What baseline laboratory tests and post‑exposure prophylaxis (PEP) medications should be given to a health‑care worker after a percutaneous needle‑prick injury?

Management of Needlestick Injuries in Healthcare Workers

After a needlestick injury, immediately wash the wound with soap and water, test the source patient for HBsAg, anti-HCV, and HIV antibody using rapid testing when possible, assess the exposed worker's hepatitis B immunity status, and initiate HIV post-exposure prophylaxis with bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) within 1-2 hours if the source is HIV-positive or unknown. 1, 2, 3

Immediate Wound Care

• Wash the puncture site thoroughly with soap and water and encourage bleeding from the wound. 1, 4
• Flush mucous membranes with water if splash exposure occurred. 1
• Do not delay care to determine source status—begin immediate decontamination first. 1

Source Patient Testing (Perform Immediately)

• Test the source patient for HBsAg, anti-HCV, and HIV antibody using rapid testing when available to guide prophylaxis decisions. 1
• Use fourth-generation HIV antigen/antibody combination tests for the most sensitive detection. 3, 5
• Do not test discarded needles or syringes for virus contamination—this is unreliable and delays appropriate care. 1, 3
• If the source is unknown, assess the epidemiologic risk of HBV, HCV, or HIV exposure based on the clinical setting. 1

Exposed Worker Baseline Testing

Immediate Assessment

• Perform a rapid or laboratory-based fourth-generation HIV antigen/antibody combination test on the exposed worker before initiating PEP to rule out pre-existing infection. 2, 3, 5
• Add HIV nucleic acid test (NAT) if the worker received long-acting injectable PrEP within the past 12 months. 3, 5
• Assess hepatitis B immunity status by reviewing vaccination history and prior anti-HBs titers. 1
• Obtain baseline renal function (creatinine, eGFR) before starting any tenofovir-based HIV PEP regimen. 2, 3
• Screen for other sexually transmitted infections at baseline. 5

HIV Post-Exposure Prophylaxis

Medication Regimen

• Initiate bictegravir 50mg/emtricitabine 200mg/tenofovir alafenamide 25mg (BIC/FTC/TAF) as a single tablet once daily for 28 days—this is the CDC's preferred first-line regimen. 2, 3, 5
• Alternative regimen: dolutegravir 50mg once daily PLUS emtricitabine 200mg/tenofovir alafenamide 25mg once daily for 28 days. 2, 3, 5
• Use tenofovir alafenamide (TAF) rather than tenofovir disoproxil fumarate (TDF) due to superior renal and bone safety. 2, 3, 5

Critical Timing

• Start PEP within 1-2 hours if possible, but no later than 72 hours post-exposure—efficacy decreases dramatically with each passing hour. 2, 3, 5
• Do not delay PEP initiation for source testing, risk assessment, or expert consultation—start immediately and adjust later if needed. 2, 3, 5

Duration and Adherence

• Complete the full 28-day course regardless of subsequent information about the source patient, as incomplete adherence significantly reduces effectiveness. 2, 3, 5
• Provide anti-emetics proactively to manage nausea and improve adherence. 3, 5
• Schedule follow-up visits or phone check-ins during the 28-day course to reinforce adherence and address side effects. 3, 5

Special Populations

• For renal impairment: Use TAF-based regimens exclusively due to minimal renal toxicity. 2, 3, 5
• For pregnancy: Do not withhold optimal PEP regimens—pregnancy is not a contraindication, though expert consultation is advised. 2, 3, 5
• For breastfeeding: Do not withhold PEP; counsel about temporary cessation during the 28-day course with expert guidance. 3

Hepatitis B Post-Exposure Prophylaxis

• For unvaccinated workers exposed to HBsAg-positive sources: Administer hepatitis B immunoglobulin (HBIG) and initiate the hepatitis B vaccine series immediately. 1, 4
• For vaccinated workers with known adequate anti-HBs response (≥10 mIU/mL): No treatment is needed. 1
• For vaccinated workers with inadequate or unknown response: Administer HBIG and a hepatitis B vaccine booster. 1, 4
• Test for anti-HBs 1-2 months after the last vaccine dose to confirm response (cannot be assessed if HBIG was given in the previous 3-4 months). 1

Hepatitis C Post-Exposure Management

• No post-exposure prophylaxis is recommended for HCV—no effective preventive medication exists. 1
• Perform baseline and follow-up anti-HCV and ALT testing at 4-6 months post-exposure. 1
• Perform HCV RNA at 4-6 weeks if earlier diagnosis is desired. 1
• Confirm repeatedly reactive anti-HCV enzyme immunoassays (EIAs) with supplemental tests. 1

Follow-Up Testing Schedule

HIV Follow-Up

• Within 72 hours: Clinical evaluation for drug toxicity and adherence assessment. 1, 2, 3, 5
• At 4-6 weeks: Fourth-generation HIV antigen/antibody test PLUS HIV nucleic acid test (NAT). 2, 3, 5
• At 12 weeks: Fourth-generation HIV antigen/antibody test PLUS HIV NAT to confirm absence of infection. 2, 3, 5
• Immediate testing if acute retroviral syndrome develops (fever, rash, lymphadenopathy, pharyngitis). 1, 3, 5

Monitoring for Drug Toxicity

• Monitor for adverse effects of antiretroviral PEP every 2 weeks through clinical evaluation and laboratory testing. 1
• Baseline and periodic monitoring should include complete blood count, renal function, and hepatic transaminases. 1

Counseling and Prevention of Secondary Transmission

• Advise the exposed worker to use barrier protection for sexual activity during the follow-up period. 1, 3, 5
• Instruct the worker to avoid blood or tissue donation during follow-up. 3, 5
• Provide counseling for emotional support and medication adherence. 1
• Seek immediate medical evaluation for any acute illness during follow-up, as this may indicate acute retroviral syndrome. 1, 2, 3, 5

Common Pitfalls to Avoid

• Never delay PEP while awaiting source testing or detailed risk assessment—start immediately and adjust later if the source is confirmed negative. 2, 3, 5
• Do not use two-drug HIV PEP regimens unless three-drug options are absolutely unavailable. 3, 5, 6
• Do not discontinue PEP early based on later source information—complete the full 28-day course. 2, 3, 5
• Do not withhold PEP from pregnant or breastfeeding workers—provide expert consultation concurrently, not as a prerequisite. 2, 3, 5

Expert Consultation Resources

• Contact the National Clinicians' Post-Exposure Prophylaxis Hotline (PEPline) at 1-888-448-4911 for complex cases, but do not delay PEP initiation while awaiting consultation. 2, 3
• Consult experts for drug-resistant source virus, pregnancy, renal/hepatic impairment, or concurrent medications with significant drug interactions. 1, 2