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Post-exposure prophylaxis

Post-exposure prophylaxis (PEP) is a preventive medical intervention involving the administration of antimicrobial agents, vaccines, or immunoglobulins shortly after potential exposure to specific infectious pathogens to avert infection establishment.^[1] This approach targets diseases such as rabies, HIV, and hepatitis B, where timely intervention exploits the pathogen's vulnerable replication phase before systemic dissemination.^[2]^[3] PEP regimens are pathogen-specific and emphasize immediacy, as efficacy diminishes rapidly with delay; for HIV, antiretroviral therapy must begin within 72 hours of exposure and persist for 28 days to reduce acquisition risk by more than 80 percent when adhered to properly.^[3]^[4] In rabies cases, where untreated symptomatic infection proves fatal in nearly 100 percent of instances, PEP combines thorough wound care, human rabies immune globulin, and a multi-dose vaccine series, achieving virtual certainty of prevention if initiated promptly post-exposure.^[2]^[5] For hepatitis B, post-exposure measures include hepatitis B immune globulin and vaccination, particularly effective in unvaccinated individuals following percutaneous or mucosal exposures.^[1] While PEP represents a cornerstone of emergency infectious disease management, its success depends on factors including exposure severity, inoculum size, host immunity, and regimen completion, with incomplete adherence or delayed access contributing to occasional failures.^[6] Notable applications extend to bacterial threats like pertussis in high-risk contacts, underscoring PEP's role in bridging gaps in pre-exposure vaccination or immunity.^[7] Emerging uses, such as doxycycline PEP for bacterial sexually transmitted infections in select populations, highlight ongoing adaptations based on empirical evidence, though broader implementation requires vigilant monitoring for antimicrobial resistance.^[8]

Definition and General Principles

Definition and Mechanisms

Post-exposure prophylaxis (PEP) constitutes the short-term administration of antimicrobial drugs, vaccines, immunoglobulins, or other targeted agents immediately following a known or suspected exposure to a pathogenic microorganism, with the objective of averting the initiation or progression of infection. This approach differs fundamentally from pre-exposure prophylaxis (PrEP), which employs ongoing preventive measures prior to any contact with the pathogen to maintain protective drug levels or immunity in anticipation of potential exposure. PEP's success hinges on rapid intervention, typically within hours to days post-exposure, capitalizing on the pathogen's intrinsic lag in establishing productive infection.^[9]^[10]^[11] At its core, PEP operates through mechanisms that disrupt the causal pathways of pathogenesis during the vulnerable early phase after inoculation, when the infectious dose remains localized and numerically limited, prior to widespread dissemination or exponential replication. Antimicrobials, for bacterial threats, inhibit cell wall synthesis, protein production, or toxin elaboration, thereby preventing the amplification of bacterial populations that would otherwise overwhelm host defenses. Antiviral agents, in contrast, interfere with viral life cycles by blocking reverse transcription, integration into host genomes, protease activity, or virion assembly, halting the propagation of viral progeny from the initial infected cells.^[12]^[13]^[6] Immunoglobulin-based PEP provides passive immunity by delivering exogenous antibodies that neutralize extracellular pathogens or toxins before they can bind to target cells or induce tissue damage, bridging the gap until endogenous adaptive responses mature. Vaccines administered post-exposure stimulate rapid humoral and cellular immunity, often augmented by adjuvants, to clear nascent infections. These interventions exploit the finite temporal window—frequently 24 to 72 hours for viruses—during which pathogen burden is low and host clearance mechanisms retain efficacy, underscoring PEP's reliance on precise timing to interrupt replication cycles grounded in microbial biology rather than mere symptom suppression. Empirical evidence from animal models and human occupational exposures confirms that efficacy diminishes sharply with delays, as pathogen loads surpass therapeutic thresholds.^[14]^[15]^[16]

Timing and Administration Guidelines

Post-exposure prophylaxis (PEP) must be initiated as soon as possible following exposure to maximize efficacy, as delays permit exponential pathogen replication that overwhelms prophylactic interventions.^[17] Animal models, including nonhuman primate studies with simian immunodeficiency virus, demonstrate that PEP success declines sharply when initiation is postponed beyond hours, due to rapid viral dissemination and establishment in host tissues before drug levels achieve therapeutic concentrations.^[17] ^[18] This causal mechanism underscores the need for immediate action, with empirical data indicating optimal windows of less than 72 hours post-exposure for most applications, though ideally within 2 hours for high-risk scenarios like potential HIV acquisition per updated 2025 guidelines.^[19] ^[6] PEP regimens typically span 7 to 28 days, calibrated to the replication kinetics of the target pathogen to ensure clearance of any nascent infection without fostering resistance.^[20] Shorter durations risk incomplete suppression, as evidenced by primate models showing superior outcomes with extended courses matching viral clearance timelines.^[20] Administration routes vary by agent—oral for antiretroviral PEP, intramuscular or intravenous for vaccines and immunoglobulins—but adherence remains critical, with incomplete courses linked to reduced protection in observational data.^[16] ^[21] Patients receiving PEP require close monitoring for adverse effects, including renal, hepatic, or gastrointestinal toxicity from agents like antiretrovirals, with baseline assessments and serial testing recommended to guide continuation or discontinuation.^[16] Adherence support, such as counseling and linkage to follow-up care, addresses common barriers like side effects or access issues, ensuring the full course is completed to align with the time-sensitive prophylactic intent.^[22]

Risk Evaluation Frameworks

Risk evaluation frameworks for post-exposure prophylaxis (PEP) systematically quantify transmission likelihood by integrating source infectivity, exposure characteristics, and host vulnerability, drawing from surveillance data and epidemiological models rather than categorical heuristics alone. These frameworks prioritize empirical transmission rates, such as those derived from occupational cohorts, to inform decisions without presuming zero risk absent confirmatory testing. For instance, HIV frameworks multiply source prevalence by per-act probabilities, adjusted for modifiable factors, yielding estimates like 0.3% for percutaneous injuries from viremic sources.^[6]^[23] Source factors dominate assessments, with pathogen load as a causal multiplier: undetectable HIV viral loads correlate with near-zero transmission, while loads exceeding 50,000 copies/mL elevate risks severalfold in meta-analyses of exposures.^[24] For rabies, source risk hinges on animal rabies status and endemicity, with confirmed rabid mammals prompting immediate PEP absent observation periods. Exposure routes are weighted by biomechanical efficiency—percutaneous or transdermal breaches (e.g., needlesticks or bites) exceed mucosal or intact-skin contacts by orders of magnitude, with HIV mucous membrane risks at 0.09% versus 0.3% for deep punctures involving hollow-bore needles.^[10] Volume, depth, and contamination (e.g., visible blood) further calibrate probabilities, as shallower or low-volume events halve baseline risks in cohort studies.^[25] Host factors, including immune competence and prior immunization, modulate net risk but receive less granular modeling due to confounding in real-world data; immunosuppression may double HIV acquisition odds post-exposure, though PEP efficacy persists if initiated promptly. Rabies frameworks incorporate vaccination history via WHO categories: unvaccinated individuals facing Category III exposures (bites or mucosal contamination) require full regimens, while pre-exposure vaccination reduces needs to boosters alone.^[26] Decision aids, such as CDC HIV risk calculators and WHO rabies trees, operationalize these via flowcharts estimating aggregate probabilities (e.g., <0.1% thresholds for deferral), ensuring PEP targets exposures exceeding evidence-based baselines like 1 in 1,000 for non-viremic sources.^[2]^[27]

Historical Development

Origins in Bacterial and Rabies Prevention

The concept of post-exposure prophylaxis (PEP) originated in the late 19th century with interventions aimed at preventing rabies following animal bites, marking the first systematic use of vaccination after potential exposure to a pathogen. In 1885, Louis Pasteur administered the inaugural rabies vaccine to a nine-year-old boy, Joseph Meister, who had been bitten multiple times by a rabid dog; the treatment involved a series of 14 doses of attenuated virus derived from rabbit spinal cords, administered over 10 days, and successfully prevented the onset of rabies symptoms.^[28] This approach built on Pasteur's earlier experiments from 1882, which demonstrated efficacy in dogs through progressive vaccination starting with weaker viral strains, establishing PEP as a timed, escalating immunization protocol to outpace viral neurotropism.^[29] By the early 20th century, such rabies PEP had become a standard for bite victims traveling to treatment centers, with thousands treated annually using nerve tissue vaccines, though later refinements addressed risks like post-vaccination encephalitis.^[30] Parallel developments in bacterial PEP emerged with tetanus prevention, focusing on antitoxin administration for contaminated wounds. Tetanus antitoxin, derived from immunized horses, was first demonstrated to confer passive protection in 1897 by Edmond Nocard, who showed its efficacy in neutralizing Clostridium tetani toxin when transferred to exposed animals.^[31] This passive immunization was rapidly applied to humans for post-wound prophylaxis, particularly in military contexts during World War I, where serum was injected into injury sites to mitigate toxin effects before symptoms like muscle spasms appeared.^[32] Empirical success reduced tetanus incidence dramatically; by World War II, widespread antitoxin use in soldiers with dirty wounds correlated with a 95% drop in cases compared to prior conflicts, underscoring PEP's role in bridging immediate passive immunity until active vaccination could take effect.^[33] World War II further codified antibiotic-based PEP norms for bacterial wound infections, integrating sulfonamides and penicillin into protocols for penetrating trauma. Penicillin, introduced to battlefield medicine in 1942, was administered prophylactically soon after injury to combat gram-positive bacteria in contaminated wounds, with early intravenous dosing followed by surgical debridement proving instrumental in averting sepsis and gas gangrene.^[34] These protocols emphasized rapid initiation—ideally within hours of exposure—to inhibit bacterial proliferation, setting precedents for modern guidelines on timing and spectrum coverage in high-risk injuries.^[35] Such empirical outcomes from military data validated PEP's causal efficacy in disrupting bacterial pathogenesis post-exposure, distinct from preemptive vaccination. Bacterial PEP principles extended to deliberate exposures like the 2001 anthrax attacks, where oral antibiotics prevented inhalational disease in potentially exposed populations. Following the mailing of Bacillus anthracis-contaminated letters, the CDC recommended 60 days of ciprofloxacin (500 mg twice daily) or doxycycline (100 mg twice daily) for over 10,000 postal workers and others with aerosol exposure risks, based on animal models showing efficacy in eradicating spores before germination.^[36]^[37] No secondary inhalational cases occurred among compliant recipients, affirming antibiotics' role in PEP for spore-forming bacteria when initiated promptly after confirmed environmental contamination.^[38]

Expansion to Viral Pathogens

The application of post-exposure prophylaxis (PEP) expanded from rabies in the early 20th century to other viral pathogens in the mid-20th century, initially focusing on passive immunization strategies before incorporating antivirals amid the HIV/AIDS epidemic. Hepatitis B virus (HBV) represented an early milestone, with hepatitis B immune globulin (HBIG)—derived from plasma of immunized donors—introduced in the 1970s for preventing infection following percutaneous or perinatal exposures. Clinical trials demonstrated HBIG's efficacy when administered within 48 hours of exposure, reducing transmission risk in high-risk scenarios like needlestick injuries among healthcare workers, though it provided only temporary passive immunity lasting 3-6 months.^[39]^[40] The 1980s AIDS crisis accelerated PEP development for systemic viruses, prompting investigations into antiretroviral agents for HIV prevention after occupational exposures, such as needlesticks from infected patients. In January 1990, the U.S. Centers for Disease Control and Prevention (CDC) issued initial guidance considering zidovudine (ZDV, also known as AZT) monotherapy as PEP, based on its inhibition of HIV reverse transcriptase and limited clinical data suggesting potential benefit when initiated promptly.^[18] This marked a shift toward active antiviral regimens, contrasting with HBIG's passive approach, driven by the absence of vaccines and high occupational HIV transmission rates estimated at 0.3% per needlestick.^[13] Preclinical validation came from simian immunodeficiency virus (SIV) challenge studies in macaques during the early 1990s, which established that short-course antiretrovirals initiated within hours of exposure could prevent systemic infection. For instance, intravenous ZDV or nucleotide analogs like PMPA administered for up to 28 days post-exposure protected against mucosal or intravenous SIV inoculation, informing human PEP durations by demonstrating dose-dependent blockade of viral replication in lymphoid tissues. These models underscored the narrow window for intervention—efficacy dropped sharply beyond 24-48 hours—while highlighting challenges like viral breakthrough in untreated controls.^[41]^[20] By the mid-1990s, accumulating occupational exposure data solidified HIV PEP protocols, with a 1997 CDC-supported case-control study of 33 U.S. healthcare workers showing ZDV reduced HIV acquisition risk by approximately 81% after needlestick injuries when started within hours. This evidence, combined with HBV precedents, broadened PEP to combination regimens for source patients with unknown viral loads, though adherence issues and side effects like anemia limited uptake. Expansion remained confined to occupational settings until late-1990s extensions to non-occupational risks, reflecting empirical prioritization of high-risk, verifiable exposures over theoretical ones.^[14]^[18]

Recent Guideline Updates (2000s–2025)

In the early 2000s, U.S. Public Health Service guidelines expanded post-exposure prophylaxis (PEP) recommendations to include non-occupational exposures, such as those from sexual assault or injection drug use, emphasizing initiation within 72 hours and a 28-day course of antiretroviral therapy.^[42] This shift incorporated evidence from observational studies supporting broader application beyond occupational settings, with regimens initially relying on nucleoside reverse transcriptase inhibitors combined with protease inhibitors or non-nucleoside reverse transcriptase inhibitors.^[11] The introduction of integrase strand transfer inhibitors, starting with raltegravir approved in 2007, marked a key evolution, as its favorable tolerability profile led to its inclusion in preferred PEP regimens by the mid-2010s, reducing reliance on drugs associated with higher toxicity like efavirenz.^[43] By 2023–2025, the CDC's updated nonoccupational PEP (nPEP) guidelines prioritized second-generation integrase inhibitors, recommending bictegravir/emtricitabine/tenofovir alafenamide or dolutegravir plus emtricitabine/tenofovir alafenamide as first-line options for most adults and adolescents, citing improved adherence due to once-daily dosing and lower rates of adverse effects compared to older combinations.^[6] These revisions reflect accumulating data on drug resistance patterns and long-term toxicity, de-emphasizing regimens with boosted protease inhibitors or efavirenz, which showed higher discontinuation rates in observational cohorts.^[44] Concurrently, the World Health Organization's 2024 guidelines reinforced a standard 28-day PEP duration for high-risk exposures while advocating task-sharing and community-based delivery to enhance access, particularly in resource-limited settings.^[21] Emerging updates for non-HIV pathogens included reinforced CDC endorsements for oseltamivir as post-exposure prophylaxis against influenza, administered twice daily for 5–10 days in close contacts, based on randomized trials demonstrating reduced symptomatic infection risk.^[45] For COVID-19, initial authorizations for monoclonal antibodies as PEP, such as bamlanivimab, faced critiques for limited durability, with real-world studies revealing waning protection against variants and minimal impact on hospitalization rates beyond early Omicron waves, prompting shifts toward vaccination and antivirals over monoclonals.^[46]^[47] These evolutions underscore a data-driven pivot toward regimens balancing efficacy, safety, and feasibility amid evolving pathogen dynamics.

Applications for Bacterial Pathogens

Tetanus

Post-exposure prophylaxis for tetanus targets wounds at high risk of Clostridium tetani infection, such as deep puncture wounds, avulsions, crush injuries, burns, or those contaminated with soil, dirt, feces, or saliva.^[48] Prophylaxis is indicated for individuals with incomplete primary vaccination (fewer than three doses of tetanus toxoid-containing vaccine), unknown history, or whose last booster was more than 10 years prior, particularly in tetanus-prone wounds.^[48]^[33] The primary goal is to neutralize unbound tetanus toxin via passive immunity while inducing active immunity; wound debridement is essential to remove bacterial sources.^[48]^[49] The standard regimen involves intramuscular administration of human tetanus immune globulin (TIG) at a dose of 250 international units (IU) in a single site, separate from the vaccine injection, for passive neutralization of circulating toxin in high-risk cases.^[50]^[48] Concurrently, a dose of tetanus toxoid-containing vaccine—such as tetanus-diphtheria (Td) or tetanus-diphtheria-acellular pertussis (Tdap) for those aged ≥7 years—is given to stimulate long-term immunity, even if TIG is administered.^[51]^[33] Antibiotics, such as metronidazole or penicillin, serve as adjunctive therapy to eradicate vegetative bacteria and prevent further toxin production but do not neutralize existing toxin and are not recommended solely for tetanus prevention.^[48]^[31] When administered promptly, tetanus PEP is highly effective, with efficacy of the tetanus toxoid inferred at nearly 100% based on serologic protection levels from complete vaccination series.^[31] In the United States, routine vaccination has reduced tetanus incidence dramatically, from thousands of cases annually before widespread immunization to fewer than 30 reported cases per year in recent decades, with most occurring in unvaccinated or inadequately boosted individuals.^[52] From 2013 to 2022, among cases with known status, only 24% had received three or more doses, underscoring vaccination's protective role.^[52] TIG provides immediate protection against toxin-mediated disease, preventing progression in exposed but unimmunized persons if given before symptoms onset.^[33]

Anthrax

Post-exposure prophylaxis (PEP) for anthrax, caused by Bacillus anthracis, primarily targets inhalation and cutaneous exposures anticipated in bioterrorism scenarios, where aerosolized spores pose the greatest risk of systemic dissemination. Following the 2001 Amerithrax attacks, which involved mailed spores contaminating postal facilities and affecting multiple individuals, U.S. public health authorities implemented PEP regimens for over 30,000 potentially exposed persons, emphasizing rapid initiation to prevent germination of dormant spores into vegetative bacteria.^[53]^[54] The standard protocol combines antimicrobial therapy with vaccination to address both bacterial replication and toxin-mediated pathology. Antimicrobial agents, such as ciprofloxacin (500 mg orally twice daily) or doxycycline (100 mg orally twice daily), are administered for 60 days in asymptomatic inhalation exposure cases to eradicate vegetative forms of B. anthracis that emerge from spores over time.^[55]^[56] These antibiotics inhibit bacterial protein synthesis or DNA replication, respectively, preventing toxin production by vegetative cells, though they do not directly neutralize spores or established toxins.^[56] Efficacy exceeds 90% in nonhuman primate models when initiated shortly after exposure but prior to symptom onset, as delays allow spore germination and irreversible toxemia.^[55] Concurrent vaccination with Anthrax Vaccine Adsorbed (AVA, BioThrax)—dosed at days 0, 14, and 28—elicits antibodies against protective antigen, a key toxin component, enhancing long-term protection beyond the antibiotic course.^[55] For cutaneous anthrax from spore contact, PEP may involve shorter antibiotic durations (7–14 days) if lesions are absent, but bioterrorism protocols default to the 60-day regimen due to potential for secondary inhalation or dissemination.^[57] Levofloxacin (500 mg orally once daily) serves as an alternative fluoroquinolone, with all options FDA-approved based on primate efficacy data and susceptibility patterns of B. anthracis.^[56] The 2023 CDC guidelines reaffirm tetracyclines like doxycycline as first-line alternatives to fluoroquinolones for PEP, particularly for those intolerant to the latter, while noting reduced tooth staining risks with short-term use in children.^[55] Adjunctive monoclonal antibodies, such as raxibacumab or obiltoxaximab targeting protective antigen, remain primarily for treatment of early symptomatic cases but are under evaluation in trials for high-risk PEP to neutralize emerging toxins preemptively.^[55] These updates incorporate pharmacokinetic modeling and animal studies confirming robust survival outcomes with oral regimens alone in pre-symptomatic phases.^[55]

Lyme Disease

Post-exposure prophylaxis for Lyme disease targets prevention of Borrelia burgdorferi infection following bites from infected Ixodes scapularis ticks in endemic regions, where transmission requires the tick to remain attached for at least 36-48 hours.^[58]^[59] Prophylaxis is reserved for high-risk exposures to minimize unnecessary antibiotic use, given the overall low probability of transmission even in endemic areas, estimated at 1-3% for attached Ixodes ticks without engorgement.^[60]^[61] Current guidelines from the CDC and IDSA recommend a single oral dose of doxycycline—200 mg for adults and 4.4 mg/kg (up to 200 mg) for children—administered within 72 hours of tick removal, but only if all criteria are met: the tick is identified as Ixodes scapularis, it was attached for ≥36 hours (evidenced by engorgement or body not flat), the bite occurred in a highly endemic area with local B. burgdorferi prevalence >20% in ticks, and the patient has no contraindications to doxycycline.^[62]^[61]^[63] Routine prophylaxis is not advised for low-risk bites, as the number needed to treat to prevent one case of early Lyme disease exceeds 40 in typical scenarios.^[64]^[65] A randomized, double-blind, placebo-controlled trial published in 2001 demonstrated that single-dose doxycycline reduced the incidence of early Lyme disease by 87% (95% confidence interval, 25-98%) compared to placebo among 482 participants with recent I. scapularis bites in endemic areas of New York State, with no cases of extracutaneous dissemination in the treatment group.^[60]^[66] This evidence supports targeted use, though guidelines emphasize serologic surveillance or watchful waiting over broad application due to the rarity of progression to objective signs like erythema migrans without prophylaxis.^[61]^[59] Concerns over prophylaxis include potential overuse in non-endemic or low-attachment scenarios, which exposes patients to doxycycline's side effects (e.g., gastrointestinal upset, photosensitivity) without benefit and contributes to broader antimicrobial resistance pressures, as Borrelia treatment already relies heavily on tetracyclines and overuse accelerates selective pressure on commensal bacteria.^[67]^[68] Empirical data from stewardship programs highlight that indiscriminate PEP prescriptions correlate with rising community doxycycline resistance in unrelated pathogens, underscoring the need for strict adherence to risk-stratified criteria to preserve antibiotic efficacy.^[69]^[68]

Applications for Viral Pathogens

Rabies

Rabies post-exposure prophylaxis (PEP) is the standard intervention following potential exposure to the rabies virus, a neurotropic RNA virus from the Lyssavirus genus that causes an acute encephalitis with near-universal fatality once clinical symptoms manifest. Transmission occurs primarily through the bite or scratch of an infected mammal, with saliva containing the virus; globally, domestic dogs account for approximately 99% of human cases outside regions with effective wildlife control. PEP aims to neutralize the virus before it reaches the central nervous system, typically via a combination of local wound care, passive immunization, and active vaccination, and is recommended for category II (minor scratches without bleeding) or category III (transdermal bites or contamination of mucous membranes) exposures per World Health Organization (WHO) criteria.^[70]^[71] The regimen begins with immediate and thorough wound cleansing, which involves flushing the site with soap and water or a virucidal agent for at least 15 minutes to reduce viral load and improve outcomes; this step alone can decrease the risk of rabies transmission by up to 50% in some models. For individuals not previously vaccinated, human rabies immune globulin (HRIG) at 20 international units per kilogram body weight is administered as soon as possible, ideally on day 0, with the full dose infiltrated into and around the wound site, and any remainder given intramuscularly at a site distant from the vaccine injection. Concurrently, a series of four 1-mL doses of modern cell-culture rabies vaccine (such as human diploid cell or purified chick embryo cell vaccine) is given intramuscularly in the deltoid (or anterolateral thigh in infants) on days 0, 3, 7, and 14; for immunocompromised patients, a fifth dose on day 28 and serological confirmation of immunity are advised. Equine rabies immunoglobulin (eRIG) serves as an alternative where HRIG is unavailable, though it carries a higher risk of adverse reactions.^[72]^[2]^[73] When initiated promptly after exposure—ideally within 24-48 hours—and completed fully, rabies PEP demonstrates efficacy exceeding 99%, with documented failures exceedingly rare and attributable to delays in administration, inadequate RIG infiltration, severe bite multiplicity, or underlying immunosuppression rather than regimen failure per se. WHO surveillance data indicate that the approximately 59,000 annual global human rabies deaths, predominantly from unvaccinated dog bites in Asia (35% of total) and Africa, could be largely averted with accessible PEP in endemic areas where dog vaccination coverage remains below 70%. In contrast, the United States reports only 1-3 human cases annually, none dog-mediated since 1993 due to widespread pet vaccination and animal control measures, underscoring PEP's role as a critical bridge in low-incidence settings pending exposure assessment via quarantine or testing of the animal.^[74]^[75]^[76]

HIV

Post-exposure prophylaxis (PEP) for HIV involves administering a 28-day course of antiretroviral medications following potential exposure to prevent infection establishment. The risk of HIV transmission varies by exposure type and source viral load; occupational percutaneous injuries from HIV-positive blood carry approximately a 0.3% risk, while mucous membrane exposures pose about 0.09%.^[77] For sexual exposures, receptive anal intercourse with an HIV-positive partner estimates a 1.4% per-act transmission risk, though this drops to negligible levels if the source has an undetectable viral load due to effective antiretroviral therapy.^[78]^[79]^[10] Source viral load is a critical determinant, as transmission does not occur from individuals with sustained undetectable levels, informing PEP decisions when source status is known.^[80] Current guidelines recommend initiating PEP within 72 hours of exposure, ideally as soon as possible, using a three-drug regimen for adults and adolescents. The preferred regimen includes bictegravir combined with tenofovir alafenamide and emtricitabine (Biktarvy), a single-tablet option offering high tolerability and efficacy against both wild-type and resistant HIV strains.^[6] Alternatives include dolutegravir plus tenofovir disoproxil fumarate/emtricitabine, selected based on renal function, drug interactions, and resistance patterns.^[21] The 2025 CDC nonoccupational PEP guidelines incorporate these integrase strand transfer inhibitor-based options, emphasizing baseline HIV testing and follow-up to exclude pre-existing infection.^[6] Observational studies indicate PEP reduces HIV acquisition risk by approximately 80%, with case-control data from healthcare workers showing an 81% efficacy for zidovudine monotherapy, extrapolated to modern multi-drug regimens.^[81] No randomized trials exist due to ethical constraints, but cohort analyses report near-zero seroconversions with timely initiation and adherence exceeding 90%.^[82] Failures, rare at around 1 per 1000 exposures, correlate with delayed start beyond 72 hours, incomplete adherence, or exposure to drug-resistant virus from the source.^[17]^[13] Adherence counseling and viral load monitoring post-completion are essential to detect any breakthroughs early.^[19]

Hepatitis B

Post-exposure prophylaxis for hepatitis B virus (HBV) infection primarily involves the administration of hepatitis B immune globulin (HBIG) combined with the hepatitis B vaccine for susceptible individuals exposed to infectious blood or body fluids from HBsAg-positive sources. This regimen is indicated for unvaccinated persons or those with unknown vaccination status following high-risk percutaneous or permucosal exposures, such as needlesticks or mucosal splashes from confirmed HBV carriers. HBIG, providing passive immunity through antibodies against HBsAg, should be administered intramuscularly as soon as possible, ideally within 24 hours of exposure, at a dose of 0.06 mL/kg body weight, while the first dose of the recombinant hepatitis B vaccine is given concurrently at a separate site. The vaccine series continues with second and third doses at 1 and 6 months post-exposure, respectively.^[83]^[84] The efficacy of this combined approach is estimated at 70–95%, significantly higher than HBIG or vaccine alone, which each achieve approximately 70–90% protection in preventing acute HBV infection and chronic carriage, particularly when initiated promptly. Seroprotection is monitored via post-vaccination testing for anti-HBs levels ≥10 mIU/mL, typically 1–2 months after the last dose, with non-responders receiving additional doses or boosters. Real-world outcomes from occupational settings, including needlestick injuries, demonstrate reduced transmission rates, though efficacy diminishes if HBIG is delayed beyond 48 hours or the vaccine beyond 7 days.^[85]^[40] In the 2020s, updated Advisory Committee on Immunization Practices (ACIP) recommendations have emphasized universal hepatitis B vaccination for all adults aged 19–59 years, regardless of risk factors, alongside screening for chronic infection, thereby reducing the pool of unvaccinated individuals requiring PEP after exposures. This shift, formalized in 2022 and reinforced in subsequent guidelines, has lowered the overall need for post-exposure interventions in low-prevalence settings by promoting preemptive immunity, with vaccination coverage among U.S. adults rising to address persistent vulnerabilities in high-risk groups like healthcare workers.^[86]

Influenza

Post-exposure prophylaxis for influenza entails the administration of neuraminidase inhibitors or endonuclease inhibitors shortly after exposure to an influenza virus to avert symptomatic infection in susceptible individuals. The primary agents include oseltamivir (oral, 75 mg twice daily for adults), zanamivir (inhaled, 10 mg twice daily), and baloxavir marboxil (single oral dose of 40–80 mg based on weight for those aged ≥5 years).^[45]^[87] Prophylaxis should commence ideally within 48 hours of exposure and continue for 7–10 days for oseltamivir or zanamivir, or as a one-time dose for baloxavir, covering the incubation period during which transmission risk persists.^[45]01357-6/fulltext) Indications prioritize close contacts, such as household members, of confirmed or suspected influenza cases during community outbreaks, particularly for high-risk populations including those aged ≥65 years, children <5 years, pregnant individuals, and those with chronic conditions like diabetes, heart disease, or immunosuppression.^[45]^[88] The U.S. Centers for Disease Control and Prevention (CDC) endorses this approach for persons at elevated risk of complications when vaccination status is inadequate or exposure occurs despite immunization.^[45] A 2024 systematic review and network meta-analysis in The Lancet analyzed randomized trials and found that post-exposure prophylaxis with zanamivir, oseltamivir, laninamivir, or baloxavir reduces the risk of symptomatic seasonal influenza by 55–89%, with risk ratios ranging from 0.11 to 0.45 across agents and populations, demonstrating moderate to high certainty of evidence.01357-6/fulltext)^[89] Efficacy holds for both influenza A and B strains, though real-world outcomes may vary due to timing, adherence, and viral load at exposure.01357-6/fulltext) Baloxavir's single-dose regimen offers comparable protection to multi-day courses, potentially improving compliance.^[45]^[87] For emerging zoonotic threats like highly pathogenic avian influenza A(H5N1), CDC interim guidance recommends oseltamivir post-exposure prophylaxis for close contacts of human cases, administered for 5–10 days starting as soon as possible after exposure, given the strain's potential for mammalian adaptation and limited human immunity.^[90]^[91] This application underscores PEP's role in outbreak containment for novel strains, though susceptibility testing may inform agent selection if resistance patterns emerge.^[90]

Other Viruses (Hepatitis A, C, Poxviruses, COVID-19)

Post-exposure prophylaxis for hepatitis A involves administration of hepatitis A vaccine or immune globulin (IG) to susceptible individuals following exposure, ideally within 14 days of the last exposure. The Centers for Disease Control and Prevention (CDC) recommends hepatitis A vaccine as the preferred PEP for persons aged 12 months and older, with IG reserved for specific high-risk groups such as infants under 12 months, immunocompromised individuals, or adults over 40 years where vaccine response may be suboptimal.^[92]^[93] Efficacy is supported by vaccine-induced immunity, though IG provides passive protection when active immunization is contraindicated; however, real-world data indicate limited use outside outbreaks due to the short incubation period and variable adherence.^[94] For hepatitis C, no established post-exposure prophylaxis exists, as antiviral regimens like direct-acting antivirals (DAAs) are not recommended routinely due to insufficient evidence of preventing infection post-exposure. CDC guidelines emphasize baseline testing, serial monitoring for seroconversion (e.g., HCV RNA at 4-6 weeks and anti-HCV at 4-6 months), and prompt treatment if acute infection is detected, rather than preemptive therapy.^[95]^[96] Studies exploring early DAA initiation have shown mixed results in reducing chronicity, but occupational exposure trials confirm low transmission rates (0.5-1.8%) without PEP, underscoring the focus on prevention over prophylaxis.^[97] Poxvirus exposures, including mpox (monkeypox) and variola (smallpox), may warrant tecovirimat or vaccinia immune globulin intravenous (VIGIV) as investigational PEP in high-risk cases, particularly for severe or immunocompromised exposures. Tecovirimat, FDA-approved for smallpox, inhibits orthopoxvirus replication and has been deployed under expanded access protocols for mpox, showing in vitro efficacy against related strains but limited clinical trial data for PEP specifically.^[98]^[99] VIGIV provides passive immunity for complications, though post-exposure vaccination (e.g., with ACAM2000 or JYNNEOS) is prioritized for contacts within 4-14 days, with antivirals reserved for progressive disease due to empirical gaps in prophylaxis outcomes.^[100]^[101] Early efforts for COVID-19 PEP relied on monoclonal antibodies like bamlanivimab combined with etesevimab, authorized by the FDA in September 2021 for post-exposure use in unvaccinated high-risk individuals, demonstrating reduced symptomatic infection in trials against pre-Omicron variants.^[102] However, emergence of variants such as Omicron BA.4/BA.5 rendered these ineffective by mid-2022, leading to revocation of authorizations and abandonment of monoclonals as standard PEP, with current guidelines favoring vaccination and isolation over prophylaxis amid variant-driven immune escape.^[103] No alternative PEP has been validated, highlighting limitations in adapting biologics to evolving SARS-CoV-2 strains.^[104]

Challenges, Criticisms, and Controversies

Efficacy Limitations and Real-World Outcomes

Observational studies of HIV post-exposure prophylaxis (PEP) report seroconversion rates as low as 0% in some cohorts after PEP initiation, contrasting with pre-PEP rates of up to 3.8%, though such data derive from non-randomized settings prone to selection bias and incomplete follow-up.^[105] However, rare seroconversions occur despite PEP, often attributable to initiation delays beyond the optimal window, where efficacy diminishes rapidly due to viral replication kinetics; animal models, showing up to 89% risk reduction, may overestimate human outcomes by assuming uniform early administration and adherence absent in real-world scenarios.^[81]^[10] Adherence gaps exacerbate limitations, with pooled rates in prospective observational studies at 77% (95% CI 68–87%), lower than idealized trial conditions, leading to incomplete courses that undermine causal efficacy; for instance, completion rates for certain regimens range from 82% to 96%, yet deviations correlate with heightened infection risk in non-occupational exposures.^[106]^[82] In rabies PEP, failures remain exceptional at under 0.1% in treated cases, but cluster around protocol deviations including delays exceeding 48 hours post-exposure, which permit irreversible neuronal progression; U.S. data from 2010–2019 document near-100% success in over 1,200 animal exposures when protocols are followed, underscoring time-dependence as a primary causal barrier in human applications where delays heighten failure odds.^[107]^[108]^[109] Proponents emphasize prevented infections inferred from low real-world seroconversion, yet critics highlight potential underreporting of failures, as observational reliance—lacking randomized controls for ethical reasons—may inflate perceived efficacy by excluding late presenters or non-adherent cases not traced back to PEP.^[110]^[6]

Side Effects, Resistance, and Overuse Risks

Post-exposure prophylaxis regimens for HIV, typically involving combinations of antiretrovirals such as tenofovir, emtricitabine, and raltegravir or dolutegravir, commonly cause gastrointestinal side effects including nausea, vomiting, diarrhea, and abdominal pain, affecting up to 50-70% of users in clinical reports.^[111]^[16] Fatigue, headache, and insomnia are also frequent, while tenofovir specifically carries risks of renal toxicity, including elevated creatinine levels and potential acute kidney injury in susceptible individuals, necessitating baseline renal function assessment before initiation.^[4]^[23] These effects are generally mild and self-limiting but can lead to poor adherence, with completion rates as low as 50% in some cohorts, exacerbating risks of prophylaxis failure.^[25] Antiretroviral resistance poses a concern in HIV PEP, particularly if the source virus harbors pre-existing mutations or if incomplete adherence allows viral replication during the 28-day course, selecting for resistant strains that compromise future treatment efficacy.^[112] Transmission of resistant HIV to healthcare workers despite PEP has been documented, with cases linked to source-patient resistance profiles, underscoring the need for source viral testing when feasible.^[113] While PEP itself rarely drives population-level resistance due to its short duration and targeted use, broader expansion of similar regimens (e.g., to pre-exposure prophylaxis) amplifies selective pressure on HIV variants.^[112] For bacterial post-exposure prophylaxis, such as ciprofloxacin for anthrax exposure, side effects include severe gastrointestinal disturbances in approximately 19% of recipients, alongside risks of tendonitis, neuropathy, and QT prolongation, prompting switches to alternatives like doxycycline in prolonged courses.^[114]^[115] In Lyme disease prophylaxis with single-dose doxycycline, photosensitivity, gastrointestinal upset, and esophageal irritation occur, though less severely than multi-week regimens.^[67] Antibiotic overuse in these contexts contributes to broader resistance, as seen with doxycycline's role in fostering tetracycline-resistant Borrelia strains and parallels in staphylococcal resistance akin to MRSA emergence from fluoroquinolone prophylaxis.^[69]^[116] Overuse of PEP antibiotics risks accelerating antimicrobial resistance without proportional benefits in low-risk exposures, where empirical data indicate transmission probabilities below 1% (e.g., community needlestick injuries), justifying withholding to preserve drug efficacy and minimize ecological impacts on microbiota.^[10] Guidelines emphasize risk stratification to avoid unnecessary prescriptions, as marginal preventive gains in low-probability scenarios fail to offset resistance propagation and side effect burdens, with studies showing no HIV seroconversions in selective PEP cohorts versus higher adherence challenges in broader application.^[117]^[25] This approach aligns with stewardship principles, prioritizing causal evidence of exposure likelihood over precautionary expansion.^[6]

Access, Cost, and Ethical Debates

Access to post-exposure prophylaxis (PEP) varies significantly by region and pathogen. In high-income countries like the United States, occupational PEP for healthcare workers is often covered by employers or workers' compensation, but non-occupational PEP for sexual or injection drug exposures faces barriers such as limited awareness among providers and patients, stigma associated with high-risk behaviors, and time-sensitive requirements that delay initiation beyond the optimal 72-hour window.^[6] Globally, in low- and middle-income countries, particularly sub-Saharan Africa, access to HIV PEP is hindered by stockouts of antiretrovirals, inadequate training of community health workers, and insufficient infrastructure for rapid testing and counseling, resulting in underutilization despite high HIV prevalence.^[118] For rabies PEP, structural barriers in rural areas of Asia and Africa include distance to facilities equipped for wound care and immunoglobulin administration, exacerbating delays that contribute to thousands of preventable deaths annually.^[119] Costs of PEP regimens impose substantial economic burdens, particularly in resource-limited settings. A standard 28-day course of HIV non-occupational PEP in the U.S. averages $1,000 to $2,000, encompassing antiretroviral drugs like tenofovir-emtricitabine plus raltegravir or dolutegravir, excluding follow-up testing and counseling.^[120] Rabies PEP, which includes human rabies immune globulin and a series of four vaccine doses, ranges from $2,500 to $7,000 in the U.S., with immunoglobulin alone often exceeding $4,000 due to its derivation from human plasma.^[121] In contrast, global averages for rabies PEP are lower at around $108 per course including indirect costs, but this masks disparities where low-income households in endemic areas face catastrophic expenses equivalent to months of income.^[122] Hepatitis B PEP costs are comparatively modest at $100–500 for the vaccine series and immunoglobulin if indicated, yet access remains uneven without universal vaccination programs.^[123] Cost-effectiveness analyses reveal PEP's variable value depending on exposure risk and prevalence. For HIV PEP after sexual exposure, studies estimate that approximately 300–400 courses are required to prevent one infection, yielding a cost-utility ratio of about $14,000 per quality-adjusted life year gained in high-prevalence scenarios, though this diminishes in low-risk populations where transmission probability falls below 1%.^[120] ^[124] Rabies PEP is highly cost-effective in endemic areas, preventing fatal outcomes at under $100 per averted death when prioritized for confirmed exposures, but overuse in low-risk animal contacts inflates costs without proportional benefits.^[125] Ethical debates center on resource allocation, prioritization, and unintended behavioral incentives. Proponents advocate broad access to mitigate inequities, emphasizing occupational exposures for healthcare workers and assaults over consensual high-risk behaviors, yet critics contend that public funding for behavioral-risk PEP diverts resources from proven primary prevention like vaccination campaigns or barrier methods, potentially fostering moral hazard by reducing incentives for abstinence or condom use.^[126] ^[127] Data indicate underutilization among truly high-risk groups due to stigma and confidentiality fears, while overemphasis on pharmaceutical interventions may undermine behavior modification programs that have demonstrated sustained risk reduction through education and partner notification.^[118] In funding debates, utilitarian analyses favor targeting verifiable high-transmission scenarios, questioning expansive eligibility criteria that strain budgets without commensurate public health gains, particularly amid competing priorities like antimicrobial resistance from PEP overuse.

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Failure of rabies PEP is rare but usually occurs due to: delayed ... Failures of post-exposure rabies prophylaxis. Vaccine, 25 (44) (2007), pp ...
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PEP refers to the use of HIV medicines to prevent HIV infection within 72 hours (3 days) after a possible exposure. PEP should be used only in emergency ...
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However, increased use of antiretroviral medications for PrEP has the potential to select for and promote HIV drug resistance, which could compromise the ...
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Antiretroviral Drug Resistance Testing: Potential Use following ...
Resistance to antiretroviral drugs may contribute to failure of prophylaxis. Resistant HIV strains have been transmitted to health care workers despite PEP with ...
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Antimicrobial postexposure prophylaxis for anthrax: adverse events ...
Adverse events associated with antimicrobial prophylaxis to prevent anthrax were commonly reported, but hospitalizations and serious adverse events as defined ...Missing: side PEP
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[PDF] UK Guideline for the use of HIV Post-Exposure Prophylaxis 2021
We provide evidence-based recommendations for the most appropriate use of HIV post-exposure prophylaxis. (PEP) following sexual, occupational and other non- ...
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HIV Post Exposure Prophylaxis: prospects, opportunities and ...
Jun 26, 2025 · Other barriers included a lack of knowledge on PEP among providers, particularly community‐based providers, and potential beneficiaries of PEP ...
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Behavioral and structural barriers to accessing human post ...
Jul 21, 2020 · We identify important behavioral and structural barriers and knowledge gaps that limit evidence-based preventive strategies against rabies.
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Cost-effectiveness of Postexposure Prophylaxis After Sexual or ...
The program was cost-effective for PEP completion rates greater than 29%, which is substantially smaller than the rate observed in the San Francisco study (78%) ...
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Incremental cost of pre- and post-exposure prophylaxis service ...
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Although the best way to prevent HIV is to prevent exposure, PrEP and PEP ... The PEP program prevented 1.26 infections and the cost-utility ratio was $14,449 per.
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Evaluating the cost-effectiveness of rabies post-exposure prophylaxis
In addition, we find that PEP is still very cost-effective even when 99% of bite victims to whom PEP is administered have not been exposed to rabies. 2. Methods.
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Jul 27, 2012 · Planning for regulatory review, financing, and implementation must therefore continue. Ethical Resource Allocation. Thousands of Americans with ...Missing: debates | Show results with:debates
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The use of PREP and routine nonoccupational PEP remains controversial due to the potential to increase high-risk sexual behavior. ... behavior change or for ...