Post exposure prophylaxis

As a post-exposure prophylaxis ( PEP ) measures is referred to possible contact with germs an infectious disease , in order to prevent the onset or ameliorate the course of which at least.

The measures can consist of drug treatment or one or more vaccinations . If several vaccinations are necessary, a passive vaccination ( tetanus , rabies ) is combined with active vaccination . Passive vaccination offers the advantage of immediate protection. Immediate protection cannot be achieved with active vaccination, in which the immune system is stimulated in such a way that after some time it produces its own defense mechanism. Passive immunization uses antibodies from other people who are themselves immune to the disease in question. For this purpose, the blood of a few thousand blood donors is processed accordingly. The aim of all of these measures is to prevent the pathogen from multiplying in the body and thus prevent the disease from breaking out after a possible infection .

HIV

Indication for HIV-PEP with sexual exposure
according to German-Austrian guidelines of the DAIG (as of 2013)

Exposure event	comment	PEP indication
Unprotected insertive or receptive vaginal or anal intercourse (e.g. as a result of a burst condom) with a person known to be HIV-positive	Transmission risk depends primarily on the treatment status or the viral load in the treated person	Recommend PEP if the index person is untreated, VL > 1000 copies / ml or treatment status can not be determined
		Offer PEP if the index person's VL is 50–1000 copies / ml
		No PEP indication if the index person is treated effectively (VL <50 copies / ml)
Unprotected sexual intercourse with unknown HIV status of the partner
Unprotected anal intercourse between men	In the case of homosexual anal intercourse between men, the statistical probability that the partner has an undiagnosed or untreated HIV infection is between approx. 1% and 3% in Germany (depending on age).	Offer PEP
Unprotected heterosexual vaginal or anal intercourse with a partner who actively uses intravenous drugs, with a bisexual partner or a partner from a high prevalence region of HIV	Statistical exposure probability in a range ~ 1: 100	Offer PEP
Unprotected heterosexual vaginal or anal intercourse when raped	Statistical exposure probability very low (≤ 1: 10,000)	No agreement on the PEP indication
Unprotected heterosexual vaginal or anal intercourse (including with a sex worker )	In the case of heterosexual intercourse, the statistical probability that the partner has an undiagnosed or untreated HIV infection is around 1: 10,000 or less in Germany	No PEP indication
Oral intercourse unprotected oral intercourse with the ingestion of semen from a certain or likely HIV-infected partner	The probability of transmission, even in the case of real exposure, is very low	No PEP indication
Kissing / contact of HIV with skin		No PEP indication

In the event of exposure to HIV risk (e.g. unprotected sexual intercourse or needlestick injuries ), it is recommended to start post-exposure prophylaxis within 24 hours after taking immediate measures. The best results can be expected within a time window of two hours. PEP is generally no longer recommended for more than 72 hours after the event. In any case, an appropriately competent facility must be visited in order to clarify in each individual case whether such prevention is necessary. The standard therapy currently consists of a combination of the integrase inhibitor Isentress ( raltegravir ), which must be taken twice a day, and Truvada (consisting of tenofovir and emtricitabine ) once a day . This therapy is comparatively low in side effects and interaction and is usually applied over a period of one month. The main side effects described are nausea, listlessness and diarrhea. The more time that passes before the start of therapy, the lower the chances of success in warding off an infection that may have occurred. In no case is there 100% protection against HIV infection. In the case of unprotected sexual intercourse with a (potentially) HIV-positive person, the treatment costs are not necessarily covered by health insurance .

Hepatitis B.

In the case of not vaccinated or insufficiently vaccinated persons (according to the vaccination status that can be determined by anti-HBs testing) who, for example, suffer a needlestick injury with the blood of an infected person, simultaneous vaccination by administering hepatitis B immunoglobulin ( passive immunization ) together with active HBV - Vaccination recommended. Newborns of infected mothers (detectable by the detection of HBs antigen in the blood) also receive a simultaneous (simultaneous) active and passive vaccination against the virus within the first 24 hours of life.

Hepatitis C.

There is still no vaccination against hepatitis C. Immediate post-exposure prophylaxis for HCV is not currently recommended. The recipient should be examined 2–4, 12 and 24 weeks after exposure (serostatus or HCV-RNA test). If an acute infection is detected, an increase in transaminases and if anti-HCV antibodies are detected, interferon monotherapy should be initiated to prevent chronification.

tetanus

For tetanus prophylaxis , after immediate cleaning of all wounds and contaminated body parts with soap or detergents and thorough rinsing with water and 70% alcohol or an iodine preparation, in the event of dangerous injuries in unvaccinated persons, the immediate simultaneous administration of tetanus immunoglobulin (passive vaccination ) and recommended for active vaccination. People who have had a full tetanus immunization in the past but have not received a booster vaccination for more than five to ten years should be given a single booster vaccination.

rabies

The post- exposure rabies prophylaxis after a bite (but also scratch wounds, contamination of mucous membranes with saliva as well as with the inoculation fluid of a vaccination bait) consists of cleaning all wounds and contaminated body parts with soap or detergents and thorough rinsing with water and 70% alcohol or an iodine preparation in the post- exposure Vaccination . For this purpose, an active vaccination takes place and (in the case of significant exposure) the additional or simultaneous administration of a rabies immunoglobulin (post- exposure immunoprophylaxis) for passive immunization. No vaccination is required if the intact skin is touched, fed or licked. The indication for rabies vaccination prophylaxis is in animals suspected of rabies such as fox, badger and other carnivores. Dogs and cats that are healthy and vaccinated can wait more than ten days after observing the animal. In the case of small rodents, hares and rabbits, no vaccination is required for unsuspecting animals, but you should ask your veterinarian or health department. If the situation is unclear or animals cannot be observed, vaccination should be carried out or the veterinarian and health department should be contacted. The indication is also provided by bodies specifically designated as rabies advice centers, mostly larger hospitals, which then also have the corresponding preparations in stock. Timely intervention can prevent a disease outbreak 100 percent. If the prophylaxis is not carried out and a rabies disease breaks out, it is always fatal - however, the time window for rabies is relatively large.

Bite injuries

In addition to the surgical treatment of bite wounds , it must be checked whether a post-exposure rabies vaccination (see above) is necessary. After bite wounds by cats or dogs, prophylactic antibiotic treatment with amoxicillin-clavulanic acid in combination with sultamicillin or doxycycline is necessary, after bite wounds by humans amoxicillin-clavulanic acid or sultamicillin in combination with cefuroxim-axetil . Moxifloxacin is available for people with penicillin allergy .

Meningococcal meningitis

Meningococcal diseases and especially meningitis are highly contagious and life-threatening. Therefore chemoprophylaxis with an antibiotic is carried out as quickly as possible for the contact persons of a sick person , whereby the group of persons depends on the type of contact, but people living in the same household should always be treated. Therapy makes sense for up to ten days after contact with the sick person.

A risk reduction by means of chemoprophylaxis should take place primarily through the elimination of germs from the nasopharynx .

Haemophilus influenzae meningitis

As with meningococcal meningitis, with meningitis caused by Haemophilus influenzae type B, the risk of developing the disease for close contacts is about 200 to 1000 times higher than the risk for the general population. Chemoprophylaxis takes place with rifampicin, in pregnancy with ceftriaxone.

Pneumococci

As with meningitis, chemoprophylaxis is mainly used in patients without a spleen after exposure to pneumococci . In particular, penicillin V is given for seven days.

Prophylaxis after needle stick injuries

• Stimulate bleeding
• disinfection
• Assess the risk of infection
• documentation
• serological examination
• Aftercare

See also

• hygiene
• Disease prevention
• Pre-exposure prophylaxis

literature

• Marianne Abele-Horn: Antimicrobial Therapy. Decision support for the treatment and prophylaxis of infectious diseases. With the collaboration of Werner Heinz, Hartwig Klinker, Johann Schurz and August Stich, 2nd, revised and expanded edition. Peter Wiehl, Marburg 2009, ISBN 978-3-927219-14-4 , pp. 318-325.

Web links

• Infektionsfrei.de
• Guideline for post-exposure prophylaxis of HIV infection, German AIDS Society (DAIG) u. a. Update 2018
• Swiss recommendations for post-exposure prophylaxis of HIV infection

Sources and individual references

1. ↑ ^{a b} Guideline Post-Exposure Prophylaxis of HIV Infection, German AIDS Society (DAIG)
2. ↑ For example, blood flow promotion through tissue compression, wound spreading and rinsing with an antiseptic, washing and cleaning of the skin, rinsing the eyes, spitting out infectious material from the oral cavity and subsequent rinsing and, if necessary, notifying the D-doctor.
3. ↑ Marianne Abele-Horn (2009), p. 322 f.
4. ↑ ^{a b} Vaccination recommendations of the Robert Koch Institute , as of 2013
5. ↑ US Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis
6. ↑ Marianne Abele-Horn (2009), p. 319 f.
7. ↑ Marianne Abele-Horn (2009), p. 318.
8. ↑ Kayser, FH et al. : Pocket textbook on medical microbiology , 11th edition, Thieme Verlag, 2005, ISBN 3-13-444811-4 .
9. ↑ Marianne Abele-Horn (2009), p. 319.
10. ↑ Marianne Abele-Horn (2009), p. 320.
11. ↑ Marianne Abele-Horn (2009), pp. 320 and 322.
12. ↑ Marianne Abele-Horn (2009), pp. 320 and 322.

This article is about a health issue. It is not used for self-diagnosis and does not replace a diagnosis by a doctor. Please note the information on health issues !