What is the post-exposure prophylaxis (PEP) protocol for a needle stick injury?

Post-Exposure Prophylaxis for Needle Stick Injury

Immediately wash the wound with soap and water, initiate HIV post-exposure prophylaxis within 1 hour (absolutely within 72 hours) using a 28-day course of combination antiretroviral therapy, administer hepatitis B immune globulin (HBIG) and hepatitis B vaccine within 24 hours if the source is HBsAg-positive and you are unvaccinated, and establish baseline testing for all three bloodborne pathogens. 1, 2, 3

Immediate First Aid (Within Minutes)

• Wash the wound thoroughly with soap and water immediately—do not squeeze the wound or apply caustic agents like bleach, as these do not reduce transmission risk and may cause harm 4, 1
• Flush mucous membranes (eyes, nose, mouth) with clean water or saline if exposed 1
• Document the exposure immediately: date, time, type of device, depth of injury, whether blood was visible, and source patient information 4, 1
• Report to your supervisor and seek emergency medical evaluation within 1 hour 1

HIV Post-Exposure Prophylaxis (Highest Priority)

Timing is Critical

• Start HIV PEP within the first hour if possible, absolutely within 72 hours—effectiveness drops dramatically after 72 hours, and PEP is not recommended beyond this window 4, 1
• Do not delay PEP initiation while waiting for source patient HIV test results 1
• The baseline risk of HIV transmission from a needlestick with HIV-infected blood is 0.3-0.36%, but PEP reduces this risk by approximately 81% when started promptly 1

Preferred HIV PEP Regimens (28-Day Course)

• First-line: Bictegravir/emtricitabine/tenofovir alafenamide (single tablet once daily) 1
• Alternative: Dolutegravir plus (tenofovir alafenamide or tenofovir disoproxil fumarate) plus (emtricitabine or lamivudine) 1
• Complete the full 28-day course—stopping early eliminates protection 1

HIV Testing Protocol

• Baseline: HIV antibody or antigen/antibody combination test 1
• Follow-up: HIV testing at 6 weeks, 3 months, and 6 months post-exposure 1
• Rapid HIV testing of the source patient is preferred to expedite PEP decisions 1

Hepatitis B Post-Exposure Prophylaxis

For Unvaccinated or Incomplete Vaccination Status

• If source is HBsAg-positive: Administer HBIG (0.06 mL/kg body weight) intramuscularly within 24 hours AND initiate hepatitis B vaccine series simultaneously at separate anatomic sites 2, 3
• The effectiveness of prophylaxis diminishes significantly after 24 hours, though efficacy may extend up to 7 days for needlestick injuries 4, 2, 3
• Hepatitis B vaccine series: 3 doses at 0,1, and 6 months (20 μg IM for adults; 10 μg IM for children under 10 years) 3

For Fully Vaccinated Healthcare Workers

• Test the exposed person for anti-HBs antibody levels 3
• If inadequate antibody response (<10 SRU by RIA): Give HBIG (0.06 mL/kg) immediately plus hepatitis B vaccine booster dose 3
• The risk of hepatitis B transmission without prophylaxis exceeds 30% after needlestick from HBsAg-positive source—far higher than HIV 1, 2

Hepatitis B Testing Protocol

• Baseline: HBsAg and anti-HBs for exposed person; HBsAg for source patient 1, 2
• Follow-up: Anti-HBs at completion of vaccine series to confirm response 2

Hepatitis C Post-Exposure Management

No Prophylaxis Available

• There is no post-exposure prophylaxis for hepatitis C—no vaccine and no immune globulin 4, 2
• The risk of hepatitis C transmission is approximately 1.8% (range 0-7%) after needlestick from HCV-positive source 1, 2

Hepatitis C Testing Protocol

• Baseline: Anti-HCV antibody and ALT at time of exposure 4, 2
• Early detection option: HCV RNA at 4-6 weeks for earlier diagnosis 1, 2
• Follow-up: Anti-HCV antibody and ALT at 4-6 months 4, 1, 2

Source Patient Evaluation

• Test source patient for HIV (rapid test preferred), HBsAg, and anti-HCV 1
• If source is HIV-positive, document stage of disease, antiretroviral therapy history, and viral load if available 4
• If source patient cannot be identified or refuses testing, initiate hepatitis B vaccine series and consider HIV PEP based on risk assessment of the exposure setting 4, 3

Baseline Testing for Exposed Healthcare Worker

• HIV antibody or antigen/antibody combination test 1
• Hepatitis B serology (HBsAg and anti-HBs) 1
• Hepatitis C antibody (anti-HCV) 1
• Pregnancy test if applicable (important for PEP medication selection) 1

Follow-Up Monitoring and Precautions

During PEP (First 28 Days)

• Monitor for drug toxicity every 2 weeks during HIV PEP 1
• Evaluate within 72 hours of starting PEP for tolerance and adherence 1

Precautions During Follow-Up Period

• Use barrier protection during sexual activity for 6 months post-exposure 1
• Do not donate blood, plasma, organs, tissue, or semen during the 6-month follow-up period 1
• Seek immediate medical evaluation for any acute illness during follow-up—may indicate acute retroviral syndrome 1

Counseling Points

• Healthcare workers exposed to HBV and HCV do not need to modify patient care responsibilities or take special precautions to prevent secondary transmission during follow-up 4
• For HIV exposures on PEP, standard precautions are sufficient 4

Common Pitfalls to Avoid

• Do not delay HBIG administration while waiting for source testing—start prophylaxis immediately if high suspicion exists for HBsAg-positive source 2
• Do not confuse hepatitis B and C protocols—there is no immune globulin or vaccine for hepatitis C 2
• Do not test discarded needles or syringes for virus contamination—focus on testing the source patient 2
• Do not apply caustic agents or squeeze the wound—this does not reduce transmission risk 4, 1
• Needle recapping is NOT recommended and increases injury risk—44% of healthcare workers incorrectly believe this is protective 5

Special Considerations

Unknown Source Exposures

• Initiate hepatitis B vaccine series within 7 days of exposure 3
• Consider HIV PEP based on the likelihood of HIV exposure in that clinical setting (e.g., HIV ward, emergency department) 4
• Found needles in public settings (parks, streets) pose minimal HIV risk due to viral inactivation from drying and typically do not warrant PEP 4

Pregnancy

• HIV PEP should not be withheld in pregnancy—benefits outweigh risks 1
• Specific antiretroviral selection may need adjustment; consult PEPline (888-448-4911) for guidance 4

Consultation Resources

• National PEPline: 888-448-4911 for challenging cases or when guidelines do not provide sufficient guidance 4