[MCOH-EH] Timing for best practices, first dose PEP for BBF exposure

[Swift, Melanie]

2 hours is what we recommend. This is largely based on macaque models using SIV. Monkeys exposed to SIV got PEP at different points postexposure. 100% protective if PEP given within 2 hours, after that there was decreased efficacy in one study (trying to find it.) Other studies showed good efficacy when PEP started at 24 hrs, but decreased at 48 and 72. Also PEP started within 4 hrs but continued for only 3 days was not effective. (in monkeys)

Melanie Swift, MD
Director, Vanderbilt Occupational Health Clinic
http://occupationalhealth.vanderbilt.edu

From: MCOH-EH [mailto:mcoh-eh-bounces at mylist.net] On Behalf Of Galaid Edward I
Sent: Monday, June 29, 2015 7:34 AM
To: Occ-Env-Med-L at listserv.unc.edu; mcoh-eh at mylist.net
Subject: [MCOH-EH] Timing for best practices, first dose PEP for BBF exposure

I'm cross posting this with MCOH and OEM-L.

We're in the process of doing a line-by-line review of our policies and procedures.  Decisionmaking for PEP is of concern, particularly as it pertains to after-hours...on the inpatient side, and now we have many varied outpatient sites scattered throughout the region...physician offices, freestanding EDs, urgent care,  surgicenters.   Our occ health nurses and the clinical managers on the floors do a very good job on staying on top of things during regular business hours for our hospitals.   Employees are directed to the EDs for afterhours.  We do not have a formal 24-hour coverage for the employee health office, but I make myself available.

This is a pretty basic question...do we have a consensus as to optimal timeframe to start PEP, if indicated?  72 hours?  That's what's stated on the aids.gov and cdc.gov websites.
In the past, I have tried to get the exposure assessment and first dose on board within 4 hours of exposure.  I thought there were some data to support this.  Now I can't find it.

I poked around the web a bit...the New York State/Johns Hopkins website says, "ideally" within two hours.

The PEP line from UCSF says, "...Efficacy is time sensitive: first dose should be given as soon as possible. Optimal time to start PEP is within hours of exposure, rather than days. Do not wait for SP test results (unless results of rapid test will be available within an hour or two) to proceed with a PEP decision and treatment, when indicated. The PEPline considers 72 hours post-exposure as the outer limit of opportunity to initiate PEP; however, a delay of that scale is believed to compromise PEP efficacy.  The 72-hour outside limit recommendation is based on animal studies; no human data are available...."

The NEJM review from 2009 by Landovitz and Currier stated, "...Postexposure prophylaxis should be initiated as rapidly as possible after exposure to HIV. Data from macaques that were exposed to challenge with simian immunodeficiency virus suggest a greater benefit of postexposure prophylaxis when it is initiated within 36 hours after exposure as compared with 72 hours after exposure."

Any insight appreciated.

Ed Galaid


Edward I. Galaid, MD, MPH
ABIM, ABPM
Medical Director, RSF Workforce Health Solutions
Roper St. Francis Healthcare   Charleston, SC
Member, ACOEM Task Group on Medical Guidance for Law Enforcement Officers
Member, NFPA 1582 Writing Group - NFPA Technical Committee on Fire Fighter Safety and Health
843-906-0519




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