What is the management for a healthcare worker with a needle stick injury without an open wound, potentially exposing them to bloodborne pathogens such as Human Immunodeficiency Virus (HIV), hepatitis B, or hepatitis C?

Management of Needlestick Injury Without Open Wound

Treat this as a standard needlestick injury requiring immediate action—the absence of a visible open wound does not eliminate bloodborne pathogen transmission risk, and you must initiate the same urgent protocol within 1 hour. 1, 2

Immediate First Aid (Within Minutes)

• Wash the puncture site thoroughly with soap and water immediately—do not squeeze or apply pressure to increase bleeding, as this does not reduce transmission risk and may cause additional tissue damage. 1, 2, 3
• Document the exact time of injury immediately, as timing is critical for determining post-exposure prophylaxis (PEP) eligibility—HIV PEP must start within 72 hours, with effectiveness dropping dramatically after this window. 1, 2
• Do not recap, bend, or break the needle after the injury occurs. 1, 3

Emergency Reporting and Evaluation (Within 1 Hour)

• Report to your supervisor immediately and seek emergency medical evaluation within 1 hour—this is non-negotiable because HIV PEP should ideally start within the first hour for maximum effectiveness. 1, 2, 3
• Document the following details: date and time of injury, type of device involved, depth of penetration, source patient details (if known), and condition of your skin at the injury site. 1, 2
• Identify and test the source patient immediately for HIV antibody (rapid testing preferred), hepatitis B surface antigen (HBsAg), and hepatitis C antibody (anti-HCV) to guide prophylaxis decisions. 2, 3

HIV Post-Exposure Prophylaxis

Start HIV PEP immediately if you present within 72 hours, even before confirming the source patient's HIV status—this is a percutaneous exposure with potential HIV transmission risk of approximately 0.36% (3-4 per 1,000 exposures), which PEP reduces by approximately 81%. 1, 2, 3

PEP Regimen Details:

• Preferred regimen: Bictegravir/emtricitabine/tenofovir alafenamide (single tablet once daily) for 28 days. 1, 2
• Alternative regimens: Dolutegravir plus tenofovir alafenamide (or tenofovir disoproxil fumarate) plus emtricitabine (or lamivudine). 2
• Complete the full 28-day course—stopping early completely eliminates protection against HIV transmission. 1, 2, 3
• Monitor for drug toxicity every 2 weeks during the PEP 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 (or unknown status):

• Administer hepatitis B immune globulin (HBIG) 0.06 mL/kg intramuscularly as soon as possible, ideally within 24 hours—the risk of HBV transmission without prophylaxis can exceed 30% after exposure to HBeAg-positive blood. 1, 3
• Begin the hepatitis B vaccine series immediately if not previously vaccinated. 1, 3

If you are vaccinated with documented protective antibody levels (anti-HBs >10 mIU/mL):

• No additional prophylaxis is needed—you have virtually zero risk of HBV transmission. 1

Hepatitis C Management

No post-exposure prophylaxis exists for hepatitis C—the management strategy focuses on early identification through testing, with HCV transmission risk of approximately 1.8% (range 0-7%) per percutaneous exposure. 1, 2, 3

• Baseline testing: Anti-HCV antibody and alanine aminotransferase (ALT) immediately. 1, 3
• Follow-up testing: Anti-HCV and ALT at 4-6 weeks and 4-6 months post-exposure; consider HCV RNA testing at 4-6 weeks for earlier diagnosis if seroconversion is suspected. 1, 2
• If HCV seroconversion occurs, refer immediately to a hepatology specialist for evaluation of early antiviral therapy—limited data suggest treatment may be beneficial when started early in acute HCV infection. 4

Baseline and Follow-Up Testing Protocol

Baseline Testing (Before Starting Prophylaxis):

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

Follow-Up Testing Schedule:

• HIV testing: At 6 weeks, 3 months, and 6 months post-exposure 1, 2, 3
• Hepatitis C testing: At 4-6 weeks and 4-6 months post-exposure 1, 2, 3
• Hepatitis B testing (if you received vaccine): Anti-HBs testing 1-2 months after the last vaccine dose 1

Precautions During 6-Month Follow-Up Period

• Use barrier protection during sexual activity throughout the follow-up period. 1, 2, 3
• Do not donate blood, plasma, organs, tissue, or semen during this time. 1, 2, 3
• Seek immediate medical evaluation for any acute illness—fever, rash, lymphadenopathy, or flu-like symptoms may indicate acute retroviral syndrome or acute hepatitis. 1, 2, 3

Critical Pitfalls to Avoid

The most common error is delaying evaluation because "there's no visible wound"—percutaneous injuries transmit bloodborne pathogens regardless of wound visibility, and the 72-hour window for HIV PEP is absolute. 1, 2

Do not wait for source patient test results before starting HIV PEP—begin immediately for substantial exposures and discontinue later if the source tests negative. 1, 2

Do not assume vaccination protects against hepatitis B without documented antibody levels—non-responders to vaccination require HBIG after exposure. 1, 3