Managing Sexual Assualt in Primary Care

Thanks to those who participated in a great discussion in AMR last week. I wanted to share some of what we talked about here…

Sexual assault is an unusal complaint inside of a primary care clinic.  Many victims head straight for the ER or a Rape Crisis Center, others never report their attack. But for many, their primary care doctor may seem like a trusted source for health care in a very scary and chaotic situation. Since it is also a scary and chaotic situation for the provider, I thought that an organized process may help you know what to do in such a scenario.


Legal Issues

The patient may need or want an exam in order to collect evidence for future charges against an attacker. There is a very specialized process that is used to collect evidence, and maintain the chain of custody.  I would recommend that you contact your Emergency Dept or Rape Crisis Center for help.  In Birmingham, the Crisis Center offers Sexual Assault Nurse Examiner (SANE) Exams in a safe and secure facility, and may be a more comfortable alternative to an ED.  They have a SANE nurse on call 24/7. Many times, this exam must be done within 72 hours of the attack.

Pregnancy Prevention

Most women should be offered post-coital contraception after a sexual assault.  The most effective oral option is Le
vonorgestrel, (Plan B is one brand name).  Ulipristal (Ella) is a newer form of emergency contraception that is effective up to 120 hours after unprotected sex.

 

STI Prevention

The CDC recommends antibiotic prophylaxis for GC, Chlamydia, and Trichomonas.  If your patient declines, you should see her back in a week for testing.  You need to give (all single dose therapies):

  • Ceftriaxone 250mg IM for Gonorrhea
  • Azithromycin 1g PO for Chlamydia
  • Metronidazole 2g PO for Trichomonas

Hepatitis B Prevention

If the Hepatitis B status of the attacker is not known, and the victim is not already immune, the victim should receive the Hepatitis B vaccine on first visit, and then at 1 and 6 months.  If the attacker has Hepatitis B, then you should offer HBIG.

HIV Prevention

There is some data that post-exposure prophylaxis with antiretroviral drugs prevents HIV transmission. Most of this data is in the healthcare setting, when folks like us are exposed with needles. The studies done in sexual exposure and IV drug users are all small and observational. Side effects with these medicines are fairly common, and usually of the GI variety.

Given limited data, and relatively low risk of transmission for a single sexual exposure (0.1% for consensual vaginal intercourse and 2% for consensual anal intercourse- transmission rates with nonconsensual sex are likely to be higher), the CDC only recommends post exposure prophylaxis (PEP) if:

  • The assailant is known to be HIV positive
  • The victim presents within 72 hours
  • There was exposure OF: eye, mouth, vaginal, rectum, other mucus membrane or nonintact skin
  • WITH: semen, vaginal fluid, blood, rectal secretions, milk, or other bodily fluids that are known to transmit HIV.

However, they do give you an option to treat other patients on a case-by-case basis. Many experts recommend that PEP is offered to all victims of sexual assault that present in the first 72 hours and have a chance at HIV exposure.  If you were going to prescribe, it should start within 72 hours (the earlier the better), and continue for 4 weeks. Three drug combinations are usually used, the same as in occupational HIV PEP.

  • Tenofovir/emtricitabine 300/200 plus Dolutegravir 50mg once daily
  • Tenofovir/emtricitabine 300/200 plus Raltegravir 400mg twice daily

Psychologic Support

Probably the most important thing that you can do. Your patient came to use because you were trusted, available, and supportive. You need to continue to be those things. After an assault, many victims will struggle with nightmares, anorexia, guilt, anxiety, and PTSD.  As a primary care doctor, you can gently ask about these issues, and guide your patients to helpful therapies and supportive environments. Again, rely on your local resources for crisis counseling and psychiatry, in addition to using all of your own talents.

Here is a NEJM article (subscription needed) if you are interested in reading more: NEngl J Med 2011; 365:834-841.

Pneumonia Shots- Part 2: Immunocompromised Adults

Welcome back to Part 2 of the great Prevnar vs Pneumovax Update here at I Hate Rashes.

Last time, I talked about the differences between the two vaccines and the current recommendations for adults >65.  To recap, Pneumovax is a polysaccharide vaccine that covers 23 serotypes of S. Pneumoniae (PPSV23).  This is great because it is so broad.  Prevnar is a Conjugate polysaccharide vaccine that covers 13 serotypes (PCV13).  This is great because conjugating the pneumococcal polysaccharide to a diphtheria toxin boosts immunity and helps lead to herd immunity.  ACIP currently recommends that we give both PCV13 and PPSV 23 to our patients over 65. It is probably best to give PCV 13 first if the patient hasn’t had any pneumococcal vaccines. 
But what about all of those adults who get the pneumococcal vaccine BEFORE age 65? What should we do with them?  It is probably helpful to divide our recommendations between the immunocompetent vs immunocompromised conditions.

Those who are immunocompromised actually have long been recommended to get both PCV13 and PPSV23. This includes patients with asplenia, CSF leaks,  cochlear implants, HIV and other immunodeficiencies, nephrotic syndrome, leukemia/lymphoma, myeloma, transplants, and iatrogenic immunosuppression.  Iatrogenic immunosuppression includes chronic steroids, radiation therapy, and probably immunomodulators used in rheumatologic diseases. Most of these will need revaccination with PPSV23 5 years after their first vaccine: there is no need to revaccinate with the PCV13.

The immunocompetent patients continue to get just the PPSV23 prior to age 65.  This is for our patients with diabetes, COPD/Asthma/smoking, chronic heart disease, and chronic liver disease/alcoholism.  Once they turn 65, give them PCV13 and then repeat the PPSV23 about a year later.

Here’s a handy chart if you are more of a visual learner.

Risk group

Underlying medical condition

PCV13

PPSV23

Recommended

Recommended

Revaccination 5 yrs after first dose

Immunocompetent persons

Chronic heart disease

Chronic lung disease§

Diabetes mellitus

Cerebrospinal fluid leak

Cochlear implant

Alcoholism

Chronic liver disease, cirrhosis

Cigarette smoking

Persons with functional or anatomic asplenia

Sickle cell disease/other hemoglobinopathy

Congenital or acquired asplenia

Immunocompromised persons

Congenital or acquired immunodeficiency

Human immunodeficiency virus infection

Chronic renal failure

Nephrotic syndrome

Leukemia

Lymphoma

Hodgkin disease

Generalized malignancy

Iatrogenic immunosuppression**

Solid organ transplant

Multiple myeloma

Let’s practice some more:  For each patient, do you give PCV13 vs PPSV2, or both

  1. 55 newly diagnosed diabetic
  2. 60 year old with COPD, never had pneumococcal vaccine before
  3. 62 year old with COPD, had PPSV23 3 years ago, takes prednisone 5mg daily.
  4. 25 year old with coclear implants, never had pneumococcal vaccine before
  5. 35 year old with well controlled HIV, never had PCV13, had PPSV23 10 years ago, at diagnosis.

Let me know your answers or questions in the comments!

Here’s a link to the CDCs Adult Vaccine Schedule- note the new guideline for adults age 65 and over is not included here, yet.  There’s also an app for that.

 

Pneumonia shots- part 1: Patients over 65

In my ever continuing struggle to stay up to date, i thought I’d post today about something that was big news back in the Fall: Two pneumonia shots for seniors.

The old news was that everyone needed a pneumonia shot at age 65- one and done, we always thought.  That “pneumonia shot” was really a vaccine against S. Pneumoniae, which causes meningitis, sepsis, along with the pneumonia that it was so nicely named for.  The standard vaccine that we used in adults was the 23-Valent polysaccharide vaccine (PPSV23), brand name Pneumovax.  This vaccine covers 23 serotypes of S. pneumoniae (that’s the 23 valent part of the name), and is made from polysaccharides found in the capsules of the bacterium (that’s the polysaccharide part of the name).  This shot is great because it covers so many different serotypes.  The downside of polysaccharide vaccines is that they can’t be given in children <2, they don’t provide lifelong immunity, and they don’t provide mucosal immunity (important because mucosal immunity promotes herd immunity). Studies on this vaccine show that it can prevent invasive pneumococcal disease, but may not be so great at preventing the noninvasive pneumococcal pneumonia.

These “polysaccharides” come from the S. pneumoniae capsule.

Enter the 13 Valent Conjugate Vaccine (PCV13), brand name Prevnar. This still uses polysaccharides from the pneumococcal bacteria, but attaches (conjugates) them to a “carrier protein”– in this case, a protein from diptheria. This carrier protein helps to rev up the immune system and induces mucosal immunity.  After several exposures, this kind of vaccine will induce lifelong immunity.  Before this year, we were commonly using this kind of vaccine in children (since the other one didn’t work), and in immunocompromised adults, but not in everyone.  We know from this vaccine, and another conjugate pneumonia vaccine (PCV7), that immunizing children reduces the prevalence of those particular serotypes in adults (remember, mucosal immunity is a key to creating herd immunity).

The new news is that the PCV13 is now recommended for all adults >65.  This recommendation came on the heels of a study performed by Pfizer (you can guess what they make) in the Netherlands.  They studied 85,000 adults >65 who had never had a pneumococcal vaccine, and compared PCV13 to Placebo.  There was a 75% reduction in vaccine-type pneumococcal disease in the vaccine group, and a 45% reduction in vaccine-type CAP.  This was convincing enough for ACIP (the group that makes vaccine schedule recommendations).  It is important to say again: participants in the study DID NOT have PPSV23 prior to the PCV13. Many of our patients have already had PPSV23.

We do know that PCV13 does induce an immune response in seniors, even if they have already had the PPSV23.  It seems to be a “higher” immune response than the PPSV23, indicating that it may be the better vaccine between the two.

So what to do?  Currently ACIP recommends that we give BOTH PCV13 and PPSV23 to our patients over 65.  The ideal scenario would be to give the PCV13 (Prevnar) first, and then the PPSV23 (Pneumovax) 6-12 months later. This is what you should do for patients who have never had any pneumococcal vaccination, as well as those who you are revaccinating because they have turned 65.  If your patient over 65 has already had PPSV23, then wait a year before giving the PCV13. See the handy chart below for potential scenarios

Pneumococcal vaccine status:

FIRST give:

THEN give:

None/Unknown

Prevnar 13
(≥ age 65)

Pneumovax 23

(6 to 12 months after Prevnar 13)

Pneumovax 23
Given AFTER 65
th birthday

Prevnar 13
(≥ 12 months after Pneumovax 23)

n/a

Pneumovax 23
Given BEFORE 65
th birthday

Prevnar 13

(≥ age 65 AND

≥ 1 year after Pneumovax 23)

Pneumovax 23
(6 to 12 months after Prevnar 13 AND
5 years after Pneumovax 23)

So what about paying for these vaccines?  That is another sticky situation. Medicare currently pays for ONE S. Pneumonia vaccine per lifetime– which now seems to run counter to ACIP guidelines.  It will take a year or two for Medicare to catch up, so don’t expect this to change until about 2016. *UPDATED INFO: Medicare, BCBS and Viva are in fact paying for the PCV13 vaccine.  My read of the Medicare website shows that the second pneumococcal vaccine will be covered if it is given 11 months after the first one.  If your patient is new to Medicare, or hasn’t had any S. pneumoniae vaccines yet, give them the PCV13– it is more immunogenic and is better to give first.  If your patient has already gotten a PPSV23 while covered by Medicare, they will likely have to pay out of pocket ($100-$150) to get the PCV13.  My advice is to wait until the Medicare guidelines catch up. After that, wait a year or so and give the PPSV23.  If they have already had the PPSV23, then give the PCV13 the next year.  It is safe to give the second shot as early as 8 weeks after the first one.

Here are some practice scenarios. Let me know which vaccine you would give, when, and why in the comments.

  1. 65 year old, no medical problems, never had a S. Pneumoniae vaccine
  2. 75 year old, Medicare patient, vaccinated with PPSV23 at age 65
  3. 65 year old with diabetes, new to Medicare, got PPSV23 at age 59 after diagnosis with DM

If you are ready to move on to Part 2, take a look at this post.

Here’s a link to the CDCs Adult Vaccine Schedule- note the new guideline for adults age 65 and over is not included here, yet.  There’s also an app for that.