If it is a percutaneous exposure or a skin exposure

wash the area with soap and water. Small puncture wounds can be

washed with an alcohol-based hand-wash; these are considered to be

virucidal for hepatitis B, hepatitis C, and HIV.19 Squeezing the wound

to express blood is not recommended nor is the use of over-the-

counter disinfectants such as bleach.27 Wash the eyes with saline or

water and flush mucous membranes with water.

Learning Break:

The blood-borne pathogens standard defines an exposure as eye, mouth,

other mucous membrane, non-intact skin, or parenteral contact with

blood or other potentially infectious materials that results from the

performance of an employee’s duties. Expanding this definition, an

exposure can also be described as: 1) a percutaneous injury such as a

needlestick or a sharps injury; 2) mucous membrane contact or non-

intact skin (skin that is abraded, chapped, or has dermatitis) contact with

blood, tissue, or potentially infectious body fluids.21

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 18

The next step is to report the exposure. This should be done as soon

as possible; do not delay reporting the incident. Information that

should be obtained and documented includes:

1. Exposure circumstances:

Documentation of the exposure circumstances should include the

date and time of the exposure, type of exposure, location of the

exposure (i.e., finger, hand, eye), estimated time of contact with

the blood or body fluid, how the exposure occurred, the body

fluid that was involved, any first aid that was done, PPE that was

in use, documentation of the affected person’s blood-borne

pathogens standard training, and, if it was a percutaneous

exposure, an estimation of the depth of the wound, if the needle

or sharp was in a blood vessel, and the size and type of the

needle or sharp.

2. Information about the affected healthcare professional:

Specific information about his/her vaccination for hepatitis B,

any previous tests for hepatitis B, hepatitis C, or HIV, status of

his/her tetanus immunization, medical history, and the names

and doses of prescription medications currently being taken.

Learning Break:

If the affected healthcare professional has received the complete hepatitis

B vaccination and she/he is known to have a response to the vaccination -

defined as Hepatitis B surface antibody concentration ≥ 10 mIU/mL - then

the source patient does not need to be evaluated for the presence of

hepatitis B and the affected person does not need post-exposure

prophylaxis.27

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 19

3. Information about the source:

The source patient should be evaluated for the presence of

hepatitis B, hepatitis C, and HIV, unless their status regarding

these diseases is known. The laws that govern testing of source

patients will not be discussed here. Affected healthcare workers

must assume that their employer will comply with these laws.

Post-Exposure Treatment And Prophylaxis For Hepatitis B

The need for post-exposure treatment and prophylaxis after exposure

to hepatitis B is determined by an evaluation of the source patient and

the affected healthcare professional.

1. Evaluation of the source patient.

a. The source patient should be tested for hepatitis B surface

antigen even if they have previously been tested.27

b. If the source patient is known to be infected or if the affected

healthcare professional has received hepatitis B vaccination and

has a documented adequate response, the source patient does

not need to be tested.

2. Evaluation of the affected healthcare professional: There are five

possibilities and there is a specific post-exposure prophylaxis plan

for each one:

a. Complete hepatitis B vaccination with response

b. There is evidence of a prior infection with hepatitis B

c. Hepatitis B vaccination has been completed but the hepatitis B

surface antibody concentration is < 10 mIU/mL

d. Hepatitis B vaccination has been completed but serologic

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 20

testing for a response has not been done or serologic testing

was done and the response is not known

e. The affected person has not been vaccinated or the

vaccination series has not been completed

For a and b there is no need for post-exposure prophylaxis. For c, d,

and e post-exposure prophylaxis may be needed depending on the

Hepatitis B status of the source. If the source patient is known as

being infected, or if the hepatitis B status of the source patient cannot

be determined, post-exposure prophylaxis should be done.27

Table 4: Post-Exposure Prophylaxis for Hepatitis B

One dose of hepatitis B immune globulin

One dose of hepatitis B vaccine

Two more doses of hepatitis B vaccine

The immune globulin and the first dose of the hepatitis B vaccine can

be given at the same time but at different injection sites. The hepatitis

B immune globulin should be give within 24 hours after the exposure

and it must be given within 7 days of the exposure.43 The second and

third doses of the hepatitis B vaccine are given 1 month and 6 months

after the initial dose even if the source patient is subsequently known

not to be infected. Testing for hepatitis B infection should be done six

months after the exposure. During this six-month period the affected

healthcare professional should not donate blood, organs, plasma,

semen, or tissue, but she or he can perform their normal duties.43 The

need for tetanus vaccination should also be considered.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 21

Post-Exposure Treatment And Prophylaxis For Hepatitis C

There is no effective post-exposure prophylaxis for hepatitis C.27 If

there has been an exposure the source patient should be tested for the

presence of hepatitis C, unless it is known that the patient is infected.

The affected healthcare professional should be tested for the presence

of hepatitis C, as well. If the source patient is not infected then no

further evaluation of the affected healthcare professional is needed. If

the source patient is infected with hepatitis C then the healthcare

professional: 1) should be counseled about the risk for transmission

and infection, 2) he/she should be tested for hepatitis C antibodies and

hepatitis C RNA at the time of exposure and every two months for six

months, and he/she should be referred to a specialist for ongoing

evaluation and, if needed, treatment.27 Donation of blood, organs,

plasma, semen, and tissue should not be done before the hepatitis C

status has been determined. The need for tetanus vaccination should

also be considered.

Post-Exposure Treatment And Prophylaxis For HIV

The need for post-exposure treatment and prophylaxis after exposure

to human immunodeficiency virus is determined by an evaluation of

the source patient and the affected healthcare professional.

1. Evaluation of the source patient.

b. If the HIV status of the source patient is unknown, rapid HIV

testing should be done. Depending on the specific test used, the

result will be available in 5-20 minutes and these tests have

excellent sensitivity and specificity.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 22

c. If the source patient is known to be HIV-positive testing is not

necessary.

2. Evaluation of the affected healthcare professional.

a. Evaluation should be done immediately after wound care or

decontamination has been completed.

b. The benefits and risks of post-exposure prophylaxis should be

thoroughly discussed.

c. If the source patient is known to have an HIV infection, post-

exposure prophylaxis should be started within 1-2 hours of the

exposure.19 Animal studies indicate that delaying administration

of post-exposure prophylaxis decreases its effectiveness,44,45 and

post-exposure prophylaxis should be started as soon as possible

and ideally within 72 hours of the exposure.21,46 It is not known

at what point after an exposure there would be no benefit from

post-exposure prophylaxis.21

d. If the HIV status of the source patient is unknown post-exposure

prophylaxis should be started and if the result of the rapid

testing is negative, treatment can be discontinued.21 Do not

delay starting treatment while waiting for the test results.

e. Laboratory evidence and confirmation of an HIV infection can be

delayed for up to 3 months after an exposure; this is commonly

termed the “window period” of HIV infection. However, the U.S.

Public Health Services Guidelines for post-exposure prophylaxis

state “... investigation of whether a source patient might be in

the window period is unnecessary for determining whether HIV

PEP is indicated unless acute retroviral syndrome is clinically

suspected.”21 In most cases, rapid testing alone is sufficient.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 23

f. The affected healthcare professional should be tested for the

presence of HIV and other blood-borne pathogens, if needed.

The need for tetanus vaccination should also be considered.

The recommended therapy is a three-drug regimen using the

nucleotide analogue reverse transcriptase inhibitor-nucleotide reverse

transcriptase inhibitor tenofovir-emtricitabine (Truvada™) and the

integrase inhibitor raltegravir (Isentress™) for four weeks.19,21 Four

weeks is recommended as in vitro studies, animal studies, and

occupational studies indicate this is the optimal duration of

treatment.21

The combination of tofovir-emtricitabine and raltegravir is a commonly

used regimen for HIV prophylaxis but there are other regimens that

are considered acceptable.21 As with any drug therapy, medications

used for post-exposure prophylaxis for HIV should be prescribed with

considerations of their effectiveness and tolerability. Tolerability is

especially important as the side effects of tofovir-emtricitabine and

raltegravir and other post-exposure prophylaxis medications can have

a negative influence of compliance with therapy.21 The potential for

drug-drug interactions is also very important. Commonly used drugs

such as oral contraceptives, H2 receptor antagonist, and proton pump

inhibitors can cause potentially serious drug interactions when used

with HIV post-exposure prophylaxis drugs.

Follow-up care is essential for persons receiving post-exposure

prophylaxis. The exposed person should be re-evaluated 72 hours

after the incident regardless of whether or not he or she is being

treated.21 Testing for HIV should be done at the time of the exposure,

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 24

and 6 weeks, 12 weeks, and 6 months after the exposure.21 A

complete blood count and measurement of hepatic and renal function

should be done at the time of exposure and two weeks later.21 In the

six months following the exposure abstinence from sexual intercourse

or the use of condoms is recommended, and the exposed healthcare

professional should not donate blood, organs, plasma, semen, or

tissues.19 These precautions are especially important in the first 6-12

weeks after an exposure. 21

Special Situations

In some circumstances of exposure to HIV an expert consultation

should be sought.

Table 5: The Need for Expert Consultation

Breastfeeding

Chronic illness that may increase drug toxicity

Delay is reporting the exposure

Current drug therapy that may increase toxicity of post-exposure

prophylaxis

Drug-resistant HIV

Pregnancy

Unknown source, i.e., a needle that is in a sharps container

Breastfeeding and pregnancy are not contraindications for the use of

post-exposure prophylaxis for HIV,21 and women who are

breastfeeding or pregnant should receive post-exposure prophylaxis if

it is indicated. There is a significant risk of in utero transmission of HIV

and transmission of HIV through breastfeeding and although the data

is limited, it does not appear that the use of post-exposure

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 25

prophylactic drugs increases the number of birth defects or is harmful

to breastfeeding infants.21,47 Efavirenz (Sustiva™) is teratogenic and

should not be used in pregnant women.48 Up-to-date information

about the use of antiviral drugs during pregnancy can be found on the

website of the Antiviral Pregnancy Registry, www.apr.com. Information

can also be obtained by calling the National Perinatal HIV Hotline, 7

days a week, 24 hours a day, 1-888-448-8765.

Exposure to, and subsequent infection with drug-resistant strains of

HIV has been reported to occur after occupational exposure to HIV,

despite early use of post-exposure prophylaxis.49-51 It is not practical

to perform drug-resistance testing immediately after exposure to HIV

so standard post-exposure prophylaxis should be initiated as soon as

possible; treatment should not be delayed while waiting for drug-

resistance testing.21 If there is a possibility that the source patient may

be infected with a drug-resistant strain of HIV, expert consultation

should be sought and without delay; post-exposure prophylaxis should

be started right away.21 The drug regimen can be changed later if this

is needed.

Exposure to a needle or a sharp from an unknown source should not

occur with good adherence to the blood-borne pathogens standards. If

an exposure of this type occurs the need for post-exposure prophylaxis

should be determined on a case-by-case basis. The needle or the

sharp does not need to be tested.21

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 26

Learning Break:

The Clinicians’ Post-Exposure Prophylaxis Hotline (PEPline) is available

from 9 a.m., to 2 a.m., seven days a week and can provide consultation

about risk assessment and post-exposure prophylaxis: 888-448-4911.

Clinical guidelines for risk assessment and treatment and post-exposure

prophylaxis recommendations for exposure to HIV, hepatitis B, and

hepatitis C are available on their website,

http://nccc.ucsf.edu/clinician-consultation/post-exposure-prophylaxis-

pep/.

Summary

The OSHA blood-borne pathogens standard was developed to help

reduce transmission of and infection with blood-borne pathogens. The

Blood-borne pathogens standard has general and specific

recommendations, and nurses are required to have a basic knowledge

of and comply with the recommendations of the standard. The

recommendations are general and specific and requirements of

standard 1910.1030 that apply to nurses and the practice of nursing

are:

• Understanding and following the engineering and work practice

controls such as proper waste disposal and adhering to the

employer’s safety and sanitary rules.

• Using PPE correctly.

• Proper handling of blood and other body fluids.

• Proper use of medical equipment, particularly needles, sharps,

and disposable medical equipment.

• Proper disposal of contaminated or potentially contaminated

medical equipment

• Hand washing

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 27

• Universal precautions

• Proper use of gloves

Familiarity with the plan is required of nurses, but as needle sticks,

sharps injuries, and splash contact with blood and body fluids are

common occupational occurrences for nurses they need more

information, such as:

• Transmission of and infection with a blood-borne pathogen is

unusual after a needlestick, sharps injury or cutaneous

exposure, but the potential medical consequences are quite

serious and research indicates that the psychological burden of a

needlestick can be significant.52,53

• The risk of transmission of and infection with a blood-borne

pathogen depends on the circumstances of the exposure, the

pathogen, and the characteristics of the exposed individual.

Hepatitis B is highly transmittable, hepatitis C and HIV much less

so, and the risk of infection from a mucous membrane exposure

to any of these viruses is slight.

• All exposures to blood-borne pathogens must be reported

immediately. Do not try and evaluate the level of risk yourself.

• Clean or flush the affected area.

• The need for treatment and post-exposure prophylaxis will

depend on the circumstances of the exposure, the infectivity of

the source patient, and the characteristics of the person who

was exposed.

• If there is a risk for infection with HIV post-exposure prophylaxis

should be started as soon as possible after the exposure,

preferably within 1-2 hours.

• There is no post-exposure prophylaxis for hepatitis C.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 28

• Post-exposure prophylaxis for hepatitis B is available.

• Expert consultation should be sought if there are special or

unusual circumstances, i.e., potential for exposure to a drug-

resistant virus.

The OSHA blood-borne pathogens standard also requires employers to

have in place a plan for managing exposures to blood-borne

pathogens. The plan should provide basic information about blood-

borne pathogen transmission and guidance about what to do in the

event of an exposure.

Please take time to help NurseCe4Less.com course planners

evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the

article, and providing feedback in the online course evaluation.

Completing the study questions is optional and is NOT a course requirement.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 29

1. The majority of occupational exposures to blood-borne

pathogens are

a. percutaneous. b. air-borne.

c. cutaneous. d. percutaneous and cutaneous together.

2. The most common blood-borne pathogens in occupational

exposures are:

a. Hepatitis B, hepatitis D, and MRSA. b. Hepatitis C, HIV, and tuberculosis.

c. Hepatitis B, hepatitis C, and HIV. d. Hepatitis E, HIV, and gram-negative bacteria.

3. The risk of HIV transmission after a percutaneous exposure is approximately

a. 3.0%.

b. 0.3%. c. 30%.

d. 13%.

4. True or False: Infection with a blood-borne pathogen can occur after contact with a contaminated surface.

a. True

b. False

5. The first step in managing an exposure to a blood-borne

pathogen is:

a. Testing of the source patient. b. Notifying the employee health department.

c. Testing of the affected healthcare professional. d. Perform basic wound care or flush the affected area.

6. An exposure to a blood-borne pathogen should be reported:

a. Within 24 hours of the exposure.

b. At the end of the shift. c. Immediately.

d. Within seven days of the exposure.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 30

7. Post-exposure prophylaxis for Hepatitis B:

a. Is not needed if vaccination is complete and the response is

adequate. b. Should be given only if the exposure involved a large amount of

blood. c. Is not needed if the source patient has had Hepatitis B for > 10

years. d. Should be given only if the source patient is not known.

8. True or False: There is effective post-exposure prophylaxis

for Hepatitis C.

a. True b. False

9. Post-exposure prophylaxis for HIV should be started:

a. Within 7 days of the exposure. b. After drug-resistance testing is completed.

c. Within 1-2 hours of the exposure. d. After tests for Hepatitis B and C and HIV have been completed.

10. The OSHA blood-borne pathogens standard requires

employers to:

a. Test each employee yearly for infection with blood-borne pathogens.

b. Provide pre-exposure prophylaxis for HIV. c. Test at-risk patient for blood-borne pathogens.

d. Have a plan for the management of exposures to blood-borne

pathogens.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 31

CORRECT ANSWERS:

1. The majority of occupational exposures to blood-borne

pathogens are

a. percutaneous.

“The majority of occupational exposures to and infections from these viruses are caused by percutaneous injury.”

2. The most common blood-borne pathogens in occupational

exposures are:

c. Hepatitis B, hepatitis C, and HIV.

“Many bacteria and viruses can be, and have been transmitted to

healthcare workers by needlesticks, sharps injury, or splash contact, but hepatitis B, hepatitis C, and the human

immunodeficiency virus (HIV) account for the greatest number of exposures and infections.”

3. The risk of HIV transmission after a percutaneous exposure

is approximately:

b. 0.3%.

“The risk of infection after a percutaneous exposure to HIV has been estimated to be 0.32% and the risk for infection after a

mucous membrane exposure to HIV has been estimated to be 0.03%-0.09%.”

4. True or False: Infection with a blood-borne pathogen can occur after contact with a contaminated surface.

a. True

“Blood-borne pathogens can contaminate surfaces and

persist in the environment and contact with these contaminated surfaces can cause infection.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 32

5. The first step in managing an exposure to a blood-borne

pathogen is:

d. Perform basic wound care or flush the affected area.

"Initial care of the exposed person involves basic wound care. The first step in managing an exposure to a blood-borne

pathogen is to clean the exposed area. If it is a percutaneous exposure or a skin exposure wash the area with soap and water.

Familiarity with the plan is required of nurses, but as needle sticks, sharps injuries, and splash contact with blood and body

fluids are common occupational occurrences for nurses they need more information, such as:... Clean or flush the affected

area.”

6. An exposure to a blood-borne pathogen should be reported:

c. Immediately.

“All exposures to blood-borne pathogens must be reported

immediately. Do not try and evaluate the level of risk yourself.”

7. Post-exposure prophylaxis for Hepatitis B:

a. Is not needed if vaccination is complete and the response is adequate.

“If the affected healthcare professional has received the

complete hepatitis B vaccination and she/he is known to have a response to the vaccination - defined as Hepatitis B surface

antibody concentration ≥ 10 mIU/mL - then the source patient

does not need to be evaluated for the presence of hepatitis B and the affected person does not need post-exposure

prophylaxis.”

8. True or False: There is effective post-exposure prophylaxis for Hepatitis C.

b. False

“There is no effective post-exposure prophylaxis for hepatitis C.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 33

9. Post-exposure prophylaxis for HIV should be started:

c. Within 1-2 hours of the exposure.

“If the source patient is known to have an HIV infection, post-

exposure prophylaxis should be started within 1-2 hours of the exposure.”

10. The OSHA blood-borne pathogens standard requires

employers to:

d. Have a plan for the management of exposures to blood-borne pathogens.

“The OSHA blood-borne pathogens standard also requires

employers to have in place a plan for managing exposures to

blood-borne pathogens.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 34

References Section

The References below include published works and in-text citations of

published works that are intended as helpful material for your further reading.

1. Occupational Safety and Health Administration. Blood-borne pathogens. Standard CFR 1910.1930. Retrieved April 15, 2015

from

https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p_id=10051.

2. Tarantola A, Abiteboul D. Rachline A. Infection risks following accidental exposure to blood or body fluids in healthcare workers:

a review of pathogens transmitted in public cases. Am J Infect Control. 2006; 34:367-75.

3. Pedrosa PB, Cardoso TA. Viral infections in workers in hospital and research laboratory settings: a comparative review of infection

modes and respective biosafety aspects. Int J Infect Dis. 2011;15:e366-76

4. Centers for Disease Control and Prevention. Sharps injuries stop sticks campaign. Centers for Disease Control and Prevention;

National Institute for Occupational Safety and Health. June 24, 2011. Retrieved April 14, 2015 from

http://www.cdc.gov/niosh/stopsticks/sharpsinjuries.html.

5. International Healthcare Worker Safety Center University of Virginia. 2011 EPINet Report: Needlestick and Sharp-Object

Injuries. Retrieved April 16, 2015 from http://www.healthsystem.virginia.edu/pub/epinet/EPINet2011-

NeedlestickRpt.pdf. 6. Karmon SL, Mehta SA, Brehm A, Dzurenko J, Phillips M. Evaluation

of bloodborne pathogen exposures at an urban hospital. Am J of Infect Control. 2013;41:185-6.

7. Henderson DK. Management of Needlestick Injuries: A House Officer Who Has a Needlestick. JAMA. 2012;307:75-84.

8. Memish ZA, Assiri AM, Eldalatony MM, Hathout HM. Benchmarking of percutaneous injuries at the Ministry of Health hospitals of

Saudi Arabia in comparison with the United States hospitals participating in Exposure Prevention Information Network

(EPINet™). Int J Occup Environ Med. 2015;6:26-33.

9. Bernard JA, Datillo JR, LaPorte D.M. The incidence and reporting of sharps exposure among medical students, orthopedic residents,

and faculty at one institution. J Surg Ed. 2013;70:660-8.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 35

10. Beltrami EM, McArthur MA,McGeer A, Armstrong-Evans M, Lyons

D, Chamberland ME, et al. The nature and frequency of blood contacts among home healthcare workers. Infect Control Hosp

Epidemiol. 2000;21:765-70. 11. Burke S, Madan I. Contamination incidents among doctors and

midwives: reasons for non-reporting and knowledge of risks. Occup Med (Lond). 1997; 357-60.

12. Hamory BH. Underreporting of needlestick injuries in a university hospital. Am J Infect Control. 1983;11:174-7.

13. Camacho-Ortiz A., Díaz-Rodríguez X, Rodríguez-López, JM, Martínez-Palomares M, Palomares-De la Rosa A, Garza-Gonzalez

E. A 5-year surveillance of occupational exposure to bloodborne pathogens in a university teaching hospital in Monterrey, Mexico.

Am J Inf Control. 2013;41: e85-8. 14. Rhode KA, Dupler AE, Postma J, Sanders A. Minimizing nurses’

risks for needlestick injuries in the hospital setting. Workplace

Health Saf. 2013; 61:197-202. 15. Yang YH, Wu SJ, Wang CL, Yang CY, Liou SH, Wu TN. Incidence of

needlestick and other sharp object injuries in newly graduated nurses. Am J Infect Control. 2013; 41:944-5.

16. Waseem M. Body fluid exposures. eMedicine. January 22, 2105. Retrieved April 16, 2015 from

http://emedicine.medscape.com/article/782611-overview. 17. Ippolito G, Puro V, Heptonstall J, Jagger J, De Carli G, Petrosillo N.

Occupational human immunodeficiency virus infection in health care workers: worldwide cases through September 1997. Clin

Infect Dis. 1999;28:365-83. 18. Ridzon R, Gallagher K, Ciesielski C, Ginsberg MB, Robertson BJ,

Luo CC, et al. Simultaneous transmission of human immunodeficiency virus and hepatitis C virus from a needle-stick

injury. N Engl J Med. 1997;33:6919-22.

19. Bartlett JG, Weber DJ. Management of healthcare personnel exposed to HIV. UpToDate. July 18, 2012. Retrieved April 16,

2015 from http://www.uptodate.com/contents/management-of-healthcare-

personnel-exposed-to-hiv?source=search_result&search=Management+of+healthcare+p

ersonnel+exposed&selectedTitle=1%7E150. 20. Ippolito G, Puro V, De Carli G. The risk of occupational human

immunodeficiency virus infection in health care workers. Arch Intern Med. 1993;153:1451-8.

21. Kuhar DT, Henderson DK, Struble KA, Heneine W, Thomas V, Cheever LW, et al. Updated US Public Health Service Guidelines for

the management of occupational exposure to human

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 36

immunodeficiency virus and recommendations for post-exposure

prophylaxis. Infect Control Hosp Epidemiol. 2013;34:875-92. 22. No authors listed. Needle stick injuries in the community.

Paedatrics. 2008;13:205-10. 23. Centers for Disease Control and Prevention. Healthcare-

associated infections. Surveillance of occupationally acquired HIV/AIDS in healthcare personnel, as of December

2010. May 23, 201. Retrieved April 17, 2015 from http://www.cdc.gov/HAI/organisms/hiv/Surveillance-

Occupationally-Acquired-HIV-AIDS.html. 24. MacCannell T, Laramie AK, Gomaa A, Perz JF. Occupational

exposure of health care personnel to hepatitis B and hepatitis C: prevention and surveillance strategies. Clin Liver Dis. 2010;14:23-

36. 25. Centers for Disease Conrol and Prevention. Recommendations for

prevention of transmission of human immunodeficiency virus and

hepatitis B virus to patients during exposure-prone procedures. 2001. Retrieved April 20, 2015 from

http://www.cdc.gov/mmwr/preview/mmwrhtml/00014845.htm 26. Dienstag JL. Acute viral hepatitis. In: Long DI, Fauci AS, Kasper

DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison’s Principles of Internal, on-line ed. 18th ed. 2012. New York, NY: McGraw-Hill.

Retrieved April 16, 2015 from http://www.accessmedicine.com.online.uchc.edu/content.aspx?aI

D=9133699&searchStr=hepatitis+b#9133699 27. Weber DJ, Rutala WA. Prevention of hepatitis B virus and hepatitis

C virus infection among healthcare workers. UpToDate. April 6, 2015. Retrieved April 17, 2015 from

http://www.uptodate.com/contents/prevention-of-hepatitis-b-virus-and-hepatitis-c-virus-infection-among-healthcare-

providers?source=search_result&search=Prevention+of+hepatitis

+b+virus+and+hepatitis+C&selectedTitle=1%7E150. 28. Strasser M, Aigner E, Schmid I, Stadlmayr A, Niederseer D, Patsch

W, et al. Risk of hepatitis C virus transmission from patients to healthcare workers: a prospective observational study. Infect

Control Hosp Epidemiol. 2013;34:759-61. 29. Medeiros WP, Setúbal S, Pinheiro PY, Dalston MO, Bazin AR, de

Oliveira SA. Occupational hepatitis C seroconversions in a Brazilian hospital. Occup Med (Lond). 2012;62:655-7.

30. Hosoglu S, Celen MK, Akalin S, Geyik MF, Soyoral Y, Kara IH. Transmission of hepatitis C by blood splash into conjunctiva in a

nurse. Am J Infect Control. 2003;31:502-4. 31. Rosen, H. R. 1997. Acquisition of hepatitis C by a conjunctival

splash. Am J Infect Control. 25:242-7.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 37

32. Sartori, M., G. La Terra, M. Aglietta, A. Manzin, C. Navino, and G.

Verzetti. 1993. Transmission of hepatitis C via blood splash into conjunctiva. Scand J Infect Dis. 25:270-1.

33. Henderson DK. Managing occupational risks for hepatitis C transmission in the health care settings. Clin Micro Rev.

2003;16:546-68. 34. Kramer A, Schwebke I, Kampf G. How long do nosocomial

pathogens persist on inanimate surfaces? A systematic review. BMC Infect Dis. 2006;16:130.

35. Bond WW, Favero MS, Petersen NJ, Gravelle CR, Ebert JW, Maynard JE. Survival of hepatitis virus after drying and storage for

one week. Lancet. 1981;1:550-1 36. Kamali, S., Krawczynski, K., McCaustland, K. Li, X., Alter, M.

Infectivity of hepatitis C virus in plasma after drying and storing at room temperature. Infect Control Hosp Epidemiol. 2007;28:519-

24.

37. Paintsil E, Binka M, Patel A, Lindenbach BD, Heimer R. Hepatitis C virus maintains infectivity for weeks after drying on inanimate

surfaces at room temperature: implications for risks of transmission. J Infect Dis. 2014;209:1205-11.

38. Patrician PA, Pryor E, Fridman M, Loan L. Needlestick injuries among nursing staff: association with shift-level staffing. Am J

Infect Control. 2011:39:477-82. 39. Olds DM, Clarke SP. The effect of hospital work hours on adverse

events and errors in health care. J Safety Res. 2010; 41:153-62. 40. Lauer AC, Reddemann A, Meier-Wronski CP, Bias H, Gödecke K,

Arendt M, et al. Needlestick and sharps injuries among medical undergraduate students. Am J Infect Control. 2014;42:235-9.

41. Cho E, Lee H, Choi M, Park SH, Yoo IY, Aiken LH. Factors associated with needlestick and sharp injuries among hospital

nurses: a cross-sectional questionnaire survey. Int J Nurs Stud.

2013; 50:1025-32. 42. Clarke SP. Hospital work environments, nurse characteristics, and

sharps injuries. Am J Infect Control. 2007;35:302-9. 43. Schillie S, Murphy TV, Sawyer M, Ly K, Hughes E, Jiles R, et

al. CDC guidance for evaluating health-care personnel for hepatitis B virus protection and for administering

postexposure management. MMWR Recommend Report. 2013;62:1-19.

44. Tsai CC, Follis KE, Sabo A, Beck TW, Grant RF, Bischofberger N, et al. Prevention of SIV infection in macaques by (R)-9-(2-

phosphonylmethoxypropyl)adenine. Science. 1995;270:1197-9. 45. Otten RA, Smith DK, Adams DR, Pullium JK, Jackson E, Kim CN, et

al. Efficacy of postexposure prophylaxis after intravaginal exposure

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 38

of pig-tailed macaques to a human-derived retrovirus (human

immunodeficiency virus type 2). J Virol. 2000;74:9771-5. 46. Smith DK, Grohskopf LA, Black RJ, Auerbach JD, Veronese F,

Struble KA, et al. Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to

HIV in the United States: recommendations from the U.S. Department of Health and Human Services. MMWR Recomm Rep.

2005;54:1-20. 47. Antiretroviral Pregnancy Registry Steering Committee.

Antiretroviral Pregnancy Registry International Interim Report for 1 January 1989 through 31 July 2011. Wilmington, NC: Registry

Coordinating Center, 2011. 48. Lexi-Drugs.® Efavirenz. April 16, 2015. Retrieved April 21, 2015

from Lexicomp® at www.uchc.edu. 49. Hawkins DA, Asboe D, Barlow K, Evans B. Seroconversion to HIV-1

following a needlestick injury despite combination postexposure

prophylaxis. J Infect. 2001;43:12-5. 50. Beltrami EM, Luo CC, de la Torre N, Cardo DM. Transmission of

drug-resistant HIV after an occupational exposure despite postexposure prophylaxis with a combination drug regimen. Infect

Control Hosp Epidemiol. 2002;23:345-8. 51. Perdue B, Wolfe Rufael D, Mellors J, Quinn T, Margolick J. HIV-1

transmission by a needle-stick injury despite rapid initiation of four-drug postexposure prophylaxis. Presented at: 6th Conference

on Retroviruses and Opportunistic Infections, 1999, Chicago. 52. Wicker S, Stirn AV, Rabenau HF, von Gierke L, Wutzler S, Stephan

C. Needlestick injuries: causes, preventability and psychological impact. Infection. 2014;42:549-52.

53. Naghavi SH, Shabestari O, Alcolado J. Post-traumatic stress disorder in trainee doctors with previous needlestick injuries.

Occup Med (Lond). 2013;63:260-5.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 39

The information presented in this course is intended solely for the use of healthcare

professionals taking this course, for credit, from NurseCe4Less.com.

The information is designed to assist healthcare professionals, including nurses, in

addressing issues associated with healthcare.

The information provided in this course is general in nature, and is not designed to

address any specific situation. This publication in no way absolves facilities of their

responsibility for the appropriate orientation of healthcare professionals.

Hospitals or other organizations using this publication as a part of their own

orientation processes should review the contents of this publication to ensure

accuracy and compliance before using this publication.

Hospitals and facilities that use this publication agree to defend and indemnify, and

shall hold NurseCe4Less.com, including its parent(s), subsidiaries, affiliates,

officers/directors, and employees from liability resulting from the use of this

publication.

The contents of this publication may not be reproduced without written permission

from NurseCe4Less.com.