What tests and treatments are recommended after a needle stick injury with potential exposure to blood borne pathogens, including Human Immunodeficiency Virus (HIV), Hepatitis B (HBV), and Hepatitis C (HCV)?

Management of Needlestick Injuries with Potential Exposure to Bloodborne Pathogens

Following a needlestick injury with potential exposure to bloodborne pathogens, immediate baseline testing for HIV, Hepatitis B, and Hepatitis C should be performed for both the exposed worker and the source patient, with appropriate follow-up testing and prophylaxis based on exposure risk assessment. 1

Initial Management

• Immediately wash the wound with soap and water; if exposure involves mucous membranes, flush the area thoroughly with water 1
• Document details of the exposure including date, time, procedure being performed, type of device involved, severity of exposure, and source patient information 2
• Report the incident to supervisor and occupational health services for proper documentation and risk assessment 1

Laboratory Testing

Source Patient Testing

• Test the source patient for HIV antibody, Hepatitis B surface antigen (HBsAg), and Hepatitis C antibody (anti-HCV) as soon as possible 1
• Consider rapid HIV testing to expedite decision-making about post-exposure prophylaxis 1
• Do not test discarded needles or syringes for virus contamination as results are unreliable 1

Exposed Worker Testing

• Perform baseline testing for HIV antibody, Hepatitis B serology (HBsAg and anti-HBs), and Hepatitis C antibody 1
• Document Hepatitis B vaccination history and immune status 1
• Offer pregnancy testing to all women of childbearing age whose pregnancy status is unknown 1

Follow-up Testing Schedule

HIV Follow-up

• Perform HIV-antibody testing at baseline, 6 weeks, 3 months, and 6 months post-exposure 1
• Conduct additional HIV testing if illness compatible with acute retroviral syndrome occurs 1

Hepatitis B Follow-up

• For those who receive hepatitis B vaccine, perform follow-up anti-HBs testing 1-2 months after the last dose 1
• Note that anti-HBs response cannot be accurately determined if HBIG was received in the previous 3-4 months 1

Hepatitis C Follow-up

• Perform baseline and follow-up testing for anti-HCV and alanine aminotransferase (ALT) at 4-6 months after exposure 1
• Consider HCV RNA testing at 4-6 weeks if earlier diagnosis of HCV infection is desired 1
• Confirm repeatedly reactive anti-HCV enzyme immunoassays (EIAs) with supplemental tests 1

Post-Exposure Prophylaxis (PEP)

Hepatitis B PEP

• For exposed persons who are unvaccinated or incompletely vaccinated:

  • If source is HBsAg-positive: Administer HBIG (Hepatitis B Immune Globulin) and begin hepatitis B vaccine series 2
  • If source is HBsAg-negative: Begin hepatitis B vaccine series 2
  • If source is unknown or not tested: Begin hepatitis B vaccine series 2

• For exposed persons who were previously vaccinated and responded:

  • No treatment is necessary 2

• For exposed persons who were vaccinated but did not respond:

  • If source is HBsAg-positive: Administer HBIG immediately and again in 1 month, or HBIG and initiate revaccination 2
  • If source is HBsAg-negative: No treatment needed 2
  • If source is unknown: Consider HBIG or HBIG and HBV revaccination if high-risk source 2

HIV PEP

• Initiate HIV PEP as soon as possible, ideally within 24 hours of exposure (but no later than 72 hours) 2, 1
• PEP regimens include either a "basic regimen" with 2 anti-HIV drugs or an "expanded regimen" with 3 anti-HIV drugs for exposures with increased transmission risk 2
• Monitor for drug toxicity with baseline testing and follow-up testing every 2 weeks 1
• Evaluate exposed persons taking PEP within 72 hours after exposure and monitor for at least 2 weeks 1

Hepatitis C PEP

• No recommended post-exposure prophylaxis for HCV 2
• Early identification through testing is the primary approach 1

Monitoring and Counseling

• Provide counseling regarding precautions to prevent secondary transmission during the follow-up period 1
• Advise exposed workers to seek medical evaluation for any acute illness occurring during follow-up 2
• For those receiving HIV PEP, monitor for adverse effects through baseline testing and follow-up testing every 2 weeks 1

Common Pitfalls to Avoid

• Failing to test the source patient when possible - this information is critical for risk assessment and management decisions 1
• Inadequate follow-up testing - ensure systems are in place to encourage exposed workers to return for all scheduled follow-up tests 1
• Delayed initiation of PEP - HIV PEP should be started as soon as possible, ideally within 24 hours 2
• Recapping needles - this practice significantly increases the risk of needlestick injuries 3
• Underreporting of needlestick injuries - complete reporting is essential for optimal treatment 4