What are the immediate steps to take after an accidental needlestick injury, considering potential exposure to bloodborne pathogens such as Human Immunodeficiency Virus (HIV), hepatitis B, and hepatitis C?

Immediate Management of Accidental Needlestick Injury

Wash the puncture site immediately with soap and water without squeezing or applying pressure, report the incident to your supervisor within 1 hour, and initiate HIV post-exposure prophylaxis (PEP) within 72 hours if indicated—the effectiveness of PEP 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. 3, 1, 4, 2
• If blood splashes into eyes, nose, or mouth, flush immediately with clean water, saline, or sterile irrigants. 3, 1, 4, 2
• Never recap, bend, or break the needle after injury. 4, 2
• Document the exact time of injury immediately, as timing is critical for PEP eligibility. 1, 2

Reporting and Initial Assessment (Within 1 Hour)

• Report the incident to your supervisor within 1 hour and seek emergency medical evaluation. 3, 1, 4, 2
• Document the type of injury including involvement of blood, source of blood, extent of injury (deep injection vs. superficial), type of device, and whether the source patient is known. 3

Source Patient Testing (Within 1-2 Hours)

• Test the source patient as soon as possible for HIV antibody (consider rapid testing), hepatitis B surface antigen (HBsAg), and hepatitis C antibody (anti-HCV). 3, 1, 4, 2
• If the source is unknown, base management decisions on the likelihood of exposure considering the source of the needle and type of exposure. 3
• Do not test discarded needles or syringes for virus contamination. 3

Baseline Testing for Exposed Healthcare Worker

Perform baseline testing before starting any prophylaxis: 1, 2

• HIV antibody or antigen/antibody combination test 1, 2
• Hepatitis B serology (assess immune status by history of hepatitis B vaccination and vaccine response) 3, 2
• Hepatitis C antibody (anti-HCV) 1, 2
• Liver function tests (alanine aminotransferase/ALT) 4
• Pregnancy test if applicable 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. 1, 4, 2 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), but PEP reduces this risk by approximately 81% when started promptly. 1, 4

Preferred PEP Regimen:

• Bictegravir/emtricitabine/tenofovir alafenamide (single tablet once daily) for 28 days 1, 2
• Alternative: Dolutegravir plus tenofovir alafenamide or tenofovir disoproxil fumarate plus emtricitabine or lamivudine 1
• Completing the full 28-day course is essential—stopping early eliminates protection. 1, 4, 2

Monitoring During PEP:

• Monitor for drug toxicity every 2 weeks during the 28-day course with complete blood count and renal/hepatic function tests. 3, 1, 4, 2

Hepatitis B Management

The risk of HBV transmission without prophylaxis may exceed 30% after exposure to HBeAg-positive blood. 4

For Unvaccinated or Incompletely Vaccinated Individuals:

• If source is HBsAg-positive: 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), and begin the hepatitis B vaccine series. 3, 5
• If source is HBsAg-negative: Begin hepatitis B vaccine series only. 3
• If source is not tested or unknown: Begin hepatitis B vaccine series. 3

For Previously Vaccinated Individuals:

• Test exposed person for anti-HBs. 3, 5
• If inadequate antibody response (less than 10 sample ratio units by RIA, negative by EIA): Give HBIG immediately plus hepatitis B vaccine booster dose, or 2 doses of HBIG, one as soon as possible after exposure and the second 1 month later. 3, 5
• If adequate antibody response: No treatment necessary. 3

Hepatitis C Management

No post-exposure prophylaxis exists for hepatitis C—early identification through testing is the primary approach. 1, 4, 2 The risk of HCV transmission is approximately 1.8% (range 0-7%) per percutaneous exposure. 1, 4, 2

Follow-Up Testing Schedule

HIV Testing:

• Perform HIV-antibody testing at baseline, 6 weeks, 3 months, and 6 months post-exposure. 3, 1, 4, 2
• Perform HIV antibody testing if illness compatible with acute retroviral syndrome occurs. 3

Hepatitis B Testing:

• Perform follow-up anti-HBs testing 1-2 months after last dose of vaccine in persons who receive hepatitis B vaccine. 3
• Anti-HBs response to vaccine cannot be ascertained if HBIG was received in the previous 3-4 months. 3

Hepatitis C Testing:

• Perform baseline and follow-up testing for anti-HCV and ALT at 4-6 months after exposure. 3, 1, 4
• Perform HCV RNA at 4-6 weeks if earlier diagnosis of HCV infection is desired. 3, 1, 4, 2
• Confirm repeatedly reactive anti-HCV enzyme immunoassays (EIAs) with supplemental tests. 3

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 the 6-month follow-up period, which may indicate acute retroviral syndrome. 1, 4, 2
• No modification of patient care responsibilities is necessary. 2

Common Pitfalls to Avoid

• Delaying HIV PEP beyond 72 hours—effectiveness drops dramatically after this window. 1, 2 Research shows zero seroconversion when immediate antiretroviral therapy is given. 6
• Failing to test the source patient when possible—this information is critical for risk assessment and management decisions. 2
• Inadequate follow-up testing—ensure a system is in place to encourage exposed healthcare workers to return for all scheduled follow-up tests. 2
• Squeezing or applying pressure to increase bleeding at the injury site—this is not recommended. 1, 4, 2
• Recapping needles, which accounts for a significant proportion of injuries (up to 34% in some studies). 7, 8