What is the appropriate management protocol for a healthcare worker after a needle‑stick injury, including immediate care, reporting, testing, HIV post‑exposure prophylaxis, hepatitis B prophylaxis, and hepatitis C follow‑up?

Needlestick Injury Protocol

Immediately wash the puncture site with soap and water without squeezing, report within 1 hour, and initiate HIV post-exposure prophylaxis within 72 hours if indicated—effectiveness drops dramatically after this window. 1

Immediate First Aid (Within Minutes)

• Wash wounds and skin sites thoroughly with soap and water—do not squeeze or apply pressure to increase bleeding, as there is no evidence this reduces transmission risk 2
• Flush mucous membranes with water if blood splashes into eyes, nose, or mouth 2, 1
• Never recap, bend, or break the needle after injury 1, 3
• Do not apply caustic agents (e.g., bleach) or inject antiseptics/disinfectants into the wound—these are not recommended 2
• Antiseptics may be used for wound care but are not required and do not provide additional protection 2

Immediate Reporting and Documentation (Within 1 Hour)

• Report to your supervisor immediately and document in your confidential medical record 2, 1
• Record the following details: 2
  • Date and time of exposure
  • Type of device involved and depth of injury
  • Type and amount of fluid/material exposed to
  • Severity of exposure (percutaneous depth, whether fluid was injected, volume and duration of contact)
  • Condition of skin (intact, chapped, abraded)
  • Details about the source patient (HIV status, stage of disease, antiretroviral therapy history, viral load if known)

Source Patient Evaluation (Within 1-2 Hours)

• Test the source patient immediately for HBsAg, anti-HCV, and HIV antibody 2, 1
• Consider rapid HIV testing to expedite decision-making about post-exposure prophylaxis 2, 4
• Do not test discarded needles or syringes for virus contamination—results are unreliable and not recommended 2, 4
• If the source is unknown (e.g., from garbage bags), assess risk based on the clinical setting and prevalence of bloodborne pathogens 5

Baseline Testing for Exposed Healthcare Worker

• Perform baseline testing before starting prophylaxis: 2, 1
  • HIV antibody or antigen/antibody combination test
  • Hepatitis B serology (HBsAg, anti-HBs, anti-HBc)
  • Hepatitis C antibody (anti-HCV)
  • Liver function tests (ALT)
• Document hepatitis B vaccination history and vaccine response 2
• Offer pregnancy testing to women of childbearing age whose pregnancy status is unknown 4

HIV Post-Exposure Prophylaxis (Within 72 Hours)

Timing is critical—PEP must be started as soon as possible, ideally within the first hour and absolutely within 72 hours. 1, 3

When to Initiate HIV PEP:

• Start immediately for percutaneous injuries involving blood, visibly bloody fluid, or other potentially infectious fluids (semen, vaginal secretions, cerebrospinal, synovial, pleural, peritoneal, pericardial, amniotic fluids) 2
• Start for mucous membrane exposures to the same fluids 2
• Start for non-intact skin exposures (dermatitis, abrasion, open wound) with direct contact to infectious fluids 2
• Start even before confirming the source's HIV status for substantial exposures 1, 3
• The baseline risk of HIV transmission from a percutaneous needlestick is approximately 0.36% (3-4 per 1,000 exposures) 3, 4
• PEP reduces this risk by approximately 81% when started promptly 3

Preferred HIV PEP Regimen:

• Bictegravir/emtricitabine/tenofovir alafenamide (single tablet once daily) for 28 days 1, 3
• Alternative basic regimen (from older guidelines): Zidovudine (ZDV) 600 mg/day in 2-3 divided doses + Lamivudine (3TC) 150 mg twice daily (available as Combivir) 2
• Completing the full 28-day course is essential—stopping early eliminates protection 1, 3

Monitoring During PEP:

• Evaluate within 72 hours after starting PEP and monitor for drug toxicity for at least 2 weeks 2
• Perform complete blood count and renal/hepatic function tests every 2 weeks during the 28-day course 1, 4

Hepatitis B Management

For Unvaccinated or Incompletely Vaccinated Healthcare Workers:

• If source is HBsAg-positive: Administer Hepatitis B Immune Globulin (HBIG) 0.06 mL/kg intramuscularly as soon as possible, ideally within 24 hours 1, 3
• Begin the hepatitis B vaccine series simultaneously 2, 1
• The risk of HBV transmission without prophylaxis can exceed 30% after exposure to HBeAg-positive blood 3, 4

For Previously Vaccinated Healthcare Workers:

• If anti-HBs is >10 mIU/mL (protective level): No treatment necessary 4
• If anti-HBs is <10 mIU/mL: Administer HBIG and a booster dose of hepatitis B vaccine 5
• Test for anti-HBs 1-2 months after the last vaccine dose 2
• Note that anti-HBs response cannot be accurately determined if HBIG was received in the previous 3-4 months 2, 4

Hepatitis C Management

• No post-exposure prophylaxis exists for hepatitis C—early identification through testing is the primary approach 2, 1, 3
• The average risk of HCV transmission after needlestick from a confirmed positive source is approximately 1.8% (range 0-7%) 1, 3, 4
• If HCV seroconversion occurs, refer immediately to a hepatology specialist for evaluation of early antiviral therapy 3

Follow-Up Testing Schedule

HIV Follow-Up:

• Perform HIV-antibody testing at baseline, 6 weeks, 3 months, and 6 months post-exposure 2, 1, 4
• Perform additional HIV antibody testing if illness compatible with acute retroviral syndrome occurs 2, 4

Hepatitis C Follow-Up:

• Perform baseline and follow-up testing for anti-HCV and ALT at 4-6 months after exposure 2, 1, 4
• Perform HCV RNA testing at 4-6 weeks if earlier diagnosis of HCV infection is desired 2, 1, 4
• Confirm repeatedly reactive anti-HCV enzyme immunoassays (EIAs) with supplemental tests 2, 4

Hepatitis B Follow-Up:

• For those who receive hepatitis B vaccine, perform follow-up anti-HBs testing 1-2 months after the last dose 2, 4

Precautions During Follow-Up Period

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

Special Considerations

If Source Patient is HIV-Negative:

• If the source is seronegative for HIV with no clinical evidence of AIDS or symptoms: No further HIV testing of the source is indicated 1
• Baseline testing or further follow-up of the healthcare worker normally is not necessary 1
• Exception: If the source has recently (within 3-6 months) engaged in high-risk behaviors (injecting drug use, unprotected sex with multiple partners, receipt of blood products before 1985), consider baseline and follow-up HIV testing at 3 and/or 6 months 1

For Pregnant Healthcare Workers:

• ZDV + 3TC (Combivir) is probably a safe regimen for pregnant healthcare workers 2
• Close monitoring of glucose levels is recommended if protease inhibitors are used, as they may exacerbate pregnancy-associated hyperglycemia 2

Common Pitfalls to Avoid

• Delaying HIV PEP beyond 72 hours—effectiveness drops dramatically after this window 1, 3
• Failing to test the source patient when possible—this information is critical for risk assessment and management decisions 1, 4
• Inadequate follow-up testing—ensure a system is in place to encourage exposed healthcare workers to return for all scheduled follow-up tests 1, 4
• Incomplete PEP course—stopping HIV PEP early eliminates protection 1, 3
• Squeezing the wound or applying caustic agents—these practices are not recommended and may cause harm 2