How should I risk‑stratify and manage a needlestick injury, including exposure history, source patient infectious status, hepatitis B immunity, and post‑exposure prophylaxis for human immunodeficiency virus, hepatitis B virus, and hepatitis C virus?

Risk Stratification and Management of Needlestick Injury

Immediately wash the puncture site with soap and water without squeezing, report within 1 hour, test both source and exposed worker for HIV/HBV/HCV, and initiate HIV post-exposure prophylaxis within 72 hours if the source is positive or unknown—hepatitis B poses the highest transmission risk at 30% for HBeAg-positive sources compared to 0.36% for HIV and 1.8% for HCV. 1, 2

Immediate First Aid (Within Minutes)

• Wash the puncture site thoroughly with soap and water—never squeeze or apply pressure to increase bleeding, as this does not reduce transmission risk. 1, 2
• If blood splashes into eyes, nose, or mouth, flush immediately with clean water or saline. 1, 2
• Do not apply caustic agents like bleach or inject antiseptics into the wound—these are not recommended and provide no benefit. 1, 2
• Never recap, bend, or break the needle after injury. 1, 2

Reporting and Documentation (Within 1 Hour)

• Report to your supervisor immediately and document the exact time of injury—timing is critical for PEP eligibility. 1, 2
• Record comprehensive exposure details: date/time, device type, depth of injury, visible blood, body fluid involved, source patient information, and skin condition (intact vs. non-intact). 1, 3

Risk Stratification by Pathogen

Hepatitis B Virus (Highest Risk)

• Transmission risk from HBeAg-positive blood is approximately 30% without prophylaxis—this is 100-fold higher than HIV risk. 4, 2
• HBeAg-positive status is the single most important predictor of HBV transmission. 2
• If you have documented hepatitis B immunity (anti-HBs ≥10 mIU/mL), your risk is virtually zero and no prophylaxis is needed. 3

HIV (Moderate Risk)

• Transmission risk is approximately 0.36% (3-4 per 1,000 exposures) from percutaneous injury with HIV-infected blood. 4, 2
• HIV PEP reduces this risk by approximately 81% when started promptly. 2

Hepatitis C Virus (Intermediate Risk)

• Average transmission risk is 1.8% (range 0-7%) per percutaneous exposure to HCV-positive blood. 1, 3
• No post-exposure prophylaxis exists—early identification through testing is the only strategy. 1, 2

Source Patient Evaluation (Within 1-2 Hours)

• Test the source patient immediately for HIV antibody (or antigen/antibody combination), hepatitis B surface antigen (HBsAg), and hepatitis C antibody (anti-HCV). 4, 1
• Consider rapid HIV testing to expedite PEP decisions—results can be available within 20 minutes. 1, 3
• Never test discarded needles or syringes for viral contamination—results are unreliable and not recommended. 1, 3

Baseline Testing for Exposed Worker

• Perform baseline testing before starting any prophylaxis: HIV antibody or antigen/antibody combination, hepatitis B serology (HBsAg, anti-HBs, anti-HBc), hepatitis C antibody (anti-HCV), and liver function tests (ALT). 1, 3
• Document hepatitis B vaccination history and prior vaccine response. 1, 3
• Offer pregnancy testing to all women of childbearing age whose pregnancy status is unknown. 3

HIV Post-Exposure Prophylaxis (Initiate Within 72 Hours)

When to Start PEP

• Start PEP immediately for percutaneous injuries involving blood or potentially infectious fluids (semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, amniotic fluid) from an HIV-positive or unknown source. 1
• Start PEP for mucous membrane exposure to these same fluids. 1
• Start PEP for non-intact skin exposure (dermatitis, abrasion, open wound) with direct contact to infectious fluids. 1
• Effectiveness drops dramatically after 72 hours—this is an absolute deadline. 1, 2

Preferred Regimen

• Bictegravir/emtricitabine/tenofovir alafenamide (single tablet once daily) for 28 days. 1, 2
• Completing the full 28-day course is essential—stopping early eliminates protection. 1, 2

Monitoring During PEP

• Evaluate within 72 hours of starting PEP and monitor for drug toxicity every 2 weeks with complete blood count and renal/hepatic function tests. 1, 3

Hepatitis B Management

For Unvaccinated or Incompletely Vaccinated 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, 2
• Begin the hepatitis B vaccine series simultaneously at a separate injection site. 1, 2

For Previously Vaccinated Workers

• If anti-HBs ≥10 mIU/mL (documented immunity): no treatment needed. 3
• If anti-HBs <10 mIU/mL: give HBIG 0.06 mL/kg plus one vaccine booster dose. 3
• Test anti-HBs 1-2 months after the final vaccine dose to confirm protective immunity. 1, 3

Hepatitis C Management

• No post-exposure prophylaxis exists for hepatitis C. 1, 2
• If HCV seroconversion occurs, refer immediately to a hepatology specialist for evaluation of early antiviral therapy. 2

Follow-Up Testing Schedule

HIV

• Perform HIV antibody testing at baseline, 6 weeks, 3 months, and 6 months post-exposure. 1, 3
• Add an extra HIV test if symptoms compatible with acute retroviral syndrome develop (fever, rash, lymphadenopathy, fatigue). 1, 3

Hepatitis C

• Obtain baseline anti-HCV and ALT, then repeat at 4-6 months post-exposure. 1, 3
• For earlier diagnosis, perform HCV RNA testing at 4-6 weeks post-exposure. 1, 3
• Confirm any repeatedly reactive anti-HCV enzyme immunoassay with supplemental testing. 1, 3

Hepatitis B

• For workers who receive hepatitis B vaccination after exposure, test anti-HBs 1-2 months after the final dose. 1, 3
• Anti-HBs results are unreliable if HBIG was administered within the preceding 3-4 months. 3

Precautions During Follow-Up Period

• No modification of patient care duties is required after exposure to HBV, HCV, or HIV. 4, 1
• Use barrier protection during sexual activity. 1, 2
• Do not donate blood, plasma, organs, tissue, or semen. 1, 2
• Seek immediate medical evaluation for any acute illness during follow-up—this may indicate acute retroviral syndrome or acute hepatitis. 1, 3

Special Considerations for Unknown Source

• When the source cannot be identified (e.g., needle found in hospital garbage or on a beach), classify as high-risk unknown source and initiate presumptive treatment without delay. 3
• Start HIV PEP within 72 hours for unknown-source exposures, especially when the needle is visibly blood-stained. 3
• Administer HBIG and begin hepatitis B vaccine series if unvaccinated or incompletely vaccinated. 3

Common Pitfalls to Avoid

• Squeezing the wound or applying caustic agents—these practices are not recommended and may cause harm. 1, 2
• Delaying HIV PEP beyond 72 hours—effectiveness drops dramatically after this window. 1, 2
• Failing to test the source patient when possible—this information is critical for risk assessment and management decisions. 1, 3
• Inadequate follow-up testing—ensure a system is in place to encourage exposed workers to return for all scheduled follow-up tests. 1, 3
• Assuming no risk because the source is unknown—management should proceed as if exposure occurred. 3
• Testing discarded needles for viral contamination—this is not recommended and results are unreliable. 1, 3