Ot protocols

OPERATING ROOM PROTOCOLS

Inclusions1. Introduction2. History3. Sterilization & asepsis4. Principles of sterile technique5. The hand scrub6. Hand towel drying7. Gloving8. Gowning9. Operating room decorum10. Operating room procedures11. Preparation of surgical site12. Draping the patient13. The close of operation

Introduction• Cleanliness of the hospital environment is the best starting

point to achieve the highest patient safety mandate.

• There is a need to decrease the bio-burden present in the environment in an operating room.

• A systematic method of precautions taken by operating team leads to a successful procedure.

History of Hygiene

Book of Leviticus

Chapter 11 – 15

Code of Hygiene

Third book of the Hebrew bible

Greek Era

• Aristotle recommends Boiling water to armies.

• Advises the Alexander

• Recommends hygiene for healthy living

HAND WASHING

• Hungarian physician of German extraction now known as an early pioneer of antiseptic procedures. Described as the "savior of mothers"

• Emphasized the importance of washing hands with chlorinated water in Obstetrics to reduce maternal mortality.

Beginning of Modern Nursing

The Very First Requirement in Hospitals that should do the sick

no harm

Florence Nightingale

( Notes on Nursing 1860 )

Starting of Modern Era Dr. Joseph Lister

• 1867 – Dr. Joseph Lister first identified

airborne bacteria and used Carbolic acid

spray in surgical areas.

• Phenol in Surgery and Decontamination

practices.

• Lister era 1868

• Carbolic Acid in decontamination,

• Reduction of Hospital associated infections

• Mortality reduced

• Morbidity reduced.

Beginning of Safe Operation Theatre Practices

• 1867 – Dr. Joseph Lister first identifies airborne bacteria and uses Carbolic acid spray in surgical areas.

• 1880 – Johnson and Johnson introduce antiseptic surgical dressings.

Sterilization & asepsisSTERILIZATION:

The process by which an article is made free of all living organisms either in

vegetative or in spore state.

DISINFECTION:

The destruction or removal of all pathogenic organism / organisms capable of

giving rise to infection.

Antiseptic & disinfectantsANTISEPTIC :

A chemical that is applied to living tissue, such as mucous membrane or skin

to reduce the number of organisms present, through inhibition of their

activity or destruction.

DISINFTECTANTS :

A chemical used on non-vital objects to kill surface vegetative pathogenic

organisms but not necessarily spore forms/ viruses.

Spaulding’s classification

• Spaulding’s classification provides a simplified outline of the

recommended processing methods for items of patient care equipment,

based on the intended use of the item.

• Depending on the intended use of an item, medical and surgical equipment

may be required to undergo the following processes between uses on

different patients:

1. cleaning, followed by sterilization

2. cleaning, followed by high, or intermediate level disinfection

3. cleaning alone

Disinfection & sterilization : infection control guidelines

Principles of sterile technique• All the materials used as a part of sterile field for an operation,

must be sterile.

• Basic items – linen, instrument set, basin

• Instrument sterilization : 1 night before just before operation

• Once the instrument is removed from sterile wrapper : use / discard

1. Linen colour : Dyed green (reduces glare from light & fatigue and eye

strain).

2. Use sterile materials only & maintain the sterility throughout the procedure.

3. Sterile area are setup just prior to use.

4. If in doubt : consider the material as unsterile.

5. Only the top surface of draped table is considered sterile.

Principles……

6. Neither the circulator nor the scrub should intrude up on the other’s area at any time.

7. The scrub should be considered as sterile person.

Principles……

• sterile person should touch the sterile materials & unsterile person should touch the unsterile materials.

• circulator (unsterile person) supplies for the sterile team members.

• gown

• glove

• drapes the table 1st nearest to them

• hand positioning

8. Sterile team members should keep their contact even with sterile area to a minimum.

9. Sterile team members should be within the sterile area & scrub nurse should allow a wide margin of safety when passing through unsterile area.

Principles……

Rules :• Sterile team members should be stand back at a safe

distance from operating table , while draping.• Pass back to back.• Unsterile person/ area should be passed by back of

sterile person.• Face a sterile person/area when passing.• Stay near the sterile table.• Used items / soiled sponges are placed into the

basin. outside of basin : sterilized; inside of basin : contaminated

9. Circulator :

• Unsterile team member

• Should provide wide margin of safety while passing

• Away from sterile area

• Face the sterile area while Passing, but should not touch

• Should not go within the sterile circle

• Notify the scrub person while passing behind him

• Stands at a safe distance while adjusting the light

• Grasp the table legs well below the table top to move the sterile table

Principles……

10. Covered sterile materials

• Edge of cover that encloses the sterile content : sterile.

• Circulator should lift the cap of solution containing bottles & the caps are

not replaced.

11. Sterile materials / area should be protected form moisture : contaminated

- sterile packages should be laid down in dry area.

- linen package remove from autoclave : wait to become cool & dry

- allow the paint to become dry before draping

- during procedure, any wet area should be covered with dry drape

Principles……

12. Micro-organisms can not be removed completely, so they should be keep

as minimum as possible

- skin can not be sterilized (staphylococcus)

- skin shaving

- head cap & mask

- hands & arms should be properly scrubbed

- dry the hands with sterile towel

- as much of the operative area is cleansed as feasible

- some area can not be rubbed vigorously

- a sponge is used once only

- sterile area should be separated from other by draping

- after incision of skin, the blade / knife should be isolated from other items

Principles……

13. Respiratory tract of patient is another source of infection.

14. Team members should not talk except when essential.

15. Bed clothes : should be removed or replaced prior to entry into OT, never

the less the patient should be covered with a coversheet at all times.

16. The doors from corridors into operating room should keep close.

17. Dressing removed from a wound should be placed at once in a bag &

should be discarded.

18. Drain should not be kept open.

Principles……

The hand scrubGood Hand Washing Practices Save many Lives

Surgical Scrub For The Operating Room.avi

1. Alcohol with Chlorhexidine.2.Alchool without Chlorhexidine.3. Chlorhexidine 2 %4. Chlorhexidine 4 %5. Povidone with Iodine 7.5 % - 10%6. Triclosan 1 %7. Phenolics8. quarternary ammonium compound9. 3 % hexachlorophane

Areas of the harboring dirt and microorganisms

• The scrub area sink should be wide enough to facilitate

easy scrubbing without touching anywhere.

• It should have depth of about 3 feet which prevents

splashing of rebound water onto the clean hands.

• The scrub sinks are fitted with doctors’ taps, rather than

ordinary taps, to facilitate its operation with the help of

arms to prevent contamination of scrubbed hands during

closing the tap.

• The peddle operated taps are ideal in scrub areas as it

permits hand free operations. The cleaned hands are

mopped with sterile towel and disinfected with antiseptic

solution.

Correct

Incorrect

Design of the washing sink

Skin antisepticHand towel drying

GlovingGowning

05 - Scrubbing_ Gowning _amp_ Gloving Part 2.avi

Gowns

Paper gown

Plastic gown

Linen gown

made up of cotton having a thread count of 240 \ sq inch for the reusable stuff .

Folding the gown for sterilization

Operating Room Decorum• The floors and walls should be absolutely smooth and easily cleanable and

should have minimum and neatly made or no joints.

• Flooring should be non porous, scratch proof, anti skid and antistatic (epoxy resin flooring) .

• The walls should also be covered with smooth material like granite with minimum joints.

• The ceilings should be painted with oil paints which give smooth finish.

• All the electrical fittings and water pipe lines in the OR must be concealed.

• The OR complex should have only one entry and all the windows should be air tight in restricted and semi-restricted area.

Operating Room Decorum• Avoid contamination of wound.

• Although Unpreventable.

• Chances of cross infection.

• Contamination of surgical wound is mostly from – skin / mucous

membrane being incised.

• Other sources : nose, throat, hand, skin of operating team members.

• Air contamination : omnipresent problem.

• All logical precaution & preparations should be done.

Stress must be laid on1. Temperature2. Humidity3. Ventilation

Temperature : 24-270 C

Relative Humidity : 450 – 600 C for adult 550 – 650 C for infants

VENTILATION / AIR CHANGE

• 1 change / hr : contamination reduced by 60%• 2 change / hr : contamination reduced by 86%• 10 change / hr : contamination reduced by 99%

Turbulant / mixing air disritribution Downword displacement piston system

Unidirectional airflow system / lamellar flow ventilation

Planning considerationZoning :To ensure the aseptic condition the operating dept is divide into 4 zone :1. Protective zone2. Clean zone3. Sterile zone4. Disposal zone

Advantages of zoning

1. Minimizes risk of hospital infection.

2. Minimizes unproductive movement of staff, supplies &

patient.

3. Increases efficacy of operative team members.

4. Ensures smooth workflow.

5. Deceases hazards in operating room.

6. Ensures proper positioning of equipments.

Protective zone

Clean zone Sterile zone Disposal zone

1. Reception

2. Waiting room

3. Changing room

4. Autoclave

5. Trolley bay

6. Control area of

electricity

1. Pre-operating

room

2. Recovery room

3. Theatre work

room

4. Plaster room

5. Blood storage &

frozen section

room

6. Doctor’s work

room

7. Anesthesia store

1. Operating room

2. Scrub room

3. Anesthesia room

4. Instrument

sterilization

5. Trolley area

1. Dirty wash room

2. Disposal corridor

Equipment planning

1. Operating table & transfer trolley system2. Operating light system3. Fixed services system (medical gases, vacuum, surgical diathermy, cold light)4. Anesthesia equipment5. Patient monitoring & resuscitation equipment6. Operating radiography system7. Operating microscopic equipment8. Extracorporeal circulation system9. Patient heating & cooling equipment10. Laboratory support equipment11. Bedpan washer / disinfector12. Furniture & fixtures

Equipments for oral & maxillofacial surgery

1. Operating table & transfer trolley system2. Operating light system3. Suction apparatus4. Radiograph viewing box5. Dental motor (drill)6. Anesthesia equipment7. Diathermy8. Laser9. Cryotherapy10. Operating microscope (up to 40X magnification)11. Instruments pertaining to surgery

Handling of the Sterilized Instruments

Operation theatre cleaning and fumigation

Need for fumigation

Surveillance studies of different zones in operation theatre showed that the

isolates were

• Staphylococcus aureus (16%)

• Coagulase negative staphylococcus aureus (26.7%)

• Acinobacter species (2.03%)

• Klebsiella (0.3%)

• E.coli, Pseudomonas species, Proteus species were also found in majority

Owens C.D., Stoessel K. Surgical site infections: Epidemiology, microbiology and prevention. Journal of Hospital Infection . 2008.70;S2:3–10

• Daily cleaning should be carried out after the operating sessions are over. • All the surfaces should be cleaned with detergent and water and may be wiped

over with a phenol if any spills with blood / body fluid are present. • All the walls must be wiped down to hand height everyday.

• The floors should be scrubbed with warm water and detergent and dried. No disinfectant is necessary.

• The O.T. table and other non clinical equipments must be wiped to remove all visible dirt and left to dry.

• Weakly cleaning of all the areas inside the operating theatre complex should be

done thoroughly with warm water and detergent and dried.

• The storage shelves must be emptied and wiped over, allowed to dry and restacked.

Procedure for fumigation:

• The windows should be sealed and

formaldehyde should be generated either by

boiling a solution of formalin 40% or by

adding it to potassium permanganate, in a

metal vessel on the floor, since heat is also

generated. The door is than closed and

sealed.

• For a 10 x 10 x 10 ft room - 150 gm

potassium permanganate and 280 ml of

formalin are used

Duration:• In case of any construction in O.T. 48 hrs• In case of infected cases 24hr• For routine clean cases 12 hrs.

• Alternatively 250 ml of formalin and 3000 ml of tap water are put into a machine (auto mist) and time is set for 2 hrs. The mist is circulated for 2hrs inside the closed room.

• Room is kept sealed for another 2 hrs for action of vapor. Ventilate for suitable time for vapor to dissipate. Room then can be used.

• Three swabs are taken from walls, all equipments, floor or O.T. table at intervals.

• 1st swab - 48 hrs after fumigation• 2nd swab- 24 hrs after 1st swab• 3rd swab - 12 hrs after 2nd swab

• All three consecutive swabs should come negative.

• In some centers, Bacillocid is being used for fumigation. It is

combination of chemically bound formaldehyde and

glutaraldehyde.

• Ideally all O.T. rooms should be fumigated once a week

Fumigation to be neutralized• Neutralize Residual

formalin gas with Ammonia by exposing 250 ml of Ammonia per liter of Formaldehyde used.

• Place the ammonia solution in the centre of the room and leave it for 3 hours to neutralize the formalin vapour

An example is set as..

• Operation Theatre Volume = L×B×H = 20 × 15 × 10 = 3000 cubic feet

• Formaldehyde required for fumigation = 500 ml for 1000 cubic feet

= So 1500 ml of formaldehyde required

• Ammonia required for neutralization = 150ml of 10% ammonia for 500 ml

of formaldehyde

= So 450 ml of 10% ammonia require

Pre-op Orders• NPO for 6 hrs : food• NPO for 3 hrs : clear fluid

• Shaving

• Lipstick, nail varnish & other cosmetics should be removed

• Patient should not be shifted in operating room with full bladder

Avoid excessive starvation

Preparation of patient in the ward

• Hospitalization 2 – 3 days prior to surgery • A good bath to clean all the dirt from the body• Outside clothing should be discarded and the patient should be provided

clean hospital clothing

Preparation of Part: • The part to be operated should be washed thoroughly with soap and water. • The hair should be removed by shaving at least 12 hours prior to the

surgery .• The clean and shaved part is vigorously scrubbed with antiseptic solution

like savlon, chlorhexidine or povidon iodine and mopped with sterile gauge.

• The cleaned part is painted with solution like mercury chrome or 2% picric acid, covered with sterile pad and sealed with adhesive taps.

Preparation of oral cavity

• The oral cavity should be thoroughly inspected for any septic foci; calculus, tarter, infected carious teeth, infected periodontal pockets etc. and they should be treated/ removed.

• Antiseptic mouth washes should be prescribed (Chlorhexidine, Povidon iodine etc.) for periodic mouth rinsing to reduce the count of microorganism.

• Loose teeth should be extracted as they may come in the way of intubations of patient and may get knocked out and aspirated during the intubation.

Operating room proceduresSURGICAL TEAM

• Chief surgeon, who directs the surgery

• One or more assistant surgeons, who help the chief surgeon

• Anesthesiologist, who controls the supply of anesthetic and monitors the person closely

• Scrub nurse, who passes instruments to the surgeon

• Circulating nurse, who provides extra equipment to the operating team

AssisstanceAssisting the surgeon – Floor nurse • Receive the patient from the ward, from the staff nurse. Details obtained

are - Particulars of the patient Elective/Emergency Diagnosis Procedure planned Consent obtained Pre-medications administered Whether pre-operative instructions have been followed and patient is prepared Confirm removal of jewellery/ornaments Patency of IV Canula Patient records – files, X-rays, investigation reports. OT dress has been changed

http://www.grh.gov.mv/images/OPERATION%20THEATRE%20ASSISTING%20DURING%20OPERATIONS.pdf

Assistance…

- Make patient wear the OT cap.

- Transfer the patient form the wheel chair/trolley to the operation table .

- After anesthesia induction, clear the operative site .

- Remove the patient’s gown and keep it in the un-sterile zone.

- Scrub nurse, scrubs, gowns and opens the set .

- Scrub nurse arranges the set and checks instrument.

- Back out form the Sterile zone and circulate in semi-sterile zone .

http://www.grh.gov.mv/images/OPERATION%20THEATRE%20ASSISTING%20DURING%20OPERATIONS.pdf

- Handing over of linen/instruments to the operating staff.

- Being prepared to scrub if needed .

- On the completion of operation, counting the instruments,

sponges, needles .

- Assist to shift the patient from the operating table to the trolley.

- Shifting the trolley to the operating theatre door.

Assistance…

http://www.grh.gov.mv/images/OPERATION%20THEATRE%20ASSISTING%20DURING%20OPERATIONS.pdf

Assisting the surgeon - Scrub Nurse

- Bringing the instruments trolley and paint the trolley with betadine

- Remove the drape/rubber sheet from the container and spread it on the

trolley (instrument/linen), using cheattle forceps

- Transfer the linens from the bin to the trolley

- Arrange to instruments in a designated fashion in the trolley and count them

- Drape the two trolleys with small drapes

- Pass the gown, gloves to the surgeon.

Assistance…

http://www.grh.gov.mv/images/OPERATION%20THEATRE%20ASSISTING%20DURING%20OPERATIONS.pdf

- Handover the paint and drapes to the surgeon

- Coordinate with the floor nurse for passing consumables

- Connect various tubes and wires as required

- Pass the instruments to the surgeon as required

- Instrument count at the end of the procedure

- Cleaning the stains from the operation site

- Assist in Surgical site dressing

- Re-gowning the patient

- De-scrubbing

Assistance…

http://www.grh.gov.mv/images/OPERATION%20THEATRE%20ASSISTING%20DURING%20OPERATIONS.pdf

Preparation of surgical site

PURPOSE:

• To reduce the resident and transient microbial counts at the

surgical site immediately prior to making the surgical incision.

• To minimize rebound microbial growth during the

intraoperative and postoperative period.

• To reduce the risk of post surgical site infection.

• To prevent injury to the patient during surgical skin

preparation.

Hair removal

• 1 night before or just prior to skin preparation• Close shave is not necessary

• Stroke against the direction that the hair is growing using short strokes. Short hair stubble will still be evident after clipping.

Management of hair

• Hair removal may or may not occur;

• Long hair may be parted along the incision line and hair secured away

from the incision with elastic bands; or short hair may have a thin strip of

hair clipped along the incision line.

1. 4% Chlorhexidine Gluconate (Betasept, Hibiclens, Dyna-Hex4)

2. Hexachlorophene 3% (Phisohex)

3. Iodine Scrub/Soap 7.5% (Wet skin with water, apply enough iodine

scrub to create lather and scrub for 5 minutes. Blot or rinse off using

sterile towel or gauze).

4. Iodine Paint 10% (Paint area to be prepped with solution and allow to

dry prior to starting procedure).

5. Duraprep/Chloroprep

6. Betadine Gel

"Recommended Practices for Skin Preparation of Patients", AORN Standards and Recommended Practices for Perioperative Nursing, 2002 (Denver, Assoc. of Operating Room Nursing, Inc., 2002) Meeker Ruth, M., Rothrock, J.C. Alexander's Care of the Patient in Surgery, II tll edition, (St. Louis: Mosby Year Book, 1999)

STEPS

1. Extraoral scrub procedure (circumoral preparation

should be done prior to intraoral procedure) .

2. Scrub should begin in the center of the area to be

prepared & then move outwards concentrically is

possibly (minimizes the contamination from

unscrubbed area).

3. Once central part is prepared, then it should not be

touched again with same sponge.

4. Start in middle & extend towards periphery.

Best Practice Guidelines, Surgical Skin Preparation

5 min.

Draping the patientPurpose I. Isolate the surgical area from other parts of body that have not been

prepared for surgery.II. Isolate from nonsterile operating room equipments & personnel.

• A double layer drape is effective.• 2,3,4, drapes can be placed over the endotracheal tube.• For isolation of mouth : clear plastic drape with an adhesive side

(vidrape)

Patient’s head is placed on sterile

sheets covered by 2 towels. Towels are

used to drape patient’s head.

Additional towels may then be added to isolate surgical area.

Clear drape is placed with adhesive surface contacting skin just below the mouth, which effectively isolates it from surgical site.

Moth or nasal area may be entered by pulling drape toward & then reisolated by returning drape to its original position.

2 towels with edges folded to outside are then joined together with towel clips & then unfolded to create opening through which

operate can enter into oral cavity.

The close of operation• Confirm the completion of all the surgical plan.

• Report the anesthetist regarding completion of procedure.

• Check for satisfactory wound closure & cessation of hemorrhage.

• Mouth should be checked for –- Clot- Debris- Swabs- Extracted teeth

• Make a count of them.

The close of operation……

• Throat pack removal.

• Write the operative notes.

• Shift the patient on a trolley equipped with oxygen cylinder & mask, assisted by 2 persons (one should be trained nurse).

The close of operation……

• Keep the patient in recovery room & in recovery position. (under observation of anesthetist.)

• Emergency situations can be managed by -surgeon/anesthetist/both.

Universal (Standard) Precautions

• “Precautions to protect against exposure must be taken when there is

any potential for exposure to bodily fluids. It is assumed that all bodily

fluids have the potential to transmit disease”

• The Universal Precaution Rule:

Treat all human blood, bodily fluids and other potentially infectious

materials as if they are infectious.

Transmission of blood-borne viruses

Transmission of HBV is approximately 100 times more efficient than transmission of HIV and approximately 10 times more efficient than HCV.

• In the case of HCV, patient-to-patient transmission has been associated with endoscopic procedures.

• The risk of transmission of HIV is estimated to be approximately 0.3% after a percutaneous needlestick injury with HIV-infected blood and 0.09% after a mucous membrane exposure.

• Transmission of HBV in the health care setting can be prevented through health care worker, patient and community hepatitis B vaccination programs.

Post-exposure prophylaxis (PEP) in the health care setting

• Depending on the nature of the exposure, PEP is available to health care workers to prevent infection with HIV and HBV.

• The sooner PEP is administered, the more likely it is to be effective in preventing infection.

• Clinicians should always refer to the most recent protocols and seek appropriate advice about administration of PEP because the area is constantly changing.

• Blood should be taken prior to or shortly after administration of PEP to check for prior exposure or infection.

Post-exposure prophylaxis (PEP) for HIV

Medication

2-drug regimen

3-drug regimen

Zidovudine (AZT) 300 mg twice a day 300 mg twice a day

Stavudine (d4T) 30 mg twice a day 30 mg twice a day

Lamivudine (3TC) 150 mg twice a day 150 mg twice a day

Protease Inhibitors 1st choice Lopinavir/ritonavir (LPV/r)400/100 mg twice a day or800/200 mg once daily with meals

2nd choiceNelfinavir (NLF)1250 mg twice a day or750 mg three times a day with empty stomach

3rd choiceIndinavir ()800 mg every 8 hours and drink 8–10 glasses (1.5 litres) of water daily

HIV PEP should be started between one and two hours after an exposure.

Post-exposure prophylaxis for HBV

• If the exposed person is not immune to HBV, or is unaware of their immune status, then HBIG should be given within 48–72 hours of exposure.

For example • If the exposed person is not immune to HBV, or is of unknown immune

status, HBIG should be administered within 72 hours of exposure

• If the exposed person is a non-responder to the HBV vaccine, HBIG should be given within 72 hours

• There is currently no PEP available to prevent HCV infection. In 1994, the Advisory Committee on Immunization Practices (ACIP) reviewed available data regarding the prevention of HCV infection with IG and concluded that using IG as PEP for hepatitis C was not supported.

Alter MJ. Occupational exposure to hepatitis C virus: a dilemma. Infect Control Hosp Epidemiol 1994;15:742--4

REFERENCES1. Chandrakant P.Taware. Oral and Maxillofacial Surgery: Hospital Management Protocol. 2009. Ed. 1.2. U. J. Moore. Principles of Oral and Maxillofacial Surgery. 2011. ed. 6.3. Chris H. Miller , Charles John Palenik. 2010. ed. 4.4. Maxine A. Goldman. Pocket Guide to theOperating Room . 2008. Ed. 3.5. Sapna, Majumdar S., Venkatesh P. The Operation Theatre : Basic Architecture . Delhi Journal of

Ophthalmology. 2011; 21(3): 9-14.6. Berkelman R L, Holland B W, Anderson R L . J. Clin. Microbiol. 1982, 15(4):635.7. Owens C.D., Stoessel K. Surgical site infections: epidemiology, microbiology and prevention. Journal of

Hospital Infection (2008) 70(S2) 3–10.8. Best Practice Protocols Clinical Procedures Safety. WHO/EHT/CPR 2004 reformatted. 2007 WHO

Surgical Care at the District Hospital 2003.9. Mangram AJ, Horan TC, Pearson ML. Guideline for Prevention of Surgical Site Infection. Guideline for

Prevention of Surgical Site Infection, 1999. Instrument Processing, Work Flow and Sterility Assurance. A Peer-Reviewed Publication by Eve Cuny, MS and Fiona M. Collins. www.ineedce.com.

10. GAYATHRI M., KAARTHIC S., KALAISELVAM S. Operation Theatre Sterilization And Efficacy Comparison Of Superoxidized Water With Various Disinfectants.PROJECT REPORT.

11. The Prevention of Transmission of Blood-Borne Diseases in the Health-Care Setting. 2005. I SBN 0-7557-1735-X.

12. Alter MJ. Occupational exposure to hepatitis C virus: a dilemma. Infect Control Hosp Epidemiol 1994;15:742—4.

13. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. Recommendations and Reports. June 29, 2001 / 50(RR11);1-42

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