What is the management for a healthcare worker with a needle prick injury, potentially exposing them to bloodborne pathogens, including Human Immunodeficiency Virus (HIV), hepatitis B, and hepatitis C?

Management of Needlestick Injury

Immediately wash the puncture site with soap and water without squeezing or applying pressure, report the incident within 1 hour, and initiate HIV post-exposure prophylaxis (PEP) within 72 hours if indicated, as effectiveness drops dramatically after this window. 1, 2

Immediate First Aid (Within Minutes)

• Wash the puncture site thoroughly with soap and water—do not squeeze or apply pressure to increase bleeding. 1, 2
• If blood splashes into eyes, nose, or mouth, flush immediately with clean water, saline, or sterile irrigants. 2
• Never recap, bend, or break the needle after injury. 2
• Report the incident to your supervisor within 1 hour and document the exact time of injury, as timing is critical for PEP eligibility. 1, 2

Source Patient Assessment (Within 1-2 Hours)

• Test the source patient as soon as possible for HIV antibody, hepatitis B surface antigen (HBsAg), and hepatitis C antibody (anti-HCV). 1, 2
• Consider using rapid HIV testing to expedite decision-making about post-exposure prophylaxis. 1
• Do not test discarded needles or syringes for virus contamination—results are unreliable. 3, 1

Baseline Testing for Exposed Healthcare Worker

• Perform baseline testing before starting any prophylaxis: HIV antibody or antigen/antibody combination test, hepatitis B serology, hepatitis C antibody (anti-HCV), and alanine aminotransferase (ALT). 1, 2
• Document immune status for HBV infection by history of hepatitis B vaccination and vaccine response. 1
• Offer pregnancy testing to all non-pregnant women of childbearing age whose pregnancy status is unknown. 1

HIV Post-Exposure Prophylaxis (Within 72 Hours)

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

• The preferred regimen is bictegravir/emtricitabine/tenofovir alafenamide (single tablet once daily) for 28 days. 2
• The risk of HIV transmission from a percutaneous needlestick with HIV-infected blood is approximately 0.36% (3-4 per 1,000 exposures), and PEP reduces this risk by approximately 81% when started promptly. 2, 4
• Completing the full 28-day course is essential—stopping early eliminates protection. 2
• Monitor for drug toxicity every 2 weeks during the 28-day course with complete blood count and renal/hepatic function tests. 2

Hepatitis B Management

For unvaccinated or incompletely vaccinated individuals exposed to HBsAg-positive source:

• Administer hepatitis B immune globulin (HBIG) 0.06 mL/kg intramuscularly as soon as possible, ideally within 24 hours. 2
• Begin the hepatitis B vaccine series simultaneously. 1, 2
• The risk of HBV transmission without prophylaxis may exceed 30% after exposure to HBeAg-positive blood. 1, 2, 4

For previously vaccinated individuals who responded:

• No treatment is necessary. 1
• For those who receive hepatitis B vaccine, perform follow-up anti-HBs testing 1-2 months after the last dose of vaccine. 1

Hepatitis C Management

No post-exposure prophylaxis exists for hepatitis C—early identification through testing is the primary approach. 3, 1, 2

• The average risk of HCV transmission after needlestick from a confirmed positive source is 1.8% (range 0-7%). 3, 4
• Do not administer immune globulin—it is not effective for HCV post-exposure prophylaxis. 3
• Do not start prophylactic interferon or direct-acting antivirals immediately after exposure. 3

Follow-Up Testing Schedule

For HIV exposure:

• Perform HIV-antibody testing at baseline, 6 weeks, 3 months, and 6 months post-exposure. 1, 2
• Conduct additional HIV antibody testing if illness compatible with acute retroviral syndrome occurs. 1

For Hepatitis C exposure:

• Perform HCV RNA testing at 4-6 weeks post-exposure if earlier diagnosis is desired. 3, 1
• Perform anti-HCV antibody and ALT testing at 4-6 months post-exposure. 3, 1
• Confirm any positive anti-HCV results with supplemental assays (such as RIBA) before communicating results, particularly if signal-to-cutoff values are low. 3, 1

Precautions During Follow-Up Period

• No special precautions are needed to prevent secondary transmission during the follow-up period, and no modification of patient care responsibilities is necessary. 5, 3
• Use barrier protection during sexual activity, do not donate blood, plasma, organs, tissue, or semen. 2
• Seek immediate medical evaluation for any acute illness during the 6-month follow-up period, particularly symptoms of acute hepatitis such as fatigue, jaundice, nausea, and right upper quadrant pain. 3, 1, 2

Co-infection Considerations

• If the source patient is co-infected with HIV and HCV, extended follow-up to 12 months may be warranted, and standard HIV post-exposure prophylaxis protocols should be followed simultaneously if indicated. 3

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 a system is in place to encourage exposed healthcare workers to return for all scheduled follow-up tests. 1
• Delaying HIV PEP beyond 72 hours—effectiveness drops dramatically after this window. 1, 2