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

Hospital Needle Injury Protocol

Immediately wash the puncture site with soap and water, report to your supervisor within 1 hour, and seek emergency medical evaluation to initiate HIV post-exposure prophylaxis (PEP) within 72 hours if indicated—timing is critical as PEP 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 3, 1, 2
• If blood splashes into eyes, nose, or mouth, flush immediately with clean water, saline, or sterile irrigants 3, 1
• Never recap, bend, or break the needle after injury 2, 4
• Document the exact time of injury immediately—this is critical for determining PEP eligibility 1, 2, 4

Reporting and Documentation (Within 1 Hour)

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

Source Patient Assessment (Within 1-2 Hours)

• Identify the source patient if possible and obtain rapid testing for HIV antibody, hepatitis B surface antigen (HBsAg), and hepatitis C antibody (anti-HCV) 3, 1, 2
• FDA-approved rapid HIV testing methods should be used to expedite decision-making about post-exposure prophylaxis 3, 2
• If the source cannot be identified, base management decisions on the likelihood of exposure considering the source of the needle and type of exposure 3

Baseline Testing for Exposed Worker

• Perform baseline testing before starting any prophylaxis: HIV antibody or antigen/antibody combination test, hepatitis B serology (anti-HBs), hepatitis C antibody (anti-HCV), and liver function tests 1, 2
• Document hepatitis B vaccination history and immune response status 3, 2

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—this is non-negotiable. 1, 2, 4

Risk Context

• The risk of HIV transmission from a percutaneous needlestick with HIV-infected blood is approximately 0.36% (3-4 per 1,000 exposures) 1, 4
• PEP reduces this risk by approximately 81% when started promptly 1, 4
• Effectiveness drops dramatically after 72 hours, making time the most critical factor 3, 1, 2, 4

PEP Regimen

• The preferred regimen is bictegravir/emtricitabine/tenofovir alafenamide (single tablet once daily) for 28 days 1, 2, 4
• Alternative regimen: 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, 2, 4
• Monitor for drug toxicity every 2 weeks during the 28-day course with complete blood count and renal/hepatic function tests 2

Hepatitis B Management

The approach depends entirely on your vaccination status and the source patient's HBsAg status. 3

If You Are Unvaccinated or Incompletely Vaccinated:

• Source HBsAg-positive: Administer HBIG (0.06 mL/kg; maximum dose: 5 mL) intramuscularly as soon as possible, ideally within 24 hours, AND begin hepatitis B vaccine series immediately 3, 1, 2, 4
• Source HBsAg-negative: Begin hepatitis B vaccine series 3
• Source not tested or unknown: Begin hepatitis B vaccine series 3

If You Were Vaccinated and Responded (anti-HBs >10 mIU/mL):

• No treatment is necessary regardless of source status 3

If You Were Vaccinated but Did Not Respond:

• Source HBsAg-positive: HBIG immediately and in 1 month OR HBIG and initiate reimmunization 3
• Source HBsAg-negative: No treatment 3
• Source not tested or unknown: If high-risk source, consider HBIG or HBIG and HBV reimmunization as for HBsAg-positive source 3

If You Were Vaccinated but Response Is Unknown:

• Source HBsAg-positive: Test exposed worker for anti-HBs immediately; if positive, no treatment; if negative, give 1 dose of HBIG and 1 dose of vaccine, then retest for anti-HBs 4-6 months later 3

Risk Context

• The risk of HBV transmission without prophylaxis can exceed 30% after exposure to HBeAg-positive blood—this is dramatically higher than HIV risk 3, 4
• Vaccinated workers with protective antibody levels (anti-HBs >10 mIU/mL) have virtually zero risk of HBV transmission 4

Hepatitis C Management

No post-exposure prophylaxis exists for hepatitis C—early identification through testing is the only approach. 1, 2, 4

• The risk of HCV transmission is approximately 1.8% (range 0-7%) per percutaneous exposure 1, 4
• If HCV seroconversion occurs, refer immediately to a hepatology specialist for evaluation of early antiviral therapy, as treatment may be beneficial when started early in acute HCV infection 4

Follow-Up Testing Schedule

HIV Testing:

• Baseline testing before starting PEP, then at 6 weeks, 3 months, and 6 months post-exposure 3, 1, 2, 4

Hepatitis C Testing:

• Baseline anti-HCV and ALT testing, then at 4-6 weeks and 4-6 months post-exposure 3, 1, 4
• HCV RNA testing at 4-6 weeks if earlier diagnosis is desired 2

Hepatitis B Testing:

• If you received the vaccine series, test for anti-HBs 1-2 months after the last vaccine dose 1, 4

Precautions During Follow-Up Period

• Use barrier protection during sexual activity for 6 months post-exposure 1, 4
• Do not donate blood, plasma, organs, tissue, or semen during the 6-month follow-up period 1, 2, 4
• Seek immediate medical evaluation for any acute illness during follow-up—this may indicate acute retroviral syndrome 1, 4
• No modification of patient care responsibilities is necessary 2

Common Pitfalls to Avoid

• Delaying HIV PEP beyond 72 hours—this is the most critical error as effectiveness drops dramatically after this window 1, 2, 4
• 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 workers to return for all scheduled follow-up tests 2
• Squeezing or applying pressure to increase bleeding at the puncture site—this is not recommended 3, 1, 2
• Recapping needles, which accounts for a significant proportion of needlestick injuries 5