DIP Episode 252 - Post Exposure Prophylaxis and The NBMEs

Okay, welcome. My name is Devine. This is episode 252 of the Divine Intervention Podcast. This podcast should hopefully be pretty short. It's just a very specific topic I want to talk about. A topic that is really high-yield on the exam these days. Especially step two CK. And the topic is mainly post-exposure prophylaxis. I have to get exposed to like, you know, particular infectious disease. You know, what are you supposed to do? What are you supposed to do? Slash give. I'll talk about the common ones that tend to pop up on exams. And then I'll talk about a few that really pop up, but when they do, people almost uniformly get them wrong. So let's jump right into it. As a reminder, if you're interested in the 10-hour USM list of 2 CK course, we can please next Saturday the if again, it's 6 to 10 a.m. Pacific, known to 4 p.m. Pacific and 6 to 8 p.m. Pacific. Again, we end up covering probably like 800 or more concepts from Pete's surgery site. I am OB-GYN and Neur. Again, very high-yield course. Again, a lot of people have attended it and they found it to be really helpful. And it's not the kind of course where it's like the same thing you hear every time. I actually update the course pretty frequently just again to kind of stay on the cutting edge of what the MBM is doing these days. So it's not going to be like a still course. It's going to like keep up with the changes that have currently been frequently being made on the exam. I would like being emphasized.

So if you're interested, just see the single email through the website or you can shoot me an email at the Divine Intervention Podcasts with an Savienda Gmail.com. So what is post-exposure prophylaxis? Basically, it's basically something you do. I mean, literally the name is very descriptive. Post-exposure prophylaxis. You've been exposed to something. You get some thin either a drug or it can be like a vaccine or an immunoglobulin that will protect you from developing a sequelie of that exposure. So developing a sequelie of that exposure or making you not even develop that problem in the first place. So this is going to jump straight into it again. Hopefully these are things you know pretty well if you don't. I better know this because trust me again, this is something your friends at the MBM really care about you knowing. So the first one I'll talk about, the classic one is heavy. So if they give you a question about they love this one, newborn. They like to test this in one of two ways. They're about a newborn to a mom that has hepatitis B. And how do you know a person has hepatitis B? Their hippy surface antigen will be positive. That's it. For persons who have a hippy surface antigen is positive. They have some kind of hippy infection. And then you look at the other stuff they give in the table. If you see IGM floating somewhere, you know it's an acute infection. If you see IGG floating somewhere, you know it's a chronic infection.

But basically, right, you know that baby right I mean remember I've talked about this in the vaccine schedule podcast. Those babies are supposed to pretty much get the vaccine when addition to getting the vaccine, they need a immune globulin right because remember for baby gets he be. It becomes chronic I think more than like 90% of the type versus an adult if they get he be it becomes chronic I think like 5% or less of the type. So you give that baby he be immune globulin and the he be vaccine just kind of make sure that. You give it in separate arms again you don't want the immune globulin to bind up the vaccine right that on the very helpful and that those circumstances. Another classic one will be like a healthcare worker right so if you're a healthcare worker you get a needle stick. Again, if you're a healthcare worker, usually you should have got in the he be vaccine probably less like some kind of condition of employment. So the thing is if whatever bizarre is in though you are on vaccinated or you know your heavy you are non immune to heavy for some reason let's say. Because you got the vaccine but you didn't respond to it. I mean believe it or not they actually people like that they get actually get the heavy vaccine. But it just just don't generate antibodies against it for those people are you're going to give them the heavy immune globulin and you're going to give them the heavy vaccine.

Even if they've been non responders in the past it doesn't matter right give them the heavy immune globulin and give them the heavy vaccine right. But if the person has been vaccinated before and they have like the person has been vaccinated before and they have antibodies right then even if they've been exposed to a person that's in fact they would have to be you actually don't need to give anything you don't need to give anything okay. And then hepsi right if this is a classic question you love to test although they love to make it as like a coexisting HIV question but the thing is for press if you're exposed to a patient that has a hepsi. You know like again needle stick or whatever unfortunately there's nothing that can be done. The person is kind of in deep trouble there although the good thing about hepsi is that they are now pretty good drugs to treat it right like so for the very deep as the hair. Harvoni if you watch TV ads right those NSB inhibitors right those drugs work pretty well. Curates is almost like 99% something like that so although those drugs are very expensive. Yes since we're doing the hepatitis alphabet let's kind of going to have a right so the thing is if you're exposed to a person that has a have a. For the most part you know again like let's say. You're exposed in some way shape or form right the thing is if you've never been vaccinated on your like a normal human being.

You just get the hip a vaccine as opposed to exposure pervlaxis and you're fine but if you notice that the person is immunocompromised right person has HIV or has one of those immunodeficiency diseases like. Brotons or Chiriacigashi or CG or CGD or IJ deficiency or like the George Saint Romani of those things then in addition to getting the have a vaccine should also get the have a immunoglobulin should also get the have a immunoglobulin okay now. He HIV right what if you've been exposed to a person that has HIV the thing is if you've been exposed to a person HIV basically they are one of two regimens you can take right. They are one of two regimens that you can take and the way I remember the regimen sees I remember like the word tells like like tells I don't know it's just I feel like it's a hand in a monic is just like T.E.L.Z right the T.E. tells you one regimen the L.C. tells you the other regimen the T.E. is just enough of here and interested a bean right or you can give lamivide in plus I do you do right so if you notice the beans right lamivide in Z.W.

Dean you give those two together or you can give ten of a year or plus a year you see the bean that's basically how you treat a person that has been exposed to HIV and basically need to be on prophylaxis for about four weeks right so basically a month right because sometimes unfortunately one thing that your friends at the end of me do is that they actually ask you like what are you supposed to do for how long and stuff like that. And then another classic post exposure prophylaxis scenario is your test is with VZV right VZV so the thing is again classic situation can be like the newborn right if you're a newborn of a mom that you know has signs of like varicella or shingles or whatever right basically for the most part you cannot vaccine in those kids right again remember the varicella Zoster vaccine is a live alternative vaccine right so you can give you two kids that are less than a year old pretty much right so that kid gets VZV.

Okay varicella Zoster immune globally that kid should get varicella Zoster immune globally that's kind of like the big thing you want to keep at the back of your mind on exams and also again if for some reason right you have again they can give you like a somewhat unusual scenario that almost puts you in that kid less than one year old category right basically people that cannot get live at an orphaned vaccines right so let's say for example if it's a pregnant woman or if it's a person that has HIV and the CD4 count is less than 200 right you should not be getting the varicella vaccine right just go ahead and give those people VZV right go ahead and give those people VZV but if you're a healthy person right if you're a healthy person you don't have anything you're not in any of those groups I just talked about you can go ahead and give the person the varicella vaccine you can also give them visit at the same time although typically you just give them the varicella vaccine and they'll be they'll be fine right you'll be fine and then another classic one right is rabies right rabies so for person has been exposed to rabies for the most part you need to give them like the rabies immune globally and the rabies vaccine and again you need to give them in separate places but one gnarly question that the enemy can throw in on exams is where you give the rabies immune globally the thing is you typically want to give them immune globally around the wound in fact if you can inject it into the wound is incredibly painful from what I've heard it's like super super super painful I hope I'm not confusing this with some other thing but I think I think I've heard that it's like incredibly painful yes for those people you do need to try to give it around the wound so that again you can infiltrate that wound bind up the toxin as much as is possible because remember once rabies gets to th

e brain that's the end of the person's life pretty much right so you give the rabies immune globally and you give the rabies vaccine on that those circumstances right and again for the most part you know the rabies vaccine you get it like the day you get the bite pretty much right and then you give it like you know I almost look at it as the so you give it three days after and then I just pretty much double the time afterwards like three times two you know around seven days seven times two you give it 14 days afterwards right so that's the way you handle a person that has been exposed to rabies right so again a we've talked about he be hepsy vis-e-v rabies Viracela talked about all those things and then another classic one you may see on the example is meningitis right if you've been exposed to a person that has meningitis basically right you can use one of three options you can use super fluxes in or you can use you can use right fan pin right right fan pin is actually the preferred regimen you can also use a safe triaxle safe triaxle is also reasonable and I think it can also use is it from my center so you can use safe triaxle is it from my sin right fan pin which is preferred or safe triaxle and obviously the person is pregnant right the only options you have are is it from my sin or safe triaxle right because remember I found it is a teradogene and super fluxes in is you know it's not very ideal for the kids attend right so if you want to kind of mess up the kids tendon being of course you can have have it with with my sermon and jaded it so again if you've been exposed right fan pin is preferred but you also have the option to do super fluxes saying is it from my sin or safe triaxle and again remember the caveats for people that are people that are pregnant and then under classic one you may see is a pertosis right so if you've been exposed to a person or pertos

is again you should have not gotten in trouble if you were vaccinated in the first place right but if you been exposed just give some kind of a microletre like clarifromycin or it's from my sin is it from my sin whatever it doesn't matter right what if for some reason the mbmi chooses to not put any of those answers or they put like some kind of strong contraindication to get in the microletre like the person's cute interval is already prolonged or something ridiculous right or the person has like a nasty ventricular rate near history then for those people you can actually give them TMP smx trying to put themselves on a foxes all and that will help on that those are circumstances and then some more usual scenarios you can take an example if you've been exposed to a person with a TB right less you've been exposed to a person with TB unfortunately remember one of the best ways to prevent yourself from getting TB is we are an N95 mask that will be a great preventive medicine question on a test surgical mask doesn't really protect you from TB right so you want to use like a respirator basically an N95 mask or a P100 mask right to protect yourself even if you know you've got in the vaccine like the BCG vaccine that people get in developing countries you still need post exposure perphylaxis and typically what you would usually do is you would for you this is one of those rare cases where you don't really need to structure it immediately just test the person first right so the first thing you do is you do like a TB skin test right or alternatively you can do that interferon gamma release assay if any of those things come back positive basically like and the thing is the interferon gamma release assay that's something the NBME generally doesn't care much about I know that many Cubans and stuff they like really really go after that stuff but for the most part the TB skin test

is when you keep in mind and what is the interracion portal for a person that has been exposed to a person that has HIV like sorry not a person that has TB is actually five because you are is almost guaranteed you probably get the TB right so you do like a TB skin test if the interracion is five millimeters right or more and you go ahead and trade the person for the most part with you basically give them the latent TB regimen right so you give basically give them a sonyazet for nine months right and again remember you don't want those people to have peripheral neuropathy while they're at that right so typically in those cases you also give them a vitamin B6 remember vitamin B6 is something they can also write as a pyrodoxyl phosphate you can also write that as pyrodoxyl phosphate on an NBME exam and then one of the one that you may see on a test is like tetness right like tetness right so the thing is you know if you this one is like more like you're getting to someone won't like stung by a nail something weird right and we're like okay let's protect you from tetness right so the thing is there are many many many many regimens you see for this thing and this thing gets very complicated very fast right very complicated very fast but let me teach you how to go about this okay if we are not sure of the presence vaccine history right so basically there are one of two pounds you can get into one of two pounds you can get into right if we're not sure of your vaccine history then typically what we will do is we will give you in fact okay maybe let me put let's see how do I do this to me this easy yeah let me put let me put you in one of two pounds to again simplify things but make it accurate because again sometimes it's not very ideal for you to simplify things to the point where you then begin to off of skater the facts so the big thing is if a person if you are not sure o

f a person's tetness history right if we're not sure of the person's tetness history or let's say the person got their tetness series more than like 10 years ago right if you fall into this so I'm going to call these people power number one right so if we're not sure right if we're not sure or you had your series more than 10 years of with you tell you this clearly in a question the thing you're supposed to do is you're supposed to give the vaccine right and you can use any vaccine you want you can use the TV vaccine or you can use the TDAB vaccine either one is fine and then in addition to that you need to give the tetness immune globulin okay you need to give the tetness immune globulin you need to give the tetness immune globulin now the thing is and again obviously you go this new clear if you're seen that man this one is like super dirty or whatever right but again I'm trying to highlight the scenarios that are most common right you've never we're not sure of your vaccine history or it's been more than 10 years ago you got your vaccine right typically the tetness immune globulin and the tetness like some kind of vaccine again either the TV vaccine or the TDAB vaccine is what you get pretty much right but if for example you have if for example you've gotten your vaccine within like the last five years right if you're getting your vaccine within the last five years for the most part what you typically doing those people for those people typically what you do is to just give nothing I'll say that again again let me let me break this up the way you want to group your tetness on exams is are you more than doing not so you can be in group A or group B group A are we not sure of your vaccination history or is it more than 10 years ago right is it more than 10 years ago that you got the tetness vaccine for those people if they exposed to like again a very nasty wound rig

ht typically what you can do is you give them the tetness vaccine and then give them the tetness immune globulin right but if it's less than five years since you got I mean if it's less than five years since you got like your vaccine series and what not for the most part regardless of the kind of wound you don't do anything so again there's the less than five year pile right and then there's the greater than 10 year pile or we are not sure of you right if you're in the first greater than 10 year pile we're not sure of you typically again if it's a very nasty wound you can give the tetness vaccine and the tetness immune globulin right but if you're less than five years out from your last vaccine regardless of the type of wound you have you don't really get anything right but I guess I can maybe introduce like a small third category here right if you fall into that first pile and you know we're not sure of we're not sure of like we're not sure of you like your vaccine history we're not sure of your or it's been more than 10 years ago since you got to whatever and it's like a very minor wound not a very contaminated wound for those people you can just give them the vaccine you don't necessarily need to give them the immune globulin okay but again for the most part I will see the first two categories I mentioned are probably the things that will carry you most of the way on your exam and I think I think I'm going to go ahead and stop here I think for the most part I feel like I've kind of hit on most of that classic things that tend to pop up on exams although I guess another one that you may see on test right is let's say for example you've been exposed to some person that has I don't know like neck fasch right like neck fasch if you've let's say you've had like some weird exposures for some reason usually you would want to get some kind of anti-biotic right you know you

can get like clandamysen or you can get a zythromycin right or you can get like a mixture of penicillin and rifampin right so either penicillin plus rifampin or is it through my sin or clandamysen um let again those are various situations you probably will never see that tested see that tested on an exam and then don't forget many times they also ask like the method of spread of some things right like the test providers see if the way those things are spread right is by improper hand wash and right or the way people get stuff or is gastroenteritis is because you know you did not refrigerate food properly right so hopefully you find this podcast to be helpful please subscribe to the You Tube channel it's called a Divine Intervention USML podcast and videos I also have this podcast on Apple podcasts on Spotify and Google Play and subscribe and then also have a Word Press website right Divine Intervention Podcasts.com that's where typically you would find the slides for the stuff I've made so and then I guess my life lesson for today is about the importance of an inner circle right so the thing is again you can have many friends right but the thing is there should be a very strong difference between your friends and your inner circle right between your friends and your inner circle because the thing is there many people that see your friends both they're just your friends for what they can get from you they are conditional friends right they are conditional friends um but you want to be able to find like there is not everyone like for example I have tons and tons and tons of friends right there's a lot of people that know me from my med school from my past and all that stuff right but the thing is in this world I can probably count on my fingers the number of real friends I have like people that I can share really deep things with right you don't want to be sharing really

deep things with people that are your friends you want to be sharing really deep things with people that are your inner circle people that don't have any vested interest in profiting from you anything like that these are just people that literally look out for your own interests right so again you want to be careful of that because again I feel like we live in a world where you know people are pretty elite box stabbers these days right so because I mean like I want to think about it right like you see people that are like oh I thought this person was my friend this is someone that's super close to you super tight with you right but the moment something bad happens in your life like you're in a bad situation or whatever you then see the real true colors right I mean people like I mean even a part of the Bible says that a brother is born for the day of adversity right like it's in the day of adversity right that you know who your true friends are right because again wealth success has many friends right but poverty and failure is an orphan right but the Bible says that there's a friend that sticks closer than a brother right for a friend to stick closer than a brother that means it's like a true friend right so that's the thing you just want to watch out for it like watch out like and again that's the thing like it's very hard to get people that you can regard as your inner circle but when you have those friendships keep them because those friendships will help you down down down the line right that many parts of your love and also I challenge you today be that kind of inner be that inner circle kind of person right don't be the person that someone has told you something in confidence you go and spread it around the world right that's no very prudent and again next time no one will want to hang out with you right so you know kind of set a career on mouth you don't have

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To provide drugs, vaccines, or immunoglobulins that protect an individual from developing a disease after exposure.

Hepatitis B immune globulin and the Hepatitis B vaccine.

Wearing an N95 or P100 respirator mask, as surgical masks do not provide adequate filtration.

Around the wound site, to help neutralize the toxin locally.

Immunocompromised patients (e.g., pregnant women or those with CD4 < 200) must receive the inactive/inactivated vaccine (VZV), not a live attenuated vaccine, due to immunosuppression risks.

Approximately four weeks (one month).

Hepatitis B immune globulin and Hepatitis B vaccine.

Tetanus vaccine (Tdap) AND Tetanus immune globulin (TIG).

Vitamin B6 (Pyridoxine), to prevent peripheral neuropathy.

Live attenuated vaccines (e.g., Varicella Zoster Vaccine).

T.E.L.Z or Lamivudine/Zidovudine combination therapy.

Day 0 (RIG + Vaccine), Day 3, Week 2, and Week 4.

Hepatitis B immune globulin and Hepatitis B vaccine.

Tetanus vaccine (Tdap) AND Tetanus immune globulin (TIG).

Vitamin B6 (Pyridoxine), to prevent peripheral neuropathy.

Live attenuated vaccines (e.g., Varicella Zoster Vaccine).

T.E.L.Z or Lamivudine/Zidovudine combination therapy.

Day 0 (RIG + Vaccine), Day 3, Week 2, and Week 4.