What is the proper procedure after a needle stick injury?

Proper Procedure After a Needle Stick Injury

Immediately wash the wound with soap and water, report the incident to your supervisor within minutes, and seek emergency medical evaluation within 1 hour to initiate HIV post-exposure prophylaxis (PEP) if indicated—timing is critical as PEP effectiveness drops dramatically after 72 hours. 1, 2

Immediate Actions (First Minutes)

• Wash the puncture site thoroughly with soap and water without squeezing or applying pressure to increase bleeding 1, 2
• If blood splashed into eyes, nose, or mouth, flush the involved area immediately with clean water or saline 1, 2
• Document the exact time of injury immediately—this is critical for determining PEP eligibility 2
• Report to your supervisor immediately and document: date, time, type of device involved, depth of injury, whether blood was visible on the device, and whether the needle had been in a vein or artery 1, 2, 3

Emergency Medical Evaluation (Within 1 Hour)

Seek emergency evaluation within 1 hour to initiate PEP if needed—the sooner PEP starts, the more effective it is, with a dramatic drop in effectiveness after 72 hours. 2, 4

Source Patient Testing (Immediate Priority)

• Obtain rapid HIV testing of the source patient to expedite PEP decisions 2, 3
• Test source for Hepatitis B surface antigen (HBsAg) and Hepatitis C antibody (anti-HCV) 1, 3
• If source cannot be identified or tested, base decisions on the likelihood of exposure considering the type of needle and exposure circumstances 1

Exposed Healthcare Worker Baseline Testing

• HIV antibody or antigen/antibody combination test 2, 3
• Hepatitis B serology (document vaccination history and anti-HBs levels) 1, 3
• Hepatitis C antibody (anti-HCV) 3
• Pregnancy test for women of childbearing age if pregnancy status unknown 3
• Do not delay the first PEP dose while waiting for laboratory results 4

HIV Post-Exposure Prophylaxis Decision

Start PEP immediately if presentation is within 72 hours (ideally within 24 hours), even before confirming the source's HIV status for substantial exposures. 2, 4

Understanding the Risk Context

• Risk of HIV transmission from a percutaneous needlestick with HIV-infected blood is approximately 0.36% (3-4 per 1,000 exposures) 1, 2, 3
• PEP reduces this risk by approximately 81% when started promptly 2
• Risk increases with: deep injury, visible blood on device, needle previously in vein/artery, high viral load in source 4

PEP Regimen (If Indicated)

Preferred regimen: Bictegravir/emtricitabine/tenofovir alafenamide (single tablet once daily) for 28 days 2, 4

Alternative regimen: Dolutegravir plus (tenofovir alafenamide or tenofovir disoproxil fumarate) plus (emtricitabine or lamivudine) 2, 4

• Complete the full 28-day course—stopping early eliminates protection 2, 4
• Monitor for drug toxicity every 2 weeks during PEP 2, 3
• Common side effects include nausea and gastrointestinal symptoms; anti-nausea medications can improve adherence 4

Hepatitis B Management

If Source is HBsAg-Positive

For unvaccinated or incompletely vaccinated exposed workers: Administer Hepatitis B Immune Globulin (HBIG) 0.06 mL/kg (maximum 5 mL) intramuscularly immediately AND begin hepatitis B vaccine series 1, 5

For previously vaccinated workers with known adequate response (anti-HBs >100 IU): No treatment necessary 1, 3

For vaccinated workers with unknown or inadequate response: Test anti-HBs levels immediately; if <10 IU, give HBIG and vaccine booster 1

• Risk context: Without prophylaxis, risk of hepatitis B transmission can exceed 30% after exposure to HBeAg-positive blood 1, 3
• Vaccination reduces this risk to virtually zero 1

Hepatitis C Management

• No post-exposure prophylaxis exists for hepatitis C—early identification through testing is the primary approach 2, 3
• Risk of HCV transmission is approximately 1.8% (range 0-7%) per percutaneous exposure 3
• Baseline anti-HCV and ALT testing 3

Follow-Up Testing Schedule

HIV Testing Timeline

• Baseline (before starting PEP) 2, 3
• 6 weeks post-exposure 2, 3
• 3 months post-exposure 2, 3
• 6 months post-exposure (final) 2, 3
• Additional testing if acute illness occurs during follow-up that may indicate acute retroviral syndrome 2, 3

Hepatitis C Testing Timeline

• Baseline anti-HCV and ALT 3
• 4-6 weeks post-exposure: Consider HCV RNA for earlier diagnosis 2, 3
• 4-6 months post-exposure: Anti-HCV and ALT (definitive) 2, 3
• Confirm repeatedly reactive anti-HCV enzyme immunoassays with supplemental tests 3

Hepatitis B Testing (If Vaccine Given)

• 1-2 months after last vaccine dose: Anti-HBs testing 3
• Note: Anti-HBs response cannot be accurately determined if HBIG was received in the previous 3-4 months 3

Precautions During Follow-Up Period

• Use barrier protection during sexual activity for 6 months post-exposure 2
• Do not donate blood, plasma, organs, tissue, or semen during the 6-month follow-up period 2
• Seek immediate medical evaluation for any acute illness during follow-up—may indicate acute retroviral syndrome 2, 3

Critical Pitfalls to Avoid

• Never delay PEP initiation beyond 72 hours—effectiveness drops dramatically after this window 2, 4
• Never stop PEP prematurely—the full 28-day course is essential for protection 2, 4
• Never attempt to test the needle itself for HIV—this is not reliable or recommended 4, 3
• Never recap needles—this increases risk of additional injury 1
• Never assume low risk means no action needed—even low-risk exposures require baseline documentation and source testing when possible 1, 2
• Ensure adequate follow-up system—many healthcare workers fail to return for scheduled follow-up testing 3