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

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 to initiate HIV post-exposure prophylaxis (PEP) within 72 hours if indicated—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, as this does not reduce transmission risk 3, 1, 2
• If blood splashes into eyes, nose, or mouth, flush immediately with clean water, saline, or sterile irrigants 3, 4
• 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 Documentation (Within 1 Hour)

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

Source Patient Assessment (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, 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 (anti-HBs to assess immune status from prior vaccination) 3, 2
• Hepatitis C antibody (anti-HCV) 3, 1
• Liver function tests (ALT) 3, 2
• 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, 2:

• The preferred regimen is bictegravir/emtricitabine/tenofovir alafenamide (single tablet once daily) for 28 days 1, 2
• Alternative regimens include 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
• The actual 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
• Monitor for drug toxicity every 2 weeks during the 28-day course with complete blood count and renal/hepatic function tests 3, 1, 2

Hepatitis B Management

For unvaccinated or incompletely vaccinated individuals exposed to HBsAg-positive source 3, 5:

• 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) 3, 5
• Begin the hepatitis B vaccine series simultaneously at a different injection site 3, 5
• The risk of HBV transmission without prophylaxis may exceed 30% after exposure to HBeAg-positive blood 4, 2

For vaccinated individuals with known adequate antibody response (≥10 mIU/mL):

• No treatment is necessary 3

For vaccinated individuals with inadequate or unknown antibody response:

• Test the exposed person for anti-HBs immediately 3
• If inadequate antibody (<10 SRU by RIA or negative by EIA), give HBIG immediately plus hepatitis B vaccine booster dose 3, 5
• Perform follow-up anti-HBs testing 1-2 months after the last dose of vaccine (cannot be accurately assessed if HBIG was received in the previous 3-4 months) 3

Hepatitis C Management

• No post-exposure prophylaxis exists for hepatitis C—early identification through testing is the primary approach 3, 1, 4, 2
• The risk of HCV transmission is approximately 1.8% (range 0-7%) per percutaneous exposure to HCV-positive blood 4, 2
• Perform baseline anti-HCV and ALT testing 3
• Perform follow-up testing for anti-HCV and ALT at 4-6 months after exposure 3, 1
• Consider HCV RNA testing at 4-6 weeks if earlier diagnosis is desired 3, 1, 2
• Confirm repeatedly reactive anti-HCV enzyme immunoassays (EIAs) with supplemental tests 3

Follow-Up Testing Schedule

For HIV exposure 3, 1, 2:

• Perform HIV-antibody testing at baseline, 6 weeks, 3 months, and 6 months post-exposure
• Perform HIV antibody testing immediately if illness compatible with acute retroviral syndrome occurs during follow-up

For HCV exposure 3, 1:

• Baseline and 4-6 months: anti-HCV and ALT
• Optional 4-6 weeks: HCV RNA for earlier diagnosis

For HBV exposure 3:

• Test for anti-HBs 1-2 months after the last dose of vaccine (if vaccine was administered)

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 3, 1
• 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, and PEP should ideally be started within the first hour 1, 2
• Failing to test the source patient when possible—this information is critical for risk assessment and management decisions 2
• Squeezing or applying pressure to increase bleeding at the puncture site—this does not reduce transmission risk 1, 4, 2
• Inadequate follow-up testing—ensure a system is in place to encourage exposed healthcare workers to return for all scheduled follow-up tests 3, 2
• Stopping HIV PEP early—completing the full 28-day course is essential for protection 1, 4, 2
• Recapping needles after injury—this increases risk of additional injuries 4, 2