What is the proper protocol for a healthcare worker who experiences a needle stick injury, potentially exposing them to bloodborne pathogens such as Human Immunodeficiency Virus (HIV), hepatitis B, and hepatitis C?

Needle Stick Injury Protocol

Immediate Actions (First 15 Minutes)

Wash the puncture site thoroughly with soap and water immediately—do not squeeze or apply pressure to increase bleeding. 1 If blood splashed into eyes, nose, or mouth, flush the area immediately with clean water or saline. 1, 2

• Document the exact time of injury immediately, as this is critical for determining post-exposure prophylaxis (PEP) eligibility. 1
• Report to your supervisor immediately and document: date, time, type of device involved, depth of injury, procedure being performed, and source patient details. 3, 1
• Do not apply caustic agents like bleach or inject antiseptics into the wound. 3

Emergency Evaluation (Within 1 Hour)

Seek emergency medical evaluation within 1 hour to initiate PEP if needed—effectiveness drops dramatically after 72 hours. 1, 2

Source Patient Testing

• Obtain rapid HIV testing of the source patient to expedite PEP decisions. 1, 2
• Test source for Hepatitis B surface antigen (HBsAg) and Hepatitis C antibody (anti-HCV). 1, 4
• The risk of HIV transmission from a percutaneous needlestick with HIV-infected blood is approximately 0.36% (3-4 per 1,000 exposures). 3, 1, 2
• Without prophylaxis, the risk of Hepatitis B transmission may exceed 30% after exposure to HBeAg-positive blood. 3, 1
• The risk of Hepatitis C transmission is approximately 1.8% (range 0-7%) per percutaneous exposure. 1, 4

Exposed Worker Baseline Testing

• HIV antibody or antigen/antibody combination test. 2, 4
• Hepatitis B serology (document vaccination history and vaccine response). 4
• Hepatitis C antibody (anti-HCV) and alanine aminotransferase (ALT). 4
• Pregnancy test for women of childbearing age whose pregnancy status is unknown. 4

HIV Post-Exposure Prophylaxis Decision

Start PEP immediately if presentation is within 72 hours, even before confirming the source's HIV status for substantial exposures (percutaneous injury, mucous membrane exposure, or contact with non-intact skin). 1, 2

• PEP reduces the risk of HIV transmission by approximately 81% when started promptly. 1, 2
• The preferred regimen is Bictegravir/emtricitabine/tenofovir alafenamide (single tablet once daily) for 28 days. 1, 2
• Alternative regimen: Dolutegravir plus (tenofovir alafenamide or tenofovir disoproxil fumarate) plus (emtricitabine or lamivudine). 1, 2
• Completing the full 28-day course is essential—stopping early eliminates protection. 1, 2

Hepatitis B Management

For unvaccinated or incompletely vaccinated workers exposed to HBsAg-positive source: administer Hepatitis B Immune Globulin (HBIG) immediately and begin the hepatitis B vaccine series. 1, 4

• For previously vaccinated workers with known adequate antibody response (anti-HBs >100 IU), no treatment is necessary. 3, 1
• Workers with antibody levels 50-100 IU should receive a booster dose within one year; those with 10-50 IU should receive a booster immediately. 3
• Follow-up anti-HBs testing should be performed 1-2 months after the last vaccine dose. 1, 4

Hepatitis C Management

No post-exposure prophylaxis exists for Hepatitis C—early identification through testing is the primary approach. 1, 4

• Baseline anti-HCV and ALT testing is recommended. 4
• Follow-up testing at 4-6 weeks (HCV RNA for earlier diagnosis) and 4-6 months (anti-HCV and ALT). 1, 4
• Repeatedly reactive anti-HCV enzyme immunoassays should be confirmed with supplemental tests. 4

Follow-Up Testing Schedule

HIV Testing

• Baseline (before starting PEP), then at 6 weeks, 3 months, and 6 months post-exposure. 1, 4
• Additional testing if illness compatible with acute retroviral syndrome occurs. 4

PEP Monitoring

• Evaluate within 72 hours of starting PEP and monitor for drug toxicity every 2 weeks during the 28-day course. 2, 4
• Monitor complete blood count and renal/hepatic function tests. 4

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 during follow-up, as it may indicate acute retroviral syndrome. 1, 2

Common Pitfalls to Avoid

• Never test discarded needles or syringes for virus contamination—results are unreliable. 4
• Do not delay reporting due to fear of consequences—immediate reporting is essential for effective PEP. 3, 1
• Avoid inadequate follow-up testing by ensuring a system is in place to encourage completion of all scheduled tests. 4
• Do not recap needles, bend them, or remove needles from syringes by hand—these actions cause most injuries. 3, 5