Postexposure management of infectious diseases

Mazen S. Bader; Annie Brooks; Deborah V. Kelly; Jocelyn A. Srigley

doi:10.3949/ccjm.84a.15049

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TABLE 1

Postexposure management of common blood-borne pathogens

Pathogen and source individual	Exposed individual	Postexposure prophylactic regimen	Initial and follow-up evaluation
Hepatitis B virus (HBV): HBV-infected patient with positive HBsAg	Unvaccinated or nonresponder to the first 3-dose vaccine series^a	A single dose of HBIG, 0.06 mL/kg IM, followed by HBV vaccine series given at 0, 1–2 months, and 6 months^c injected at different site than HBIG; give HBIG within 24 hours but no later than 7 days after exposure	Source individual: HbsAg if status is unknown Exposed individual: Baseline HbsAg, anti-HBs, anti-HBc HbsAg and anti-HBc at 6 months No work or school restriction for exposed individuals, including healthcare providers
	Currently receiving first 3-dose vaccine series	A single dose of HBIG 0.06 mL/kg IM, followed by completion of 3-dose vaccine series
	Previous HBV infection or vaccinated with adequate response^b	Not required

Hepatitis C virus (HCV): HCV-infected patient with positive anti-HCV and HCV RNA	Hepatitis C seronegative	None is available	Source individual: Anti-HCV, HCV RNA if status is unknown Exposed individual: Anti-HCV, HCV RNA, and ALT at baseline HCV RNA and ALT at 4 weeks Anti-HCV, HCV RNA, and ALT at 12 weeks Anti-HCV and ALT at 24 weeks No work or school restriction for exposed individuals, including healthcare providers

Human immunodeficiency virus (HIV): HIV-infected patient	HIV seronegative	Tenofovir-emtricitabine 300/200 mg once daily plus raltegravir 400 mg orally twice daily	Source individual: Anti-HIV1/HIV2 if status is unknown Exposed individual: Anti-HIV1/HIV2 at baseline, 6 weeks, and 16 weeks postexposure Complete blood count, urea, creatinine, liver function tests, serum glucose (if on PIs), and creatine phosphokinase (if on raltegravir) at baseline, 2 weeks, and 4 weeks after initiating ARV drugs No work or school restriction for exposed individuals, including healthcare providers

↵a Serum level of anti-HBs < 10 mIU/mL.
↵b Serum level of anti-HBs > 10 mIU/mL.
↵c Day 0 is the day when the first dose of vaccine was given.
ALT = alanine aminotransferase; anti-HBc = antibody against hepatitis B core antigen; anti-HBs = antibody against hepatitis B surface antigen; anti-HCV = antibody against hepatitis C virus; anti-HIV1/HIV2 = antibodies against human immunodeficiency virus1 and 2; ARV = antiretroviral; HBIG = hepatitis B immune globulin; HBsAg = hepatitis B surface antigen; IM = intramuscularly; PI = protease inhibitor

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TABLE 2

Postexposure management of sexually transmitted diseases

Disease and source individual	Exposed individual	Postexposure prophylactic regimen	Initial and follow-up evaluation
Chlamydia: Symptomatic or asymptom-atic patients with infection confirmed by microbiologic testing (NAAT or culture)	Sexual contact with the index case within 60 days before onset of symptoms or diagnosis ^a	Azithromycin 1 g orally as single dose or doxycycline 100 mg orally twice daily for 7 days or ofloxacin 300 mg orally twice daily for 7 days	Symptom screening and testing of partner for chlamydia by NAAT of genital and extragenital, if indicated, sites or first-catch urine^b Treat partner for chlamydia^c Counsel confirmed cases and partner(s) to abstain from sexual intercourse until 7 days after a single-dose regimen or after completion of a multiple-dose regimen, with resolution of symptoms and partner treatment Test of cure for pregnant women
Gonorrhea: Patient with any type of gonococcal infection, including asymptomatic infection, confirmed by microbiologic testing (NAAT or culture)	Sexual contact with the index case within 60 days prior to onset of symptoms or diagnosis^a	Ceftriaxone 250 mg IM, single dose, plus either single dose azithromycin 1 g orally or doxycycline 100 mg orally twice daily for 7 days or cefixime 400–800 mg orally, single dose, plus either single dose azithromycin 1 g orally or doxycycline 100 mg orally twice daily for 7 days	Symptom screening and testing of partner for gonorrhea by NAAT of genital and extragenital, if indicated, sites or first-catch urine^b Treat partner for gonorrhea^c Counsel index case with confirmed infection and partner(s) to abstain from sexual intercourse until 3 days after completion of therapy, with resolution of symptoms and partner treatment Test of cure for pregnant women and those treated with cefixime or azithromycin
Pediculosis pubis: Patient with active infestation	Sexual contact with index case within 30 days before onset of symptoms or diagnosis	Permethrin 1% cream, single application to the affected areas and washed off after 10 minutes (preferred regimen) or pyrethrins with piperonyl butoxide (0.33%), single application to the af-fected area and washed off after 10 minutes or ivermectin 250 μg/kg orally two doses, 2 weeks apart	Counsel index case with confirmed infestation and partner(s) to abstain from sexual intercourse until completion of treatment, with resolution of symptoms and partner treatment No work or school restriction for either infested or exposed individuals
Syphilis: Patient with early syphilis (primary, secondary or early latent syphilis)^d	Sexual contact with the index case within: Primary: preceding 90 days plus duration of symptoms Secondary: preceding 6 months plus duration of symptoms Early latent: preceding 12 months	Benzathine penicillin G 2.4 MU IM single dose (preferred regimen) or doxycycline 100 mg orally twice daily for 14 days	Symptom screening and testing of partner with nontreponemal assays at baseline, 3, and 6 months Treat partner for syphilis^e Counsel partner and index case with confirmed infection to abstain from sexual intercourse until completion of treatment, documented serologic response and partner treatment
Trichomoniasis: Patient with active trichomoniasis	Sexual contact with the index case within 4 weeks before onset of symptoms or diagnosis	Metronidazole 2 g orally, single dose or metronidazole 500 mg orally twice daily for 7 days (preferred in HIV-infected women) or tinidazole 2 g orally, single dose	Symptom screening of partner Test index case and partner for bacterial vaginosis Treat partner, regardless of symptoms, simultaneously with index case Counsel partner and index case with confirmed infection to abstain from sexual intercourse until 1 week after treatment, with resolution of symptoms and partner treatment

↵a If index case had no sexual contacts within 60 days or if a partner within the 60-day period tests negative, then the index case’s last sexual partner should be screened and treated for chlamydia or gonorrhea, even if contact was > 60 days before symptom onset or diagnosis.
↵b Genital mucosal sites include urethra for men and vagina and endocervix for women. Extragenital mucosal sites include oropharynx and rectum. Testing of extragenital sites is indicated when the exposed individual has symptoms or signs suggestive of infection of these sites (eg, pharyngitis, proctitis), has a history of unprotected oral or anal sex, or is a man who has sex with men.
↵c Empiric treatment should be given to the partner while awaiting the results of screening, particularly when the exposure is recent (within 1 week), patient follow-up is in question, or the screening test used is not NAAT.
↵d Early latent syphilis can be diagnosed with seroconversion of nontreponemal antibody testing, a fourfold increase in the nontreponemal antibody titer, documented primary or secondary syphilis, sex partner with documented primary or secondary syphilis, or positive treponemal test and nontreponemal antibody testing and exposure to infectious index case, all within the previous 12 months.
↵e Individuals whose last sexual contact with the index case was within 90 days of diagnosis of early syphilis or more than 90 days if follow-up is uncertain should be treated empirically for syphilis without waiting for, or regardless of, serologic test results.
IM = intramuscular; MU = million units; NAAT = nucleic acid amplification testing

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TABLE 3

Postexposure management of infections transmitted by the airborne route

Infection and disease status of source individual	Disease status of exposed individual	Postexposure prophylactic regimen	Initial and follow-up evaluation
Measles: Patient with active infection (4–5 days before onset of rash to 4 days after rash)	Nonimmune immune-competent contacts^a	Live measles virus-containing vaccine (2 doses MMR, or MMRV if indicated [eg, patient not immune to varicella], at least 28 days or 3 months apart, respectively) SC within 3 days of exposure	Exclusion of exposed nonimmune individuals from work from day 5 to 21 after exposure, unless vaccine was given within 3 days of exposure Exclusion of symptomatic individuals immediately from work until ≥ 4 days after onset of rash
	Nonimmune pregnant women, infants aged < 12 months, or immunocompromised contacts (regardless of immune status)	A single dose of immune globulin 0.5 mL/kg IM or 400 mg/kg IV within 6 days of exposure

Tuberculosis (TB): Patient with untreated pulmonary or laryngeal TB ^b	Close contacts with unprotected exposure, regardless of history of TB or vaccination with BCG vaccine	One of the following regimens for LTBI, if TB disease is ruled out: Isoniazid 5 mg/kg orally daily plus vitamin B₆ 25–50 mg orally daily for 9 months or isoniazid 900 mg orally once weekly plus vitamin B 25–50 mg orally daily 6 plus rifapentine 900 mg orally once weekly for 3 months	TB symptom screen and TST or IGRA at presentation and 8–12 weeks postexposure if initially negative for TB infection Chest radiography if TST or IGRA is positive at presentation or follow-up Baseline and monthly liver function tests while on treatment for LTBI No work or school restriction for ex-posed asymptomatic individuals with or without LTBI

Varicella and disseminated herpes zoster (HZ): Patient with active infection from 1–2 days before onset of rash for varicella or from onset of rash for HZ, until all lesions have crusted	Nonimmune immunocompetent contacts^c Nonimmune pregnant women or immunocompromised contacts	Two doses of varicella vaccine SC 1 month apart, first dose within 5 days of exposure A single dose of VariZIG 125 units/10 kg IM/IV within 96 hours (up to 10 days postexposure) or immune globulin 400 mg/kg IV if VariZIG is not available	Exclusion of nonimmune exposed individuals from work from day 8 to 21 after last exposure (from day 8 to 28 if they received VariZIG) Exclusion of symptomatic individuals with varicella or disseminated HZ from work until all lesions are dry and crusted

↵a An individual is considered immune if any of the following applies: documentation of vaccination with 2 doses of live measles virus-containing vaccine, with the first dose of the vaccine being administered ≥ 12 months of age and the second dose at least 28 days after the first one; laboratory evidence of immunity; laboratory confirmation of disease; or birth before 1957 (except healthcare providers, who require one of the other indicators for immunity).
↵b For patients with pulmonary TB that tests positive on acid-fast bacilli smear, the contagious period starts 3 months before the collection date of the first smear-positive sputum or onset of symptoms, whichever is earlier, and ends when the patient is in airborne isolation or the date of collection for the first consistently negative smear results. For patients with pulmonary TB that tests negative on acid-fast bacilli smear, the contagious period starts 1 month before onset of symptoms and ends when the patient is in airborne isolation.
↵c An individual is considered immune to varicella or HZ if any of the following applies: documentation of vaccination with 2 doses of varicella vaccine; diagnosis or verification of history of varicella disease or HZ by a healthcare provider; serologic evidence of either immunity or disease; or birth in the United States before 1980 (except in healthcare providers, immunocompromised individuals, and pregnant women, who require one of the other indicators for immunity).
BCG = bacillus Calmette-Guérin; IGRA = interferon-gamma release assay; IM = intramuscularly; IV = intravenously; LTBI = latent tuberculosis infection; MMR = measles, mumps, rubella; MMRV = measles, mumps, rubella, varicella; SC = subcutaneously; TST = tuberculin skin test; VariZIG = varicella zoster immunoglobulin

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TABLE 4

Postexposure management of infections transmitted by the droplet route

Infection and disease status of source individual	Disease status of exposed individual	Postexposure prophylactic regimen	Initial and follow-up evaluation
Group A streptococcus: Patient with invasive GAS infection (eg, streptococcal toxic shock syndrome, necrotizing fasciitis, meningitis, or pneumonia), from 7 days before symptom onset until 24 hours of effective antibiotic therapy	High-risk household contacts and close contacts	One of the following regimens should be considered within 24 hours, and up to 7 days, after the last exposure: Cephalexin 250–500 mg orally 2 to 4 times daily for 10 days or amoxicillin 500 mg orally 3 times daily for 10 days or clindamycin 300 mg orally 3 times daily for 10 days or azithromycin 500 mg orally daily for 3–5 days	No work or school restriction for exposed asymptomatic individuals
Influenza: Symptomatic patient with laboratory-confirmed seasonal influenza A, B, or H1N1 infection, from 1 day before onset of symptoms until 24 hours after resolution of fever	Close contacts at high risk of complications of influenza or who are in close contact with individuals at high risk of influenza complications	One of the following regimens should be given within 48 hours of last exposure: ^a Oseltamivir 75 mg orally once daily for 10 days, or during outbreaks for a minimum of 2 weeks and up to 1 week after identification of the last case or zanamavir 10 mg (2 inhalations) once daily for 10 days, or during outbreaks for at least 2 weeks and up to 1 week after identification of the last case ^b	No work or school restriction for asymptomatic exposed individuals Exclusion of symptomatic health-care provider with confirmed influenza from patient care until afebrile ≥ 24 hours without the use of antipyretics
Mumps: Patient with laboratory-confirmed mumps infection, from 7 days before onset of parotitis to 9 days after	Nonimmune close contacts	None^a	No work or school restriction for asymptomatic exposed individuals, including healthcare providers, who are either fully vaccinated or received one dose of the MMR vaccine Exclusion of susceptible exposed individuals from work from day 12 after first unprotected exposure through day 25 after last exposure Exclusion of symptomatic individuals with mumps, including health care providers, from work for 9 days from onset of parotitis
Meningitis: Patient with invasive meningococcal infection (meningitis or bacteremia) from 7 days before onset of illness until 24 hours of effective antibiotic therapy^c	Household and close contacts, regardless of vaccination status	One of the following regimens should be given as soon as possible, and up to 14 days after exposure: A single dose of ciprofloxacin 500 mg orally ^d or a single dose of ceftriaxone 250 mg IM or rifampin 600 mg orally twice daily for 2 days	No work or school restriction for asymptomatic exposed individuals, including healthcare providers
Pertussis: Symptomatic patient in the first 3 weeks of illness confirmed with culture, polymerase chain reaction testing, or serology based on patient’s age	Household and close contacts, regardless of vaccination status	One of the following regimens should be given as early as possible but no later than 3 weeks after onset of cough in the index case:^a Azithromycin 500 mg orally on day 1 followed by 250 mg daily on days 2 through 5 or TMP-SMX 1 double-strength tablet (TMP 160 mg, SMX 800 mg) orally twice daily for 14 days	No work or school restriction for asymptomatic individuals, including healthcare providers Exclusion of symptomatic individuals from work until 5 days of effective antibiotic therapy or negative micro-biologic testing (if not treated)
Rubella: Patient with confirmed rubella, from 1 week before to 7 days after onset of rash	Nonimmune contacts	None^a	Acute and convalescent serology in susceptible pregnant women who had unprotected exposure; if seroconversion occurs, counseling about risk of congenital rubella syndrome Exclusion of susceptible exposed individuals from work from day 5 after first exposure to day 23 after last exposure Exclusion of symptomatic individuals with rubella, including healthcare providers, from work immediately until 7 days after rash onset

↵a Unvaccinated or incompletely vaccinated individuals should be vaccinated according to the adult vaccination schedule.
↵b Zanamavir is not recommended for patients with underlying airway disease because of the risk of bronchospasm and decline in pulmonary function.
↵c Penicillins are ineffective in the eradication of N meningitidis from the nasopharynx because of their inability to achieve high levels in nasopharyngeal secretions; therefore, they are not recommended for postexposure prophylaxis.
↵d A single oral dose of azithromycin 500 mg is an option in areas where fluoroquinolone-resistant strains of N meningiditis have been identified.
GAS = group A Streptococcus; IM = intramuscular; MMR = measles, mumps, and rubella; TMP-SMX = trimethoprim-sulfamethoxazole

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TABLE 5

Postexposure management of infections via contact, injury, and bite routes

Infection and disease status of source individual	Disease status of exposed individual	Postexposure prophylactic regimen	Initial and follow-up evaluation
Hepatitis A virus (HAV) Confirmed HAV infection from the incubation period (15–50 days) until one week after onset of jaundice	Nonimmune, healthy close contacts between 12 months and 40 years of age	Two doses of inactivated HAV vaccine (1,440 ELISA units per 1 mL for Havrix or 1 mL (50 U) for Vaqta IM in the deltoid muscle 6–18 months apart or immune globulin (IG) 0.02 mL/kg IM, single dose, in the deltoid or gluteal muscle	Source patient: anti-HAV IgM if status is unknown Exclusion of individuals with HAV infection from patient care, patient environment, food handling, or daycare until 7 days after onset of jaundice No work or school restriction for asymptomatic exposed individuals
	Nonimmune close contacts with immunocompromising condition, chronic liver disease, < 12 months old, adults > age 40, or severe allergy to HAV vaccine	IG 0.02 mL/kg IM, single dose, in deltoid or gluteal muscle within 2 weeks of exposure
	Immune close contacts (previously infected or vaccinated at least 2 weeks prior to exposure)	Not recommended

Rabies: Bites or contact with suspected rabid animal Contact with patients infected with rabies from 2 weeks before onset of symptoms	Previously unvaccinated	HRIg 20 IU/kg^b single dose and four doses of rabies vaccine (1 mL) IM on days 0, 3, 7, and 14 (5th dose on day 28 for immunocompromised only)^c	No work or school restriction for asymptomatic exposed individuals
	Previously vaccinated^a	Two doses of rabies vaccine IM on days 0 and 3

Scabies: Patient with untreated infestation^d	Close and sexual contacts within the preceding month before onset of symptoms or confirmed diagnosis	Permethrin 5% cream (preferred regimen), apply from neck to toe and wash off after 8–14 hours; repeat in 1–2 weeks or crotamiton 10% cream, lotion, after a bath, apply from chin to toes; repeat in 24 hours or two doses of ivermectin 200 μg/kg orally 2 weeks apart	Exclusion of infested individuals until the end of treatment or, for infested individuals with crusted scabies, until skin scrapings are negative No work or school restriction for asymptomatic exposed individuals

Tetanus: Not applicable	Individuals with tetanus-prone injuries: Completed primary vaccination series (≥ 3 doses) Unknown vaccination history or incomplete primary vaccination series (< 3 doses)	Clean, minor wounds: a single booster of age-appropriate tetanus toxoid-containing vaccine IM (DTaP, Tdap, DT, Td, TT) if at least 10 years since last dose of vaccine Other wounds: a single booster of age-appropriate tetanus toxoid-containing vaccine IM (DTaP, Tdap, DT, Td, TT) if ≥ 5 years since last dose of vaccine Clean, minor wounds: age-appropriate tetanus toxoid-containing vaccine IM (DTaP, Tdap, DT, Td, TT) and complete vaccine series according to schedule Other wounds: age-appropriate tetanus toxoid-containing vaccine IM (DTaP, Tdap, DT, Td, TT) and complete vaccine series according to schedule plus a single dose of tetanus immune globulin (TIg) 250 U IM, or immune globulin IV if TIg is not available, at a different site with different syringes than the vaccine	No work or school restriction for asymptomatic exposed individuals

↵a Individuals are considered vaccinated if they received a complete series of a cell-culture vaccine such as human diploid cell vaccine or purified chick-embryo cell vaccine, three 1-mL doses given intramuscularly in the deltoid area on days 0, 7, and 21 or 28.
↵b Full dose of HRIg should be infiltrated in and around the wound if anatomically feasible, with the rest administered into the deltoid muscle, lateral or anterior thigh, or the gluteal region in a separate syringe and site from the vaccine. If HRIg is not administered when active vaccination is begun, it can be administered until day 7.
↵c Day 0 is when the first dose of rabies vaccine was administered. Administer in the deltoid muscle; never administer in the gluteal muscle because of the low titer of neutralizing antibodies.
↵d Affected individuals should be instructed to wash clothing, linens, and towels used within the previous week in hot water and dry at high heat and to vacuum the entire house, furniture, and car interior.
DTaP = diphtheria, tetanus, acellular pertussis vaccine; DT = diphtheria-tetanus toxoids adsorbed; ELISA = enzyme-linked immunosorbent assay; HRIg = human rabies immune globulin; IM = intramuscularly; IV = intravenous; IU = international units; N/A = not applicable; Td = tetanus-diphtheria toxoids adsorbed; Tdap = tetanus toxoid, reduced diphtheria toxoid, acellular pertussis vaccine; TT = tetanus toxoid; U = unit