What is the recommended preoperative screening protocol for hepatitis B, hepatitis C, and HIV in patients undergoing surgery?

Preoperative Screening for Hepatitis B, C, and HIV in Surgical Patients

Routine universal serologic screening for hepatitis B, C, and HIV is not recommended for all surgical patients; instead, use risk-based screening combined with universal precautions for all procedures.

Risk-Based Screening Approach

When to Screen for Hepatitis B

Screen high-risk patients undergoing major abdominal, orthopedic, or gynecological surgery, and consider screening all patients undergoing open heart surgery where blood exposure risk is substantial. 1

• Take a detailed history focusing on:

  • Country of birth (hepatitis B prevalence varies by region) 1
  • Intravenous drug use 1
  • Sexual history and multiple partners 1
  • History of blood transfusions in high-prevalence areas 1
  • Household contacts with known hepatitis B 1

• Physical examination should identify needle puncture sites or other signs of high-risk behavior 1

When to Screen for HIV

HIV antibody testing should only be performed on clinical grounds for high-risk patients, and only after counseling and obtaining informed consent. 1

• HIV testing is required for:

  • Transplant donors 1
  • Blood, sperm, or milk donation 1

• Consider testing for patients with risk factors:

  • Homosexual or bisexual males 1
  • Intravenous drug abusers 1
  • Persons with penetrative sexual contact with partners from high HIV prevalence areas 1
  • Recipients of unscreened blood transfusions in high-prevalence areas 1
  • Hemophilic patients who received untreated blood products 1
  • Sexual partners of any of the above 1
  • Children born to seropositive mothers 1

When to Screen for Hepatitis C

Hepatitis C screening should follow similar risk-based criteria as HIV, as most patients at high risk for HIV are also at high risk for hepatitis C. 1

• The detection rate for hepatitis C (5.2%) is significantly higher than HIV (1.6%) or hepatitis B surface antigen (1.4%) in surgical populations 2

Geographic and Surgical Risk Considerations

High-Prevalence Areas

In areas of high HIV or hepatitis prevalence, all patients admitted for emergency surgery should be considered high risk, and preoperative screening should be considered essential. 1

• Emergency operations requiring full precautions include:
  • Major abdominal surgery 1
  • Orthopedic operations 1
  • Burns 1
  • Trauma and fracture surgery 1

Low-Prevalence Areas

In areas of low HIV prevalence (most of the United Kingdom and similar regions), additional precautions and routine screening may not be necessary. 1

• A study from San Francisco showed that knowing HIV status made no difference in the incidence of sharps injuries when universal precautions were implemented 1

Evidence Against Universal Screening

The cost-benefit ratio of routine universal screening is poor, with very low detection rates of new infections. 3

• In a 10-year study of 10,011 screened orthopedic surgery patients, only 4 cases (0.4‰) of previously unknown infection were detected 3

• Routine testing identifies abnormalities in only 0.8-22% of cases, with management changes occurring in merely 1.1-4% of abnormal results 4

Alternative to Serologic Screening: Clinical History

The primary screening method should be a careful history including specific questions about:

• Sexual behavior and number of partners 1
• Drug abuse history 1
• Travel to HIV or hepatitis endemic areas 1
• Previous blood transfusions 1
• Occupational exposures 1

Universal Precautions: The Foundation

Regardless of screening results, universal precautions must be implemented for all surgical procedures. 1

Standard Precautions for All Patients

• All surgeons must be vaccinated against hepatitis B 1
• Cover all cuts and abrasions with waterproof dressings 1
• Never pass sharps hand to hand 1
• Never guide needles with fingers 1
• Never resheath needles 1
• Dispose of all sharps safely into approved containers 1
• Regular hand-washing and basic hygiene 1

Additional Precautions for Known or High-Risk Cases

• Double gloving for high-risk patients (though this decreases sensitivity) 1
• Plastic aprons and disposable gloves when handling used materials 1
• Disinfect theatre floor with hypochlorite (1000 ppm available chlorine) between cases 1

Important Caveats

Testing for HIV alone would detect only 24% of patients infected with a bloodborne pathogen, as hepatitis C is more prevalent and predictive of co-infection. 2

Screening is expensive and the evidence shows that universal precautions are more effective than selective precautions based on known serostatus. 1

If screening is performed, informed consent after counseling is mandatory for HIV testing. 1

The primary benefit of screening may be for patient management (early treatment initiation) rather than infection control, as universal precautions should be used regardless. 1