What baseline serologic tests and prophylactic measures are indicated for a health‑care worker after a percutaneous needle‑stick injury, including management of hepatitis B (HBV), human immunodeficiency virus (HIV), and hepatitis C (HCV)?

Management of Needlestick Injury: Baseline Testing and Prophylaxis

Immediately wash the puncture site with soap and water without squeezing, report within 1 hour, test both source and exposed worker for HIV, HBV, and HCV within 1-2 hours, and initiate HIV post-exposure prophylaxis within 72 hours (ideally within 1 hour) if the source is positive or unknown. 1, 2

Immediate First Aid (Within Minutes)

• Wash the wound thoroughly with soap and water—do not squeeze or apply pressure to increase bleeding, as this provides no protective benefit. 1, 2, 3
• If blood splashes into eyes, nose, or mouth, flush immediately with clean water, saline, or sterile irrigants. 1, 2, 3
• Never apply caustic agents (bleach) or inject antiseptics into the wound—these are not recommended and provide no benefit. 2, 3
• Do not recap, bend, or break the needle after injury. 2, 3

Reporting and Documentation (Within 1 Hour)

• Report to your supervisor immediately and document the exact time of injury, type of device, depth of puncture, visibility of blood, body fluid involved, source patient details, and skin condition (intact vs. non-intact). 1, 2, 3
• Timing is critical because HIV post-exposure prophylaxis must be started within 72 hours, with effectiveness declining dramatically after this window. 1, 2

Source Patient Testing (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). 1, 2
• Consider rapid HIV testing to expedite post-exposure prophylaxis decisions. 1, 2
• Do not test discarded needles or syringes for viral contamination—the reliability and interpretation of such findings are unknown. 1, 3
• If the source cannot be identified, assess the exposure epidemiologically based on the prevalence of bloodborne pathogens in that setting (e.g., AIDS unit vs. nursing home) and the type of device (blood-filled hollow needle vs. injection needle). 1

Baseline Testing of Exposed Healthcare Worker

Perform baseline serologic testing before initiating any prophylaxis: 1, 2

• HIV antibody or antigen/antibody combination test 1, 2
• Hepatitis B serology: HBsAg, anti-HBs (to document immunity), and anti-HBc 1, 2, 4
• Hepatitis C antibody (anti-HCV) 1, 2
• Liver function tests (ALT) 1, 2
• Document hepatitis B vaccination history and prior vaccine response (anti-HBs ≥10 mIU/mL indicates protective immunity). 1, 2, 4
• Pregnancy testing should be offered to all women of childbearing age whose pregnancy status is unknown, as this influences HIV post-exposure prophylaxis drug selection. 1, 2, 3

HIV Post-Exposure Prophylaxis (Initiate Within 72 Hours)

When to Start HIV PEP

• Start immediately for percutaneous injuries involving blood or other potentially infectious fluids (semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, amniotic fluid) from an HIV-positive or unknown-status source. 1, 2
• Start for mucous membrane exposure to the same fluids. 2
• Start for non-intact skin exposure (dermatitis, abrasion, open wound) with direct contact to infectious fluids. 2
• The risk of HIV transmission from a percutaneous needlestick with HIV-infected blood is approximately 0.3-0.36% (3-4 per 1,000 exposures), but post-exposure prophylaxis reduces this risk by approximately 81%. 2, 3, 5

Preferred HIV PEP Regimen

• Bictegravir/emtricitabine/tenofovir alafenamide (single tablet once daily) for 28 days is the preferred regimen. 2, 3
• Older guidelines recommended zidovudine (ZDV) 600 mg/day in 2-3 divided doses plus lamivudine (3TC) 150 mg twice daily (Combivir) as an alternative basic regimen. 2
• Completing the full 28-day course is essential—stopping early eliminates protection. 2, 3

Monitoring During HIV PEP

• Evaluate the worker within 72 hours of starting post-exposure prophylaxis and monitor for drug toxicity every 2 weeks during the 28-day course with complete blood count and renal/hepatic function tests. 2
• Inform the healthcare worker that only zidovudine has been proven to prevent HIV transmission in humans, that data on other antiretroviral drugs are limited, and that any or all drugs may be declined. 1

Special Considerations

• For pregnant healthcare workers, a regimen of zidovudine plus lamivudine (Combivir) is considered probably safe. 2
• If protease inhibitors are used in pregnancy, monitor glucose levels closely due to risk of exacerbating pregnancy-associated hyperglycemia. 2

Hepatitis B Management

Unvaccinated or Incompletely Vaccinated

If the source is HBsAg-positive: 1, 2, 4

• Administer hepatitis B immune globulin (HBIG) 0.06 mL/kg intramuscularly as soon as possible, ideally within 24 hours (but still effective up to 7 days). 1, 2, 4
• Begin the hepatitis B vaccine series simultaneously at a separate anatomic site. 1, 2, 4
• The risk of HBV transmission without prophylaxis can exceed 30% after exposure to HBeAg-positive blood—approximately 100-fold higher than HIV risk. 2, 3

If the source is HBsAg-negative: 1

• Begin the hepatitis B vaccine series; no HBIG is needed. 1

If the source is not tested or unknown: 1

• Begin the hepatitis B vaccine series. 1
• If the source is high-risk, consider HBIG or HBIG plus vaccine as for HBsAg-positive source. 1

Previously Vaccinated with Documented Immunity (Anti-HBs ≥10 mIU/mL)

• No treatment is necessary, regardless of source status. 1, 2, 4

Previously Vaccinated but Did Not Respond (Anti-HBs <10 mIU/mL)

If the source is HBsAg-positive: 1

• Give HBIG 0.06 mL/kg immediately and a second dose of HBIG in 1 month, or HBIG and initiate revaccination. 1, 4

If the source is HBsAg-negative: 1

• No treatment is needed. 1

If the source is not tested or unknown and high-risk: 1

• Consider HBIG or HBIG plus HBV revaccination as for HBsAg-positive source. 1

Previously Vaccinated but Response Unknown

If the source is HBsAg-positive: 1, 4

• Test the exposed worker for anti-HBs immediately; if positive (≥10 mIU/mL), no treatment is needed. 1, 4
• If negative (<10 mIU/mL), give 1 dose of HBIG (0.06 mL/kg) and 1 dose of hepatitis B vaccine at separate sites immediately, without waiting for results. 1, 4
• Retest for anti-HBs 4-6 months after HBIG administration (not 1-2 months) to avoid detecting passively transferred antibodies. 1, 4

Critical Timing for HBIG

• HBIG effectiveness declines markedly after 7 days for percutaneous exposure and after 14 days for sexual exposure. 4
• Do not withhold HBIG solely because more than 24 hours have passed—protective activity persists through the first week after percutaneous exposure. 4

Hepatitis C Management

• No post-exposure prophylaxis exists for hepatitis C—early identification through testing is the primary approach. 1, 2, 3
• The average risk of HCV transmission after needlestick from a confirmed positive source is approximately 1.8% (range 0-7%). 2, 3
• If HCV seroconversion occurs, refer immediately to a hepatology specialist for evaluation of early antiviral therapy, as limited data suggest treatment may be beneficial when started early in acute HCV infection. 3

Follow-Up Testing Schedule

HIV

• Perform HIV antibody (or antigen/antibody combination) testing at baseline, 6 weeks, 3 months, and 6 months post-exposure. 1, 2, 3
• If the source person is seronegative for HIV and has no clinical evidence of AIDS or symptoms of HIV infection, baseline testing or further follow-up of the healthcare worker normally is not necessary. 1, 2
• If the source person has recently (within the last 3-6 months) engaged in high-risk behaviors for HIV transmission (injecting drug use, sexual contact with HIV-positive partner, unprotected sex with multiple partners), baseline and follow-up HIV-antibody testing at 3 and/or 6 months post-exposure should be considered. 2
• Add an extra HIV test if the worker develops symptoms compatible with acute retroviral syndrome (fever, rash, lymphadenopathy, myalgia). 2

Hepatitis C

• Obtain baseline anti-HCV antibody and ALT testing at the time of exposure. 1, 2
• Perform follow-up anti-HCV antibody and ALT testing at 4-6 months post-exposure. 1, 2, 3
• If earlier diagnosis is desired, perform HCV RNA testing at 4-6 weeks post-exposure. 1, 2
• Confirm any repeatedly reactive anti-HCV EIA with supplemental testing. 2

Hepatitis B

• For workers who receive hepatitis B vaccination after exposure, test anti-HBs 1-2 months after the final vaccine dose (if HBIG was not given). 1, 2, 4
• If HBIG was administered, delay anti-HBs testing until 4-6 months after HBIG to avoid detecting passively acquired antibodies. 1, 2, 4

Precautions During Follow-Up Period

• No modification of patient-care duties is required after exposure to HBV, HCV, or HIV—healthcare workers do not need to take any special precautions to prevent secondary transmission during the follow-up period. 1, 2, 3
• Use barrier protection during sexual activity. 2, 3
• Do not donate blood, plasma, organs, tissue, or semen. 2, 3
• Seek immediate medical evaluation for any acute illness during the follow-up period, as this may indicate acute retroviral syndrome. 1, 2, 3

Management When Source Is Unknown

• Treat the exposure as high-risk and initiate presumptive HIV post-exposure prophylaxis and HBV prophylaxis (HBIG and vaccine series) without delay. 2, 3
• Base decisions on the epidemiologic likelihood of exposure: an injury in a geographic area where injecting-drug use is prevalent or on an AIDS unit suggests higher risk than one in a nursing home for the elderly. 1
• A blood-filled hollow needle or visibly bloody device suggests higher-risk exposure than a needle likely used for giving an injection. 1

Common Pitfalls to Avoid

• Failing to test the source patient when possible—this information is critical for risk assessment and management decisions. 2
• Delaying HIV post-exposure prophylaxis beyond 72 hours—effectiveness drops dramatically after this window. 1, 2, 3
• Inadequate follow-up testing—ensure a system is in place to encourage exposed healthcare workers to return for all scheduled follow-up tests. 2
• Not completing the full 28-day HIV post-exposure prophylaxis course—stopping early eliminates protection. 2, 3
• Assuming immunity without documented serologic testing after hepatitis B vaccination. 4
• Not recognizing that persons with documented immunity (anti-HBs ≥10 mIU/mL) do not require HBIG after exposure. 4
• Withholding HBIG solely because more than 24 hours have passed—it remains effective up to 7 days for percutaneous exposure. 4
• Squeezing the wound or applying caustic agents—these practices are not recommended and provide no benefit. 1, 2, 3