What is the recommended immediate and follow‑up management for a health‑care worker who sustains a needlestick injury, including wound care, reporting, baseline serologic testing, human immunodeficiency virus (HIV) post‑exposure prophylaxis, hepatitis B virus (HBV) immunoglobulin and vaccination, hepatitis C virus (HCV) monitoring, tetanus prophylaxis, and follow‑up schedule?

Management of Needlestick Injuries

Immediate Wound Care

Immediately wash wounds and skin sites that contacted blood or body fluids with soap and water; flush mucous membranes with water. 1, 2

• Antiseptics may be used for wound care but are not required, as there is no evidence they further reduce HIV transmission risk 1
• Do NOT apply caustic agents (e.g., bleach) or inject antiseptics/disinfectants into the wound 1
• Do NOT express fluid by squeezing the wound 1
• Encourage bleeding from the wound site 3

Immediate Reporting and Documentation

Report the exposure immediately—HIV post-exposure prophylaxis (PEP) is most effective when started as soon as possible after exposure, ideally within hours. 1

Document the following in the healthcare worker's confidential medical record 1:

• Date and time of exposure
• Details of the procedure and how the exposure occurred
• Type and amount of fluid/material involved
• Severity of exposure (depth of injury for percutaneous exposures; volume and duration for mucous membrane exposures; skin condition for skin exposures)
• Source patient information (HIV, HBV, HCV status if known; if HIV-positive, viral load and antiretroviral therapy history)
• Details of counseling, management, and follow-up plan

Risk Assessment

Evaluate whether the exposure poses a risk for bloodborne pathogen transmission based on the type of body substance and route of exposure. 1, 2

High-risk exposures requiring further evaluation include 1:

• Percutaneous injury (needlestick or other sharps) with blood, visibly bloody fluid, or other potentially infectious fluids (semen, vaginal secretions, cerebrospinal, synovial, pleural, peritoneal, pericardial, or amniotic fluids)
• Mucous membrane contact with these fluids
• Non-intact skin (dermatitis, abrasion, open wound) contact with these fluids
• Prolonged or large-area intact skin contact (evaluate case-by-case)

Source Patient Testing

Test the source patient immediately for HBsAg, anti-HCV antibodies, and HIV antibodies (rapid antigen/antibody test preferred). 4, 2

• Use available medical record information (laboratory results, diagnosis, history) to assess infection risk 1
• Do NOT test discarded needles or syringes for viral contamination—results are unreliable 4, 2

Baseline Testing of Exposed Healthcare Worker

Obtain baseline testing immediately 4, 2:

• HIV antibody test (fourth-generation antigen/antibody test preferred)
• Anti-HCV antibodies
• Alanine aminotransferase (ALT)
• Document hepatitis B vaccination history and prior anti-HBs titers

Hepatitis B Post-Exposure Prophylaxis

For unvaccinated workers exposed to HBsAg-positive or unknown source, administer hepatitis B immune globulin (HBIG) as soon as possible AND initiate hepatitis B vaccine series simultaneously. 2

• For vaccinated workers with known adequate anti-HBs response: no treatment needed
• For vaccinated workers with inadequate or unknown response: give HBIG and/or vaccine booster based on source status 3
• Test for anti-HBs response 1-2 months after the final vaccine dose 4, 2
• If HBIG was given within the prior 3-4 months, postpone anti-HBs testing because results cannot be accurately interpreted 4

HIV Post-Exposure Prophylaxis

Initiate HIV PEP within 72 hours of exposure (ideally within hours) if the source is HIV-positive or unknown and the exposure is high-risk. 2, 5

• Basic regimen includes Zidovudine (ZDV) 600 mg/day and Lamivudine (3TC) for 28 days 2, 3
• Evaluate the healthcare worker within 72 hours of PEP initiation and monitor for drug toxicity at least every 2 weeks 4, 2
• Consider expanded regimen based on source viral load and exposure severity 1

HIV Follow-Up Testing Schedule

For healthcare workers NOT on PEP: 4, 6

• Baseline: immediately
• 6 weeks post-exposure
• 3 months post-exposure
• 6 months post-exposure (definitive test)

For healthcare workers ON PEP: 4, 6

• Baseline: laboratory-based antigen/antibody test AND diagnostic NAT (especially if recent antiretroviral exposure)
• 4-6 weeks after PEP initiation: laboratory-based antigen/antibody test AND diagnostic NAT
• 12 weeks after PEP initiation: laboratory-based antigen/antibody test AND diagnostic NAT (definitive test to rule out infection)
• Note: A negative test during PEP does NOT rule out HIV because PEP medications may suppress detection 6

If the source is co-infected with HIV and HCV, extend HIV surveillance to 12 months because coinfection can delay seroconversion. 4

Test immediately if acute retroviral syndrome develops (fever, rash, fatigue) at any time, regardless of scheduled timeline. 4, 6

Hepatitis C Management

No post-exposure prophylaxis exists for HCV—surveillance is the primary management strategy. 4, 2

Follow-up testing schedule 4, 2:

• Baseline: anti-HCV antibodies and ALT immediately
• 4-6 months post-exposure: anti-HCV and ALT (required)
• Optional: HCV RNA at 4-6 weeks if earlier diagnosis is clinically desired
• Confirm repeatedly reactive anti-HCV enzyme immunoassays with supplemental testing 4, 2

Tetanus Prophylaxis

Administer tetanus prophylaxis according to standard wound management protocols based on vaccination history and wound characteristics 3

Precautions During Follow-Up Period

During the entire 6-month follow-up period, exposed healthcare workers should: 4, 2

• Use barrier protection (e.g., condoms) for all sexual activity
• Avoid blood, plasma, organ, tissue, or semen donation
• Seek immediate medical evaluation for any acute illness (fever, rash, fatigue, jaundice)

Critical Pitfalls to Avoid

• Do NOT delay HIV PEP—it is most effective when started within hours, and efficacy decreases significantly after 72 hours 1, 5
• Do NOT omit the 6-month HIV test even if earlier tests are negative—although most seroconversions occur by 6-7 weeks, ≥95% are detectable only by 6 months 4
• Do NOT use oral fluid-based rapid HIV tests in the PEP context—they are less sensitive for acute infection than blood tests 6
• Do NOT assume a negative HIV test rules out infection in healthcare workers taking PEP—antiretrovirals can suppress viral load and delay seroconversion 6
• Approximately 81% of healthcare workers who seroconvert develop acute retroviral syndrome around 25 days after exposure—maintain high clinical suspicion 4