What is the protocol for managing a needle stick injury?

Needle Stick Injury Protocol

Immediately wash the puncture site thoroughly with soap and water without squeezing or applying pressure to increase bleeding, report the incident to your supervisor within 1 hour, and seek emergency medical evaluation within 1 hour to initiate HIV post-exposure prophylaxis (PEP) if needed, as effectiveness drops dramatically after 72 hours. 1, 2

Immediate First Aid (Within Minutes)

• Wash the needle-stick site with soap and water immediately without squeezing or applying pressure to increase bleeding 3, 1, 2
• If blood splashes into eyes, nose, or mouth, flush the involved area immediately with clean water, saline, or sterile irrigants 3, 1
• Document the exact time of injury immediately, as timing is critical for PEP eligibility (must be within 72 hours) 1, 2
• Do not recap, bend, or break the needle after injury 3, 4

Immediate Reporting and Documentation (Within 1 Hour)

• Report the incident to your supervisor immediately and seek medical treatment within 1 hour 3, 1, 2
• Document the type of injury including: 3
  • Date and time of exposure
  • Type of device involved (hollow-bore needle carries higher risk)
  • Extent of injury (deep injection vs. superficial puncture)
  • Involvement of blood or other potentially infectious body fluids
  • Source patient identification if possible

Source Patient Assessment (Immediate)

• Identify the source patient if possible and determine their serologic status for HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) 3, 2
• Obtain consent and test source patient as soon as possible for: 2
  • HIV antibody (FDA-approved rapid testing available)
  • Hepatitis B surface antigen (HBsAg)
  • Hepatitis C antibody (anti-HCV)
• If source is unknown or cannot be tested, base prophylaxis decisions on the likelihood of exposure considering the source of needle and type of exposure 3, 1

Exposed Healthcare Worker Baseline Testing (Before Starting Prophylaxis)

• Obtain baseline testing for the exposed worker: 1, 2
  • HIV antibody or antigen/antibody combination test
  • Hepatitis B serology (anti-HBs if vaccination status unknown)
  • Hepatitis C antibody (anti-HCV)
  • Pregnancy test if applicable
  • Complete blood count and renal/hepatic function tests

HIV Post-Exposure Prophylaxis (Within 1-2 Hours, Maximum 72 Hours)

Start PEP immediately if presentation is within 72 hours, even before confirming the source's HIV status for substantial exposures. 1, 2

• Preferred PEP regimen: Bictegravir/emtricitabine/tenofovir alafenamide (single tablet once daily) for 28 days 1, 2
• Alternative regimens: Dolutegravir plus tenofovir alafenamide or tenofovir disoproxil fumarate plus emtricitabine or lamivudine 1
• The risk of HIV transmission from a percutaneous needlestick with HIV-infected blood is approximately 0.3-0.36% (3-4 per 1,000 exposures), and PEP reduces this risk by approximately 81% when started promptly 1, 2
• Completing the full 28-day course is essential—stopping early eliminates protection 1, 2

Hepatitis B Prophylaxis (Within 24 Hours)

Follow this algorithm based on exposed worker's vaccination status and source patient's HBsAg status: 3, 5

If exposed person is unimmunized against hepatitis B:

• Source HBsAg-positive: Administer hepatitis B immune globulin (HBIG) 0.06 mL/kg intramuscularly (maximum dose: 5 mL) immediately and begin hepatitis B vaccine series 3, 5
• Source HBsAg-negative: Begin hepatitis B vaccine series 3
• Source not tested or unknown: Begin hepatitis B vaccine series 3

If exposed person was immunized and responded (anti-HBs positive):

• No treatment is necessary 3

If exposed person was immunized and did not respond (anti-HBs negative):

• Source HBsAg-positive: HBIG immediately and in 1 month, or HBIG and initiate reimmunization 3
• Source HBsAg-negative: No treatment 3
• Source not tested or unknown: If high-risk source, consider HBIG or HBIG and HBV reimmunization as for HBsAg-positive source 3

If exposed person was immunized but response is unknown:

• Source HBsAg-positive: Test exposed for anti-HBs; if positive, no treatment; if negative, 1 dose of HBIG and 1 dose of vaccine, retest exposed for anti-HBs 4-6 months later 3

The risk of HBV transmission without prophylaxis may exceed 30% after exposure to HBeAg-positive blood, making this a critical intervention. 2, 5

Hepatitis C Management

• No post-exposure prophylaxis exists for hepatitis C 1, 2
• The risk of HCV transmission is approximately 1.8% (range 0-7%) per percutaneous exposure 2
• Early identification through testing is the primary approach 1, 2

Follow-Up Testing Schedule

HIV testing: 1, 2

• 6 weeks post-exposure
• 3 months post-exposure
• 6 months post-exposure

Hepatitis C testing: 1, 2

• HCV RNA at 4-6 weeks for earlier diagnosis (optional)
• Anti-HCV at 4-6 months post-exposure

Drug toxicity monitoring during PEP: 1, 2

• Monitor every 2 weeks during the 28-day PEP course
• Perform complete blood count and renal/hepatic function tests

Precautions During Follow-Up Period (6 Months)

• Use barrier protection during sexual activity 1, 2
• Do not donate blood, plasma, organs, tissue, or semen 1, 2
• Seek immediate medical evaluation for any acute illness, which may indicate acute retroviral syndrome 1, 2

Common Pitfalls to Avoid

• Delaying wound washing: Must be done immediately, not after reporting or documentation 4
• Squeezing the wound: This does not reduce infection risk and may cause tissue damage 1, 2, 4
• Waiting for source patient results before starting PEP: Start immediately for substantial exposures, do not delay 1, 2
• Incomplete PEP course: Stopping early eliminates protection; adherence is critical 1, 2
• Recapping needles: This is the most common behavior associated with needlestick injuries and must be avoided 3, 6

Prevention Measures for Future Incidents

• Never recap, bend, or break needles or remove needles from a syringe by hand 3
• Dispose of needles immediately after use into impermeable and puncture-proof sharps containers at the point of use 3
• Use safety-engineered devices designed to reduce the risk of needle sticks 3, 4
• Ensure sharps containers are not overfilled (seal when two-thirds full or after four weeks of use) 3