What is the approach to a percutaneous exposure (needle stick injury)?

From the Guidelines

The approach to a percutaneous exposure, such as a needle stick injury, involves immediate action to minimize infection risk, including washing the wound with soap and water, reporting the incident, and considering post-exposure prophylaxis (PEP) based on the source patient's status, as outlined in the most recent guidelines 1. The management of a needle stick injury should prioritize the prevention of bloodborne pathogen transmission, including HIV, hepatitis B, and hepatitis C.

• The first step is to wash the wound with soap and water for several minutes, then apply an antiseptic solution like povidone-iodine or alcohol.
• The incident should be reported to the supervisor and occupational health department immediately.
• Blood tests should be conducted for both the injured person and the source patient (if known) for HIV, hepatitis B, and hepatitis C.
• Post-exposure prophylaxis (PEP) may be necessary depending on the source patient's status.
• For HIV exposure, PEP typically includes a three-drug regimen such as tenofovir/emtricitabine plus dolutegravir, started within 72 hours (ideally within 2 hours) and continued for 28 days, as recommended by recent guidelines 1.
• For hepatitis B, if the injured person is not immune, hepatitis B immunoglobulin (HBIG) 0.06 mL/kg IM and hepatitis B vaccine series should be administered, as outlined in the most recent guidelines 1.
• No PEP exists for hepatitis C, but early detection through follow-up testing is crucial.
• Follow-up testing should occur at 6 weeks, 3 months, and 6 months post-exposure. These measures are essential because bloodborne pathogens can enter the bloodstream through percutaneous injuries, with transmission risk varying by pathogen (0.3% for HIV, up to 30% for hepatitis B in unvaccinated individuals) 1. Key considerations in the management of a needle stick injury include:
• Determining the risk associated with the exposure, including the type of fluid and the type of exposure.
• Evaluating the exposure source, including assessing the risk of infection and testing for HBsAg, anti-HCV, and HIV antibody.
• Evaluating the exposed person, including assessing immune status for HBV infection and considering PEP.
• Providing immediate care to the exposure site, including washing wounds and skin with soap and water and flushing mucous membranes with water.
• Ensuring follow-up for the potentially exposed employee, including repeat serologic testing for hepatitis C and HIV at 6 months after potential exposure.

From the FDA Drug Label

For greatest effectiveness, passive prophylaxis with Hepatitis B Immune Globulin (Human) should be given as soon as possible after exposure (its value beyond 7 days of exposure is unclear). If Hepatitis B Immune Globulin (Human) is indicated (see Table 1), an injection of 0. 06 mL/kg of body weight should be administered intramuscularly (see PRECAUTIONS) as soon as possible after exposure and within 24 hours, if possible. In all exposures, a regimen combining Hepatitis B Immune Globulin (Human) with hepatitis B vaccine will provide both short- and long-term protection, will be less costly than the two-dose Hepatitis B Immune Globulin (Human) treatment alone, and is the treatment of choice. For inadvertent percutaneous exposure, a regimen of two doses of Hepatitis B Immune Globulin (Human), one given after exposure and one a month later, is about 75% effective in preventing hepatitis B in this setting.

The approach to a percutaneous exposure (needle stick injury) involves:

• Administering Hepatitis B Immune Globulin (Human) as soon as possible after exposure, ideally within 24 hours
• Using a dose of 0.06 mL/kg of body weight intramuscularly
• Combining Hepatitis B Immune Globulin (Human) with hepatitis B vaccine for both short- and long-term protection
• Considering a second dose of Hepatitis B Immune Globulin (Human) one month after the first dose if the person refuses hepatitis B vaccine 2, 2 Key points:
• Prompt administration of Hepatitis B Immune Globulin (Human) is crucial
• Combination therapy with hepatitis B vaccine is the treatment of choice
• A second dose of Hepatitis B Immune Globulin (Human) may be necessary in certain situations

From the Research

Approach to Percutaneous Exposure

The approach to a percutaneous exposure, such as a needle stick injury, involves several key steps to minimize the risk of transmission of blood-borne pathogens.

• Immediate reporting of the incident is crucial, as it allows for prompt evaluation and treatment 3.
• The injured individual should take measures to disinfect and flush the injury, with nearly all incidents (98.3%) involving such measures 4.
• Postexposure prophylaxis (PEP) should be undertaken as soon as possible, ideally within 2 hours of the incident, with 85.1% of individuals exposed to HIV or unknown infection risk undertaking PEP within this timeframe 4.
• Follow-up examination is essential, with 97.4% of individuals attending follow-up examinations 4.

Prevention Strategies

Prevention strategies are also critical in reducing the risk of needle stick injuries.

• The use of safety-engineered injection devices and safe use and disposal of needles can significantly reduce the risk of injury 5.
• Educational training programs can also be effective in reducing the risk of needle stick injuries, with studies showing a reduction in glove perforations and improved awareness of safe practices 6.
• Standardized protocols and algorithms for managing needle stick injuries can help ensure optimal treatment and minimize the risk of transmission of blood-borne pathogens 3.

Key Considerations

Key considerations in the approach to percutaneous exposure include:

• The importance of immediate reporting and treatment of the incident 3.
• The need for prompt postexposure prophylaxis and follow-up examination 4.
• The role of prevention strategies, including the use of safety-engineered devices and educational training programs, in reducing the risk of needle stick injuries 5, 6.