Hospital Medicine

Needlestick Injury and Postexposure Prophylaxis

I. Problem/Challenge.

Needlestick injuries are a common occupational hazard in the hospital setting. According to the Centers for Disease Control and Prevention approximately 385,000 hospital-based healthcare workers experience occupational percutaneous injuries annually.

More than 20 blood-borne pathogens might be transmitted from contaminated needles or sharps, including human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV).

II. Identify the Goal Behavior.

Confirm the exposure by defining both the portal of entry and the body fluid known to transmit blood borne pathogens.

The portal of entry must include: percutaneous, mucous membrane or cutaneous exposure with non-intact skin to body fluids known to transmit human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C (HCV).

Body fluids known to transmit HIV are: Blood, semen, vaginal fluids, amniotic fluids, breast milk, cerebrospinal fluid, pericardial fluid, peritoneal fluid, pleural fluid and synovial flood.

Saliva, vomitus, urine, feces, sweat, tears and respiratory secretions do not transmit HIV (unless visibly bloody). The risk of HBV and HCV transmission from non-bloody saliva is negligible.

If the exposure does not encompass both the portal of entry and the at risk body fluids listed above, there is no risk of transmission and further evaluation is not required.

III. Describe a Step-by-Step approach/method to this problem.

After any needlestick injury, an affected healthcare worker should:

  • Wash the area with soap and water immediately.

  • Seek care in the facilities area responsible for managing occupational exposures.

  • Healthcare providers should always be encouraged and supported to report all sharps-related injuries to such departments.

  • Source patient should be identified and evaluated for potentially transmissible diseases, including HIV, HBV, and HCV. Source patient should undergo appropriate serological testing and any indicated antiviral prophylaxis should be initiated for healthcare worker.

Post-exposure prophylaxis should be initiated after evaluation by the appropriate occupational health department. General principles include:

  • HIV

    • Risk after needlestick: Ranges from 0.3 – 0.9% depending on mechanism of injury.

    • Post-exposure prophylaxis (PEP): A 28-day course of a combination of three antiretroviral drugs determined on a case-by-case basis. Act as quickly as possible, preferably within hours to initiate prophylaxis.

  • HBV

    • Risk after needlestick: 0% in healthcare workers previously vaccinated who have developed immunity; 6% to 30% in unvaccinated healthcare workers.

    • If the exposed healthcare worker is known to be immune (e.g., they were told they had a positive response to the vaccine series, as measured by a follow-up hepatitis B surface antibody (HBsAb) titer ≥10 mIU/mL), they are considered to have lifelong immunity and need no hepatitis B testing or treatment.

    • Post-exposure prophylaxis (PEP):Hepatitis B immunoglobulin (HBIG) alone or in combination with vaccine (if not previously vaccinated) is thought to provide 75-95% protection from HBV infection. Administer preferably within 24 hours, no later than 7 days.

  • HCV

    • Risk after needlestick: 1.8%.

    • There is no post-exposure prophylaxis for HCV.

IV. Common Pitfalls.

  • Treatment initiation of the exposed worker should not be delayed while waiting for test results. Post exposure prophylaxis can be stopped once results are negative.

V. National Standards, Core Indicators and Quality Measures.

The Occupational Safety and Health Adminstration (OSHA) suggests preventive measures to reduce and eliminate needlestick exposures: use of safety device needles with mechanisms such as Self-Sheathing Safety Features, Retractable Technology, Self Blunting Technology or Needleless Connector Systems. OSHA also advises against unsafe needle handling practices such as bending or recapping needles.

If a source patient’s HIV, HBV, and HCV status are unknown, occupational health personnel can interview the patient to evaluate his or her risks and initiate testing. Specific information about the time and nature of exposure should be documented.

When testing is indicated, it should be done following institutional and state-specific exposure control policy and informed consent guidelines. In all situations, the decision to begin antiviral PEP should be carefully considered, weighing benefits of PEP versus the risks and toxicity of treatment.

VII. What’s the Evidence?

If you have questions about appropriate medical treatment for occupational exposures, assistance is available from the Clinicians’ Post Exposure Prophylaxis (PEP) Line at : 1-888-448-4911.

http://www.nccc.ucsf.edu/

Recommendations for the management of occupational exposures to blood:

Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis.

Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis.

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