What are the management and treatment protocols for a patient who has experienced a needle stick injury, potentially exposing them to bloodborne pathogens such as sometime after the incident?

Needlestick Injury Management

Immediately wash the puncture site with soap and water without squeezing, report to your supervisor within 1 hour, and seek emergency medical evaluation to initiate HIV post-exposure prophylaxis (PEP) within the first hour—ideally before confirming the source patient's status—as effectiveness drops dramatically after 72 hours. 1, 2, 3

Immediate First Aid (Within Minutes)

• Wash the puncture site thoroughly with soap and water without squeezing or applying pressure to increase bleeding 1, 2, 3
• If blood splashed into eyes, nose, or mouth, flush immediately with clean water or saline 1, 3
• Do not recap, bend, or break the needle 2
• Document the exact time of injury immediately, as timing is critical for PEP eligibility 2, 3

Immediate Reporting and Documentation (Within 1 Hour)

• Report the incident to your supervisor immediately 1, 2, 3
• Document: date, time, type of device, depth of injury, source patient information, and all interventions 3
• Seek emergency medical evaluation within 1 hour to initiate PEP if needed 1, 2, 3

Source Patient Testing (Immediate)

The source patient should be tested as soon as possible for: 2, 3

• HIV antibody (rapid testing preferred) 1
• Hepatitis B surface antigen (HBsAg) 2, 3
• Hepatitis C antibody (anti-HCV) 2, 3

Note: Six index patients in one study received their first diagnosis of bloodborne infection (2 HCV, 4 HIV) after a needlestick incident, highlighting the importance of source testing 4

HIV Post-Exposure Prophylaxis (PEP)

Risk Context

• The 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 1, 2

PEP Initiation Decision

• Start PEP immediately if presentation is within 72 hours, even before confirming the source's HIV status for substantial exposures 1, 3
• PEP effectiveness drops dramatically after 72 hours 1, 2, 3
• In one study, 85.1% of healthcare workers exposed to HIV undertook PEP within 2 hours, and another 12.8% within 10 hours 4

Preferred PEP Regimen

• Bictegravir/emtricitabine/tenofovir alafenamide (single tablet once daily) for 28 days 1, 3
• Alternative: Dolutegravir plus (tenofovir alafenamide or tenofovir disoproxil fumarate) plus (emtricitabine or lamivudine) 1, 3
• Completing the full 28-day course is essential—stopping early eliminates protection 1, 3

Hepatitis B Management

Risk Assessment

• The risk of HBV transmission without prophylaxis may exceed 30% after exposure to HBeAg-positive blood 2
• Hepatitis B is the most common bloodborne infection transmitted through work-related exposure 5

Prophylaxis Protocol (Based on Vaccination Status)

For unvaccinated or incompletely vaccinated exposed workers with HBsAg-positive source: 2, 3, 6

• Administer Hepatitis B Immune Globulin (HBIG) 0.06 mL/kg intramuscularly as soon as possible, ideally within 24 hours (value beyond 7 days is unclear) 6
• Begin hepatitis B vaccine series: first dose within 7 days, second and third doses at 1 and 6 months 6

For previously vaccinated workers with known adequate antibody response: 3

• No treatment necessary 3

For vaccinated workers with inadequate antibody response: 6

• Give HBIG immediately plus hepatitis B vaccine booster dose, or 2 doses of HBIG (one immediately and one at 1 month) 6

Hepatitis C Management

• No post-exposure prophylaxis exists for hepatitis C 1, 2, 3
• The risk of HCV transmission is approximately 1.8% (range 0-7%) per percutaneous exposure 2, 3
• Early identification through testing is the primary approach 1, 2, 3
• One study documented one case of hepatitis C transmission that was successfully treated 7

Baseline Testing for Exposed Healthcare Worker

Before starting any prophylaxis, obtain: 2, 3

• HIV antibody or antigen/antibody combination test 1, 3
• Hepatitis B serology 1, 3
• Hepatitis C antibody (anti-HCV) and alanine aminotransferase (ALT) 2, 3
• Pregnancy test if applicable 1

Follow-Up Testing Schedule

HIV Follow-Up

• Test at 6 weeks, 3 months, and 6 months post-exposure 1, 2, 3
• In one study, 97.4% of healthcare workers attended follow-up examination 4

Hepatitis C Follow-Up

• Test at 4-6 weeks and 4-6 months post-exposure 1, 2, 3
• Consider HCV RNA at 4-6 weeks for earlier diagnosis 1

Hepatitis B Follow-Up

• Test for anti-HBs 1-2 months after the last vaccine dose 3

PEP Monitoring

• Monitor for drug toxicity every 2 weeks during the 28-day PEP course 1, 2
• Perform complete blood count and renal/hepatic function tests 2

Precautions During Follow-Up Period (6 Months)

• Use barrier protection during sexual activity 1, 3
• Do not donate blood, plasma, organs, tissue, or semen 1, 3
• Seek immediate medical evaluation for any acute illness, as it may indicate acute retroviral syndrome 1, 3
• Modifying patient care responsibilities is not necessary to prevent transmission to patients 8

Common Pitfalls to Avoid

• Never squeeze or apply pressure to increase bleeding at the injury site 1, 2, 3
• Never delay PEP initiation waiting for source patient test results in substantial exposures 1, 3
• Never stop PEP early—incomplete courses eliminate protection 1, 3
• Never assume low risk based on patient population—one study found one in five index patients infected with at least one bloodborne pathogen 7
• Needlestick injuries are widely underreported; complete reporting is essential for optimal treatment 7, 9, 5

Psychological Considerations

• Three-quarters of healthcare workers felt concerned following needlestick injury, and 12.2% were very concerned 4
• Through adequate management and follow-up, low transmission rates can be achieved 4
• No virus transmissions occurred in one prospective study of 112 needlestick injuries with infectious index patients over 3.5 years 4