What is the testing protocol for a healthcare worker after a needle stick injury?

Needlestick Injury Testing Protocol

After a needlestick injury, immediately wash the site with soap and water without squeezing, report within 1 hour, test both source patient and exposed healthcare worker for HIV, HBV, and HCV, and initiate HIV post-exposure prophylaxis within 72 hours if indicated—timing is critical as PEP effectiveness drops dramatically after this window. 1, 2

Immediate Actions (Within Minutes)

• Wash the puncture site thoroughly with soap and water—do not squeeze or apply pressure to increase bleeding 1, 2, 3
• If blood splashes into eyes, nose, or mouth, flush immediately with clean water, saline, or sterile irrigants 1, 2, 3
• Never recap, bend, or break the needle after injury 4, 1, 3
• Document the exact time of injury immediately, as timing is critical for determining PEP eligibility 1, 2

Reporting and Initial Assessment (Within 1 Hour)

• Report to your supervisor within 1 hour and seek emergency medical evaluation 1, 2, 3
• Document the date, time, type of device involved, depth of injury, source patient details, and condition of your skin (intact vs. non-intact) 4, 1
• The 1-hour window is essential because HIV PEP must be started as soon as possible, ideally within the first hour and absolutely within 72 hours 1, 2

Source Patient Testing (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) 4, 1, 2, 3
• Consider using rapid HIV testing to expedite decision-making about post-exposure prophylaxis 2
• In prospective studies, approximately 20% of source patients tested positive for at least one bloodborne pathogen 5

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) 4, 1, 2, 3
• Document immune status for HBV by history of hepatitis B vaccination and vaccine response 2, 3

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, 3
• The risk of HIV transmission from a percutaneous needlestick with HIV-infected blood is approximately 0.36% (3-4 per 1,000 exposures) 4, 1, 3
• PEP reduces this risk by approximately 81% when started promptly 1, 3
• The preferred regimen is bictegravir/emtricitabine/tenofovir alafenamide (single tablet once daily) for 28 days 1, 2, 3
• Completing the full 28-day course is essential—stopping early eliminates protection 1, 2, 3
• In clinical practice, 85.1% of exposed healthcare workers initiated HIV-PEP within 2 hours, and another 12.8% within 10 hours 6
• Monitor for drug toxicity every 2 weeks during the 28-day course with complete blood count and renal/hepatic function tests 2, 3

Hepatitis B Management

• If you are unvaccinated or incompletely vaccinated and the source is HBsAg-positive, administer Hepatitis B Immune Globulin (HBIG) 0.06 mL/kg intramuscularly as soon as possible, ideally within 24 hours 1, 2, 3
• Begin the hepatitis B vaccine series simultaneously 1, 2, 3
• The risk of HBV transmission without prophylaxis can exceed 30% after exposure to HBeAg-positive blood 4, 1, 3
• Healthcare workers who have been fully immunized and have protective antibody levels (anti-HBs >10 mIU/mL or >100 IU) have virtually zero risk of HBV transmission 4, 1

Hepatitis C Management

• No post-exposure prophylaxis exists for hepatitis C—early identification through testing is the primary approach 1, 2, 3
• The risk of HCV transmission is approximately 1.8% (range 0-7%) per percutaneous exposure 1, 3
• Baseline anti-HCV and ALT testing should be performed immediately 4, 1

Follow-Up Testing Schedule

• For HIV: Testing at baseline, 6 weeks, 3 months, and 6 months post-exposure 1, 2, 3
• For Hepatitis C: Baseline anti-HCV and ALT testing, then follow-up testing at 4-6 weeks and 4-6 months post-exposure 4, 1, 3
• For HCV RNA testing, perform at 4-6 weeks post-exposure if earlier diagnosis is desired 2, 3
• For Hepatitis B (if you received vaccine): Anti-HBs testing 1-2 months after the last vaccine dose 1
• In prospective studies, 97.4% of healthcare workers attended follow-up examinations 6

Precautions During Follow-Up Period

• Use barrier protection during sexual activity 1, 2, 3
• Do not donate blood, plasma, organs, tissue, or semen 1, 2, 3
• Seek immediate medical evaluation for any acute illness during the follow-up period—this may indicate acute retroviral syndrome 4, 1, 2, 3
• No modification of patient care responsibilities is necessary to prevent transmission to patients after an exposure 4, 2

Common Pitfalls to Avoid

• Failing to test the source patient when possible—this information is critical for risk assessment and management decisions 2
• Delaying HIV PEP beyond 72 hours—effectiveness drops dramatically after this window 1, 2, 3
• 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, 2, 3