Quiz Week 4

A 55 year old lady arrives in the ER - comatose. She was picked up by the Ambulance crew by a sidewalk. It has snowed outside and most of the city of Philadelphia has come to a standstill as it is the first snow of the season and the weather was too warm to be expecting this prior to today.
Your colleague from the ER calls you down to see the patient as soon as she arrives because he is anticipating an admission to the Intensive care unit.
While you are examining the patient, the ER nurse does the fingerstick glucose check. It is 98. She is clearing the area to help you examine but accidentally pricks her own finger with the lancet. She has been immunized against Hepatitis B about 6 months ago and her antibody titers are not known. She has never had hepatitis B. The nurse is 35 years old and is worried about HIV.
Q1. Which of the following statements is FALSE regarding the fingerstick injury :

The nurse has no risk for HIV

Baseline blood should be drawn ASAP(as soon as possible) from the nurse.

Nurse has 24 hours within which period her hepatitis antibody titer should be checked and any necessary action taken.

Since she is immunized against Hepatitis B, her risk for HIV is higher than that for Hepatitis.

She should exercise protected sex with her husband for 6 months at least.

This was a difficult one. The Answer is choice 4 for the first Question and choice 3 for the second Question.
Explanation:
The risk for hepatitis in this case is higher than HIV. Firstly we do not know her status of Hepatitis vaccine effectiveness and secondly, according to current literature is "The nurse has no risk for HIV" because the lancet is a solid needle (besides being a well known medical journal from Europe) and there have been no documented cases of transmission of HIV by solid needles. There is a risk with hollow contaminated needles which is approximately 1 in 200-1000. (Maybe most doctors who answered this did not notice that it was a solid needle in the question.   2 doctors did but only one got both the questions right). If you have a case of HIV due to a solid needle, It is a reportable case and you must publish it.
Blood for investigation should be drawn from the nurse and the patient. Whether the patient has to give consent - last time I checked, patient consent was not required for the test in this situation.
The nurse must be offered HIV prophylaxis within 3 hours. Most hospitals now have an in-house stock of AZT + 3TC for such situations. If the source patient was on AZT then the nurse should also get a protease inhibitor.
The time limit on the other hand for Hepatitis B is 24 hours. If the serology shows the antibody titers to be inadequate, she should receive Immune globulin + Vaccine booster.
As for syphilis, if the patient is VDRL+ve, the nurse should get empiric treatment. We do not wait for any other results to decide this.
The nurse should exercise protected sex using a condom until her last check at 6 months.
During this period her follow up visits should be as delineated in  Healthcare workers and ID   and not every month.
It has been extremely difficult for me to memorize the Ant HIV medications

Q2.  In a patient with risk of acquiring HIV from occupational exposure, which of the following is not indicated.

Re-assure that the risk of acquiring the virus in needlestick injury is 1 in 200.

Make the employer pay for the prophylactic treatment if the nurse does not have insurance.

Tell the nurse that she has to come for monthly follow up until 6 months.

Ask the source patient to get tested for suspected Hepatitis/HIV/Syphilis

Empirically treat the nurse for syphilis if the patient's RPR is positive.