What is the recommended post‑exposure prophylaxis for HIV, hepatitis B, rabies, tetanus, pertussis, influenza, and COVID‑19 exposures?

Post-Exposure Prophylaxis Recommendations

Immediate wound care with soap and water is the first critical step for all exposures, followed by pathogen-specific prophylaxis based on exposure type and source patient status.

General Approach to All Exposures

The management algorithm begins with:

• Immediate wound washing with soap and water for skin exposures
• Flushing mucous membranes with water for splash exposures
• Risk assessment based on fluid type (blood, visibly bloody fluid, other potentially infectious material) and exposure mechanism (percutaneous, mucous membrane, nonintact skin) 1

HIV Post-Exposure Prophylaxis

For occupational HIV exposures, initiate antiretroviral PEP within 72 hours using a basic two-drug regimen, with the preferred regimen being zidovudine (ZDV) 600 mg daily plus lamivudine (3TC) 150 mg twice daily (available as Combivir). 1

HIV PEP Protocol:

• Start PEP as soon as possible, ideally within hours of exposure
• Continue for 4 weeks total duration
• Test source patient for HIV antibody using rapid testing when possible
• Monitor exposed person at baseline, 6 weeks, 3 months, and 6 months for HIV seroconversion
• Evaluate for drug toxicity within 72 hours and monitor every 2 weeks during treatment 1

Alternative HIV regimens if basic regimen contraindicated:

• Lamivudine + stavudine (d4T 40 mg twice daily if >60 kg, 30 mg if <60 kg)
• Consider expanded 3-drug regimen for high-risk exposures 1

Important caveat: For mass-casualty events or non-occupational exposures, HIV PEP is generally NOT warranted unless exposure to a known HIV-infected source is highly likely 2. The risk of side effects often outweighs the extremely low transmission probability in most community exposures 3.

Hepatitis B Post-Exposure Prophylaxis

Administer hepatitis B vaccine and/or HBIG based on the exposed person's vaccination status and the source patient's HBsAg status. 1

HBV PEP Decision Points:

• Unvaccinated exposed person + HBsAg-positive source: Give HBIG immediately AND start HBV vaccine series
• Previously vaccinated with known adequate response: No treatment needed
• Previously vaccinated with unknown response or inadequate response: Test anti-HBs; give HBIG and/or vaccine booster based on titer
• Follow-up anti-HBs testing 1-2 months after last vaccine dose 1

Hepatitis C Post-Exposure Management

No post-exposure prophylaxis is recommended for HCV. 1

Instead, implement surveillance protocol:

• Baseline testing for anti-HCV and ALT
• Follow-up testing at 4-6 months
• Consider HCV RNA at 4-6 weeks if earlier diagnosis desired
• Confirm positive EIA results with supplemental testing 1

Tetanus Post-Exposure Prophylaxis

All persons with tetanus-prone wounds (puncture wounds, crush injuries, contamination with soil/feces/saliva) who cannot confirm tetanus booster within 5 years should receive Tdap (or Td if Tdap unavailable or age >65 years). 2

Tetanus-Prone Injury Protocol:

• Adults: Tdap if no booster in 5 years (Td if Tdap unavailable or age >65)
• Children <7 years: DTaP
• Children 7-10 years: Tdap or Td
• Children ≥11 years: Tdap preferred
• Appropriate wound debridement is critical
• Administer regardless of delay from time of injury 2

Pertussis Post-Exposure Prophylaxis

Administer antibiotic prophylaxis to all exposed persons regardless of immunization history. 4

The standard regimen is azithromycin, though one study in Tdap-vaccinated healthcare workers showed that daily symptom monitoring without PEP may be considered, this approach did not meet noninferiority criteria and warrants caution 5. Given the public health implications of pertussis transmission, err on the side of providing antibiotic PEP 4, 6.

Rabies Post-Exposure Prophylaxis

Administer rabies PEP regardless of delay from exposure time for high-risk animal exposures (bites from bats, raccoons, skunks, foxes, or other carnivores) 4. This includes both rabies immune globulin and rabies vaccine series.

Influenza and COVID-19 Post-Exposure Prophylaxis

The provided guidelines do not contain specific PEP protocols for influenza or COVID-19 exposures. Based on general medical knowledge, these would typically involve:

• Influenza: Consider antiviral prophylaxis (oseltamivir) for high-risk exposed persons during outbreaks
• COVID-19: Current guidance varies by exposure setting and individual risk factors; consult current CDC recommendations

Critical Timing Considerations

The window for effective PEP varies by pathogen:

• HIV: Must start within 72 hours (ideally within hours)
• HBV: HBIG most effective within 24 hours, acceptable up to 7 days
• Tetanus: Administer regardless of delay
• Rabies: Administer regardless of delay
• Pertussis: As soon as exposure identified 1, 2, 4

Common Pitfalls to Avoid

• Do not test discarded needles or syringes for virus contamination—this is unreliable 1
• Do not delay HIV PEP while waiting for source patient test results if high-risk exposure
• Do not assume immunity without documented vaccination records or serologic confirmation
• Do not forget to counsel exposed persons about preventing secondary transmission during follow-up period 1
• Do not overlook other bloodborne pathogens when focusing on HIV—always assess HBV and HCV risk 3