Posts filed under ‘Profilaxis Post-Exposición’

Editor’s Choice: Editorial Commentary: Decision Science at Work: The Case of Hepatitis C Virus Postexposure Prophylaxis

Clinical Infectious Diseases January 1, 2017 V.64 N.1 P.100-101

Joshua A. Barocas and Benjamin P. Linas

1Division of Infectious Diseases, Massachusetts General Hospital

2Boston University Schools of Medicine and Public Health

3Boston Medical Center, Massachusetts

In this issue of Clinical Infectious Diseases, Naggie et al discuss clinical decision making and present the results of a decision analysis examining the cost of hepatitis C virus (HCV) postexposure prophylaxis (PEP) among healthcare workers who experience a needlestick exposure to HCV-positive body fluids.

The authors discuss that, in an era when we can cure essentially all HCV infections, there are only 3 motivations for PEP. First, it may make sense to use PEP to prevent infections if doing so would decrease HCV transmission during the period of active HCV viremia.

The paper succinctly reviews the evidence and quickly makes clear that among healthcare workers in the United States with a known HCV exposure, basic universal precautions reduce the risk of forward transmission to essentially zero.

 

A second motivation might be cost. Given that HCV medications are expensive, a shorter course PEP may be cost saving compared with full treatment for HCV infection. To address the possible economic rationale for PEP, the authors developed a decision tree to estimate the costs of PEP for HCV in a hypothetical cohort of 100 healthcare workers who had suffered a needlestick injury.

They used the model to compare the outcomes with PEP to those with a strategy of “no PEP and treat only patients who develop chronic HCV infection.”

A few notable assumptions were made—namely, that PEP was 100% effective at preventing infection, while treatment for chronic HCV was only 98% effective with the first line of therapy.

In addition, individuals who failed first-line treatment for chronic HCV infection were retreated with 100% . . .

PDF

https://cid.oxfordjournals.org/content/64/1/100.full.pdf+html

December 24, 2016 at 2:04 pm

Editor’s Choice: Hepatitis C Virus Postexposure Prophylaxis in the Healthcare Worker: Why Direct-Acting Antivirals Don’t Change a Thing

Clinical Infectious Diseases January 1, 2017 V.64 N.1 P.92-99

Susanna Naggie, David P. Holland, Mark S. Sulkowski, and David L. Thomas

1Duke Clinical Research Institute

2Duke University School of Medicine, Durham, North Carolina

3Emory University School of Medicine, Atlanta, Georgia

4Johns Hopkins School of Medicine, Baltimore, Maryland

Currently, 380 000–400 000 occupational exposures to blood-borne pathogens occur annually in the United States.

The management for occupational HIV or hepatitis B virus exposures includes postexposure prophylaxis (PEP) when necessary; however, PEP is not recommended for hepatitis C virus (HCV) exposures.

Recent approval of HCV direct-acting antivirals (DAAs) has renewed discussions as to whether these therapies could be used to prevent infection after exposure. There are no published studies addressing this question, but the prescribing of DAAs for PEP has been reported.

We will discuss the differences in transmission of the 3 most common blood-borne pathogens, the natural history of early HCV infection, and the scientific rationale for PEP.

In particular, we will discuss how the low feasibility of conducting an adequately powered clinical trial of DAA use for PEP and the low cost-effectiveness of such an intervention is not supportive of targeting limited resources for such use.

PDF

https://cid.oxfordjournals.org/content/64/1/92.full.pdf+html

December 24, 2016 at 2:02 pm

2015 UK National GUIDELINE for the Use of HIV PEP Following Sexual Exposure

The British HIV Association

Introduction

We present the updated British Association for Sexual Health and HIV (BASHH) guidelines which aim to provide evidence-based recommendations for the most appropriate use of HIV post-exposure prophylaxis following sexual exposure (PEPSE).

The aim of PEPSE is to prevent HIV transmission. Risk of transmission, timing of PEP, preferred regimen, drug-drug interactions, follow-up, risk reduction and special scenarios are discussed. Consideration is given to the role of PEPSE within the broader context of HIV prevention and sexual health.

The guideline is intended to be complementary to existing Department of Health and Expert Advisory Group on AIDS (EAGA) guidance on PEP (1).

It is aimed primarily at clinicians and policymakers in sexual health, sexual assault referral centres (SARCs), and primary and emergency care providers within the UK who should consider the development of appropriate local pathways.

It is likely that this guideline will also be used for information provision by voluntary sector agencies to provide information for individuals.

The recommendations are aimed primarily at individuals aged 16 or older and may not be appropriate for use in all situations, including occupational exposures.

Decisions to follow these recommendations must be based on the professional judgment of the clinician and consideration of individual patient circumstances and available resources.

PDF

https://www.bashh.org/documents/PEPSE%202015%20guideline%20final_NICE.pdf

December 3, 2016 at 9:31 am

Treatment and prophylaxis of melioidosis.

Int J Antimicrob Agents. 2014 Apr;43(4):310-8.

Dance D1.

Author information

1Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People’s Democratic Republic; Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK. Electronic address: david.d@tropmedres.ac

Abstract

Melioidosis, infection with Burkholderia pseudomallei, is being recognised with increasing frequency and is probably more common than currently appreciated. Treatment recommendations are based on a series of clinical trials conducted in Thailand over the past 25 years. Treatment is usually divided into two phases: in the first, or acute phase, parenteral drugs are given for ≥10 days with the aim of preventing death from overwhelming sepsis; in the second, or eradication phase, oral drugs are given, usually to complete a total of 20 weeks, with the aim of preventing relapse. Specific treatment for individual patients needs to be tailored according to clinical manifestations and response, and there remain many unanswered questions. Some patients with very mild infections can probably be cured by oral agents alone. Ceftazidime is the mainstay of acute-phase treatment, with carbapenems reserved for severe infections or treatment failures and amoxicillin/clavulanic acid (co-amoxiclav) as second-line therapy. Trimethoprim/sulfamethoxazole (co-trimoxazole) is preferred for the eradication phase, with the alternative of co-amoxiclav. In addition, the best available supportive care is needed, along with drainage of abscesses whenever possible. Treatment for melioidosis is unaffordable for many in endemic areas of the developing world, but the relative costs have reduced over the past decade. Unfortunately there is no likelihood of any new or cheaper options becoming available in the immediate future. Recommendations for prophylaxis following exposure to B. pseudomallei have been made, but the evidence suggests that they would probably only delay rather than prevent the development of infection.

PDF

http://www.ijaaonline.com/article/S0924-8579(14)00018-1/pdf

January 12, 2016 at 3:52 pm

GeSIDA/National AIDS Plan: Consensus document on antiretroviral therapy in adults infected by the human immunodeficiency virus (Updated January 2014).

Enferm Infecc Microbiol Clin. 2014 Aug-Sep;32(7):446.e1-42.

Article in Spanish

Panel de expertos de GeSIDA; Plan Nacional sobre el Sida.

Abstract

OBJECTIVE:

This consensus document is an update of combined antiretroviral therapy (cART) guidelines for HIV-1 infected adult patients.

METHODS:

To formulate these recommendations a panel composed of members of the Grupo de Estudio de Sida and the Plan Nacional sobre el Sida reviewed the efficacy and safety advances in clinical trials, cohort and pharmacokinetic studies published in medical journals (PubMed and Embase) or presented in medical scientific meetings. Recommendations strength and the evidence in which they are supported are based on modified criteria of the Infectious Diseases Society of America.

RESULTS:

In this update, antiretroviral therapy (ART) is recommended for all patients infected by type 1 human immunodeficiency virus (HIV-1). The strength and grade of the recommendation varies with the clinical circumstances: CDC stage B or C disease (A-I), asymptomatic patients (depending on the CD4+ T-lymphocyte count: <350cells/μL, A-I; 350-500 cells/μL, A-II, and >500 cells/μL, B-III), comorbid conditions (HIV nephropathy, chronic hepatitis caused by HBV or HCV, age >55years, high cardiovascular risk, neurocognitive disorders, and cancer, A-II), and prevention of transmission of HIV (mother-to-child or heterosexual, A-I; men who have sex with men, A-III). The objective of ART is to achieve an undetectable plasma viral load. Initial ART should always comprise a combination of 3 drugs, including 2 nucleoside reverse transcriptase inhibitors and a third drug from a different family (non-nucleoside reverse transcriptase inhibitor, protease inhibitor, or integrase inhibitor). Some of the possible initial regimens have been considered alternatives. This update presents the causes and criteria for switching ART in patients with undetectable plasma viral load and in cases of virological failure where rescue ART should comprise 2 or 3 drugs that are fully active against the virus. An update is also provided for the specific criteria for ART in special situations (acute infection, HIV-2 infection, and pregnancy) and with comorbid conditions (tuberculosis or other opportunistic infections, kidney disease, liver disease, and cancer).

CONCLUSIONS:

These new guidelines updates previous recommendations related to cART (when to begin and what drugs should be used), how to monitor and what to do in case of viral failure or drug adverse reactions. cART specific criteria in comorbid patients and special situations are equally updated.

PDF

http://apps.elsevier.es/watermark/ctl_servlet?_f=10&pident_articulo=90340091&pident_usuario=0&pcontactid=&pident_revista=28&ty=107&accion=L&origen=zonadelectura&web=www.elsevier.es&lan=es&fichero=28v32n07a90340091pdf001.pdf

June 13, 2015 at 10:40 am

Evaluation of Hepatitis A Vaccine in Post-Exposure Prophylaxis, The Netherlands, 2004-2012

PLOS ONE October 2013  V.8 N.10  e78914

Jane Whelan1*, Gerard J. Sonder1,2, Lian Bovée1, Arjen Speksnijder3, Anneke van den Hoek1,21 Department of Infectious Diseases, Amsterdam Public Health Service (GGD), Amsterdam, The Netherlands, 2 Department of Internal Medicine, Division of Infectious Diseases, Tropical Medicine and AIDS, Academic Medical Center, Amsterdam, The Netherlands, 3 Laboratory of Public Health, Amsterdam Public Health Service (GGD) Amsterdam, The Netherlands

Background

The secondary attack rate of hepatitis A virus (HAV) among contacts of cases is up to 50%. Historically, contacts were offered immunoglobulin (IG, a human derived blood product) as post-exposure prophylaxis (PEP). Amid safety concerns about IG, HAV vaccine is increasingly recommended instead. Public health authorities’ recommendations differ, particularly for healthy contacts ≥40 years old, where vaccine efficacy data is limited. We evaluated routine use of HAV vaccine as an alternative to immunoglobulin in PEP, in those considered at low risk of severe infection in the Netherlands

Methods

Household contacts of acute HAV cases notified in Amsterdam (2004-2012) were invited ≤14 days post-exposure, for baseline anti-HAV testing and PEP according to national guidelines: immunoglobulin if at risk of severe infection, or hepatitis A vaccine if healthy and at low risk (aged <30, or, 30-50 years and vaccinated <8 days post-exposure). Incidence of laboratory confirmed secondary infection in susceptible contacts was assessed 4-8 weeks post-exposure. In a vaccinated subgroup, relative risk (RR) of secondary infection with estimated using Poisson regression.

Results

Of 547 contacts identified, 191 were susceptible to HAV. Per-protocol, 167 (87%) were vaccinated (mean:6.7 days post-exposure, standard deviation(sd)=3.3) and 24 (13%) were given immunoglobulin (mean:9.7 days post-exposure, sd=2.8). At follow-up testing, 8/112 (7%) had a laboratory confirmed infection of whom 7 were symptomatic. All secondary infections occurred in vaccinated contacts, and half were >40 years of age. In healthy contacts vaccinated per-protocol ≤8 days post-exposure, RRref. ≤15 years of secondary infection in those >40 years was 12.0 (95%CI:1.3-106.7).

Conclusions

Timely administration of HAV vaccine in PEP was feasible and the secondary attack rate was low in those <40 years. Internationally, upper age-limits for post-exposure vaccination vary. Pending larger studies, immunoglobulin should be considered PEP of choice in people >40 years of age and those vulnerable to severe disease.

Full Text

http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0078914

PDF

http://www.plosone.org/article/fetchObject.action?uri=info%3Adoi%2F10.1371%2Fjournal.pone.0078914&representation=

 

November 10, 2013 at 9:18 pm

Interventions to prevent sexually transmitted infections, including HIV infection.

Clin Infect Dis. 2011 Dec;53 Suppl 3:S64-78.

Marrazzo JM, Cates W.

Source

Department of Medicine, Division of Allergy and Infectious Diseases, University of Seattle, WA 98104, USA. jmm2@uw.edu

Abstract

The Centers for Disease Control and Prevention (CDC) Sexually Transmitted Disease (STD) Treatment Guidelines were last updated in 2006. To update the “Clinical Guide to Prevention Services” section of the 2010 CDC STD Treatment Guidelines, we reviewed the recent science with reference to interventions designed to prevent acquisition of STDs, including human immunodeficiency virus (HIV) infection. Major interval developments include (1) licensure and uptake of immunization against genital human papillomavirus, (2) validation of male circumcision as a potent prevention tool against acquisition of HIV and some other sexually transmitted infections (STIs), (3) failure of a promising HIV vaccine candidate to afford protection against HIV acquisition, (4) encouragement about the use of antiretroviral agents as preexposure prophylaxis to reduce risk of HIV and herpes simplex virus acquisition, (5) enhanced emphasis on expedited partner management and rescreening for persons infected with Chlamydia trachomatis and Neisseria gonorrhoeae, (6) recognition that behavioral interventions will be needed to address a new trend of sexually transmitted hepatitis C among men who have sex with men, and (7) the availability of a modified female condom. A range of preventive interventions is needed to reduce the risks of acquiring STI, including HIV infection, among sexually active people, and a flexible approach targeted to specific populations should integrate combinations of biomedical, behavioral, and structural interventions. These would ideally involve an array of prevention contexts, including (1) communications and practices among sexual partners, (2) transactions between individual clients and their healthcare providers, and (3) comprehensive population-level strategies for prioritizing prevention research, ensuring accurate outcome assessment, and formulating health policy.

PDF

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3213401/pdf/cir695.pdf

August 7, 2013 at 2:31 pm

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