eMedicine Specialties > Emergency Medicine > Infectious Diseases

Needle-stick Guideline

Brenda Cosens, RN, Director, Developmental Disabilities Provider Services, Metrocare Services, Incorporated
Robert E Suter, DO, MHA, Professor, Division of Emergency Medicine, University of Texas at Southwestern Medical School

Updated: Aug 18, 2009

Introduction

Background

Concern regarding the management of occupational exposure to human immunodeficiency virus (HIV) was heightened when it was realized that HIV is transmitted by body fluids. In spite of this concern, the risk of hepatitis continues to be the greater occupational threat.

Pathophysiology

The major pathogens of concern in occupational body fluid exposure are HIV, hepatitis A, hepatitis B, hepatitis C, and hepatitis D.^{[1,2,3 ]}These pathogens are viruses that require percutaneous or mucosal introduction for infectivity. The major target organs are the immune system (HIV) and the liver (hepatitis). A lesser theoretical concern is tetanus, which attacks the CNS.

Frequency

United States

The rate of occupational transmission from an HIV-positive source is believed to be 0.3% for a percutaneous exposure and 0.09% for a mucous membrane exposure.^{[4,5 ]}The rate of transmission from a hepatitis B-positive source to a nonimmunized host is 6-24% and 1-10% for exposure to hepatitis C.^{[2 ]}

Clinical

History

• No symptoms of disease should be expected from the needle-stick exposure, upon a timely presentation.
• The history should focus on the patient's medical history, including immunizations and risk factors for both HIV and hepatitis.
• Specific questions include the following:
• Complete immunization record, including tetanus and hepatitis B
• Previous occupational exposure to body fluids
• Intravenous drug abuse
• Sexual history
• Body piercing or tattooing
• Receiving blood and/or blood products
• Any history of dialysis
• Travel outside the United States in the last year

Physical

• No abnormal physical findings, other than evidence of the reported trauma, should be expected upon a timely presentation.
• At a minimum, a baseline screening examination of the lungs, liver, and lymph nodes should be documented for future reference.

Causes

• Risk factors for occupational exposure to body fluids include the following:
  • Failure to adhere to universal precautions
  • Using equipment designed without appropriate safety features
  • Performance of exposure-prone procedures

Workup

Laboratory Studies

• Source patient (if available)
  • HIV
  • Hepatitis B antigen
  • Hepatitis C antibody
  • Aspartate aminotransferase/alanine aminotransferase (AST/ALT) and alkaline phosphatase levels
• Victim/health care worker
  • Hepatitis B surface antibody
  • HIV
  • Hepatitis C antibody testing at 2 weeks, 4 weeks, and 8 weeks
• Prior to initiating retrovirals
  • Pregnancy test (stat)
  • CBC count with differential and platelets
  • Serum creatinine/BUN levels
  • Urinalysis with microscopic analysis
  • AST/ALT levels
  • Alkaline phosphatase level
  • Total bilirubin level

Treatment

Prehospital Care

• If the exposure is mucosal or the wound is large enough to irrigate, irrigate with copious amounts of saline or other clean fluid.^{[5 ]}

Emergency Department Care

• Irrigate and clean wound.
• The need for tetanus and/or hepatitis B prophylaxis is based on medical history.^{[6 ]}Health care providers should have been immunized against hepatitis B. Hepatitis A prophylaxis may (rarely) need to be considered depending on the source-patient situation.
• The need for HIV or chemoprophylaxis (antiretrovirals) is based on an assessment of the risk by using the 3-step process developed by the Centers for Disease Control and Prevention (CDC).^{[5 ]}
• Step 1: Determine exposure code.
  • Is the source material blood, bloody fluid, other potentially infectious material, or an instrument contaminated with one of these substances?
    • If not, there is no risk of HIV transmission.
    • If yes, what type of exposure occurred?
  • If the exposure was to intact skin only, there is no risk of HIV transmission.
  • If the exposure was to mucous membrane or integrity-compromised skin, was the volume of fluid small (ie, few drops, short duration) or large (ie, several drops or major splash, long duration)?
    • If small, the category is exposure code 1.
    • If large, the category is exposure code 2.
  • If the exposure was percutaneous, was it a solid needle or a superficial scratch (ie, less severe)?
    • If yes, the category is exposure code 2.
  • Was it from a large-bore hollow needle, a device with visible blood, or a needle used in a source patient's artery or vein (ie, more severe)?
    • If yes, the category is exposure code 3.
• Step 2: Determine HIV status code.
  • What is the HIV status of the exposure source?
    • If HIV negative, no postexposure prophylaxis is needed.
    • If HIV positive, was the exposure low titer or high titer?
      • Low-titer exposures are asymptomatic patients with high CD4 counts. These are HIV status code 1.
      • High-titer exposures are patients with primary HIV infection, high or increasing viral load or low CD4 counts, or advanced acquired immunodeficiency syndrome (AIDS). These are HIV status code 2.
    • If HIV status is unknown or the source is unknown, the HIV status code is unknown.
• Step 3: Match exposure code with HIV status code to determine if any postexposure prophylaxis is indicated.
  • Postexposure prophylaxis recommendation
    • Exposure code 1 and HIV status code 1: Postexposure prophylaxis may not be warranted. Exposure type does not pose a known risk. The exposed health care worker and the treating clinician should decide whether the risk for drug toxicity outweighs the benefit of postexposure prophylaxis.
    • Exposure code 1 and HIV status code 2: Consider the basic regimen. Exposure type poses a negligible risk for HIV transmission. A high HIV titer in the source may justify consideration of postexposure prophylaxis. The exposed health care worker and the treating clinician should decide whether the risk for drug toxicity outweighs the benefit of postexposure prophylaxis.
    • Exposure code 2 and HIV status code 1: Recommend the basic regimen. Most HIV exposures are in this category. No increased risk for HIV transmission has been observed, but use of postexposure prophylaxis is appropriate.
    • Exposure code 2 and HIV status code 2: Recommend expanded regimen. Exposure type represents an increased HIV transmission risk.
    • Exposure code 3 and HIV status code 1 or 2: Recommend expanded regimen. Exposure type represents an increased HIV transmission risk.
    • HIV status code unknown: If the source or, in the case of an unknown source, the setting where the exposure occurred suggests possible risk for HIV exposure and the exposure code is 2 or 3, consider the postexposure prophylaxis basic regimen.
• Basic regimen: 4 weeks of zidovudine (600 mg/d in 2-3 divided doses) and lamivudine (150 mg twice daily)
• Expanded regimen: Basic regimen plus either indinavir (800 mg q8h) or nelfinavir (750 mg 3 times/d).
• Interferon ribavirin prophylaxis decreases risk by 40%. Exposed workers should be counseled on the risks of disease transmission based upon their specific exposure.

Consultations

Consult an infectious disease specialist if risks and/or benefits of drug treatment cannot be easily defined.

Medication

When indicated, medications are used to prevent disease transmission.

Immunizations

Vaccines containing epitopes that can elicit an immune response are very effective in inducing a protective response.

Diphtheria and tetanus vaccine (Diftavax)

Used to induce active immunity against tetanus in selected patients. The immunizing agent of choice for most adults and children <7 y are tetanus and diphtheria toxoids. Necessary to administer booster doses to maintain tetanus immunity throughout life.
Pregnant women should receive only tetanus toxoid, not a diphtheria antigen-containing product.
May administer into deltoid or midlateral thigh muscles in children and adults. Preferred site of administration in infants is the mid-thigh laterally.

Dosing

Adult

Primary immunization: 0.5 mL IM, give 2 injections 4-8 wk apart and a third dose 6-12 mo after second injection
Booster dose: 0.5 mL q10y

Pediatric

Administer as in adults

Interactions

Patients receiving immunosuppressants, including corticosteroids or radiation therapy, may remain susceptible despite immunization due to poor immune response; cimetidine may enhance or augment delayed-hypersensitivity responses to skin-test antigens; avoid concurrent use of medication with systemic chloramphenicol since it may impair amnestic response to tetanus toxoid; concurrent use of tetanus-immune globulin may delay development of active immunity by several days (interaction is nevertheless clinically insignificant and does not preclude its concurrent use)

Contraindications

Documented hypersensitivity; history of neurologic symptoms following administration of this product; FDA recommends that elective tetanus immunization be deferred during any outbreak of poliomyelitis because tetanus toxoid injections are an important cause of provocative poliomyelitis

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus

Precautions

Not for use to treat actual tetanus infections or for immediate prophylaxis of unimmunized individuals (use tetanus antitoxin instead, preferably human tetanus immune globulin); diminished antibody response to active immunization may be seen in patients receiving immunosuppressive therapy; better to defer primary diphtheria immunization until immunosuppressive therapy discontinued; routine immunization of symptomatic and asymptomatic HIV-infected persons is recommended

Tetanus immune globulin (Hyper-Tet)

Used for passive immunization of any person with a wound that might be contaminated with tetanus spores. Administer if immunization status is unclear or patient is allergic to diphtheria/tetanus vaccine.

Dosing

Adult

Prophylaxis: 250-500 U IM in opposite extremity to tetanus toxoid lesion
Clinical tetanus: 3000-10,000 U IM

Pediatric

Prophylaxis: 250 U IM in opposite extremity to tetanus toxoid
Clinical tetanus: 3000-10,000 U IM

Interactions

None reported

Contraindications

Because antibodies in globulin preparation may interfere with immune response to vaccination, do not administer within 3 mo of live-virus immune globulin administration; may be necessary to revaccinate persons who received immune globulin shortly after live-virus vaccination

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Persons with isolated immunoglobulin A (IgA) deficiency have potential for developing antibodies to IgA and could have anaphylactic reactions to subsequent administration of blood products that contain IgA; do not perform skin testing because intradermal injection of concentrated gamma globulin may cause localized area of inflammation and can be misinterpreted, causing the medication to be withheld from a patient not allergic to this material; true allergic responses to human gamma globulin given in prescribed IM manner are extremely rare; do not administer with other medications since usually incompatible

Hepatitis B vaccine (Recombivax HB, Engerix-B)

Recombinant vaccine used to provide immunization against all known subtypes of hepatitis B virus.

Dosing

Adult

1 mL IM as early as possible (24 h) following a needlestick
1-month booster: 1 mL
6-month booster: 1 mL

Pediatric

0.5 mL IM as early as possible (12 h) after birth
<10 years:
Initial dose:
Recombivax HB: 0.25 mL
Engerix-B: 0.5 mL
1-month booster:
Recombivax HB: 0.25 mL
Engerix-B: 0.5 mL
6-month booster:
Recombivax HB: 0.25 mL
Engerix-B: 0.5 mL
>10 years:
Initial dose:
Recombivax HB: 0.5 mL
Engerix-B: 1 mL
1-month booster:
Recombivax HB: 0.5 mL
Engerix-B: 1 mL
6-month booster:
Recombivax HB: 0.5 mL
Engerix-B: 1 mL

Interactions

May decrease effects of immunosuppressive agents

Contraindications

Documented hypersensitivity; patients with IgA deficiency

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus

Precautions

Immunosuppressed patients may require larger doses to respond as well as healthy individuals; vaccine does not protect against the hepatitis A virus; instances of multiple sclerosis exacerbations following administration of hepatitis B vaccine have occurred; caution with thrombocytopenia or coagulation disorders

Antiretrovirals

These agents are inhibitors of reverse transcriptase and thus, cause chain termination when incorporated into a growing viral strand.

Zidovudine (AZT, ZDV, Retrovir)

Thymidine analog that inhibits viral replication.
Educate patient on risk versus benefits, including, but not limited to, the lack of substantiated evidence that postexposure chemoprophylaxis will prevent infection. Patient should also learn about side effects, lack of data regarding mutagenesis, and teratogenesis. Obtain a signed consent form.
Perform pretreatment laboratory tests including CBC counts with differential and platelets, serum creatinine level, UA with microscopic analysis, AST level, alkaline phosphatase level, total bilirubin level, and pregnancy test.

Dosing

Adult

200 mg PO tid for 4 wk

Pediatric

90-180 mg/m²/dose PO q6h

Interactions

Acetaminophen may decrease bioavailability; toxicity increases when administered concurrently with amphotericin B, flucytosine, vincristine, vinblastine, doxorubicin, cimetidine, indomethacin, probenecid, lorazepam, aspirin, acyclovir, ganciclovir, dapsone, and pentamidine

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in impaired hepatic or renal function; reduce or stop therapy in patients who develop hematologic disorders, such as thrombocytopenia, granulocytopenia, and severe anemia

Lamivudine (3TC, Epivir)

Thymidine analog that inhibits viral replication.

Dosing

Adult

150 mg PO bid for 4 wk

Pediatric

4 mg/kg PO bid

Interactions

Trimethoprim/sulfamethoxazole increases bioavailability of lamivudine; lamivudine increases concentration of zidovudine when administered concurrently

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus

Precautions

Adjust dose in renal impairment; caution in history of pancreatitis

Follow-up

Further Outpatient Care

• Follow up with occupational health or infectious disease in 24-72 hours.
• Discuss need for safe sex practices until follow-up laboratory testing is negative for HIV. Most now recommend a follow-up screen at 3 or 6 months.

Inpatient & Outpatient Medications

• Antiretrovirals, as indicated, by the 3-step assessment process (see Treatment section)

Deterrence/Prevention

• Universal precautions^{[7 ]}

Complications

• Infection

Prognosis

• Most health care workers with occupational exposure to body fluids do not develop disease. For those who do, prognosis is the same as for other routes of transmission.
• For more specific information, see the relevant eMedicine topic.
  • HIV
  • Hepatitis A
  • Hepatitis B
  • Hepatitis C
  • Hepatitis D
  • Tetanus

Patient Education

• Refer to occupational health for extensive patient education. Having a brochure available to be given out in the ED is helpful to alleviate fear.
• For excellent patient education resources, visit eMedicine's Infections Center. Also, see eMedicine's patient education article Tetanus.

Miscellaneous

Related guidelines

HIV prophylaxis following occupational exposure

Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis

HIV post-exposure prophylaxis for children beyond the perinatal period

Diagnosis, management, and treatment of hepatitis C

Medicolegal Pitfalls

• With the advent of CDC recommendations for HIV postexposure prophylaxis, failure to counsel patients on the existence of retroviral treatment (eg, explain its risk/benefits) could be the source of a significant judgment if the patient subsequently develops HIV.
• Involvement of an informed patient in the decision-making process is essential.

References

1. Bassett IV, Freedberg KA, Walensky RP. Two drugs or three? Balancing efficacy, toxicity, and resistance in postexposure prophylaxis for occupational exposure to HIV. Clin Infect Dis. Aug 1 2004;39(3):395-401. [Medline].

2. CDC. Recommendations for follow-up of health-care workers after occupational exposure to hepatitis C virus. MMWR Morb Mortal Wkly Rep. Jul 4 1997;46(26):603-6. [Medline].

3. Merchant RC, Keshavarz R. HIV postexposure prophylaxis practices by US ED practitioners. Am J Emerg Med. Jul 2003;21(4):309-12. [Medline].

4. Cardo DM, Culver DH, Ciesielski CA, et al. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. Centers for Disease Control and Prevention Needlestick Surveillance Group. N Engl J Med. Nov 20 1997;337(21):1485-90. [Medline].

5. CDC. Public Health Service guidelines for the management of health-care worker exposures to HIV and recommendations for postexposure prophylaxis. Centers for Disease Control and Prevention. MMWR Recomm Rep. May 15 1998;47(RR-7):1-33. [Medline].

6. Sidwell RU, Green JS, Novelli V. Management of occupational exposure to HIV--what actually happens. Commun Dis Public Health. Dec 1999;2(4):287-90. [Medline]. [Full Text].

7. Houston SH, Sinnott JT, Palumbo SJ. Employee health and safety. In: Reese, ed. Practical Approach to Infectious Diseases. 1996:706-724, 1406-1409.

8. CDC. Recommendations for Postexposure Interventions to Prevent Infections with Hepatitis B Virus, Hepatitis C Virus, or Human Immunodeficiency Virus, and Tetanus in Persons Wounded During Bombings or Similar Mass-Casualty Events - United States, 2008. MMWR [serial online]. August 2008;57(RR-6):1-19. Available at www.cdc.gov/mmwr/pdf/rr/rr5706.pdf.

9. Hsieh WB, Chiu NC, Lee CM, Huang FY. Occupational blood and infectious body fluid exposures in a teaching hospital: a three-year review. J Microbiol Immunol Infect. Aug 2006;(4):321-7. [Medline].

10. Merchant RC, Becker BM, Mayer KH, Fuerch J, Schreck B. Emergency department blood or body fluid exposure evaluations and HIV postexposure prophylaxis usage. Acad Emerg Med. Dec 2003;10(12):1345-53. [Medline].

11. Moran GJ. Emergency department management of blood and body fluid exposures. Ann Emerg Med. Jan 2000;35(1):47-62. [Medline].

12. Peate I. Occupational exposure of staff to HIV and prophylaxis therapy. Br J Nurs. Oct 28-Nov 10 2004;13(19):1146-50. [Medline].

13. Rinnert KJ. A review of infection control practices, risk reduction, and legislative regulations for blood-borne disease: applications for emergency medical services. Prehosp Emerg Care. Jan-Mar 1998;2(1):70-5. [Medline].

14. Schriger DL, Mikulich VJ, Centers for Disease Control and Prevention. The management of occupational exposures to blood and body fluids: revised guidelines and new methods of implementation. Ann Emerg Med. Mar 2002;39(3):319-21. [Medline].

15. U.S. Public Health Service. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. MMWR Recomm Rep. Jun 29 2001;50(RR-11):1-52. [Medline]. [Full Text].

Keywords

blood, body fluids, other potentially infectious materials, OPIM, needle stick, sharps injury, hepatitis, HBV, HCV, HDV, human immunodeficiency virus, HIV, acquired immunodeficiency syndrome, AIDS, tetanus, hepatitis A, hepatitis B, hepatitis C, hepatitis D, occupational transmission of disease, occupational exposure to body fluids 

Contributor Information and Disclosures

Author

Brenda Cosens, RN, Director, Developmental Disabilities Provider Services, Metrocare Services, Incorporated
Brenda Cosens, RN is a member of the following medical societies: Emergency Nurses Association
Disclosure: Nothing to disclose.

Coauthor(s)

Robert E Suter, DO, MHA, Professor, Division of Emergency Medicine, University of Texas at Southwestern Medical School
Robert E Suter, DO, MHA is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

William G Gossman, MD, Associate Clinical Professor of Emergency Medicine, Creighton University School of Medicine; Consulting Staff, Department of Emergency Medicine, Creighton University Medical Center
William G Gossman, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eric L Weiss, MD, DTM&H, Director of Stanford Travel Medicine, Medical Director of Stanford Lifeflight, Assistant Professor, Departments of Emergency Medicine and Infectious Diseases, Stanford University School of Medicine
Eric L Weiss, MD, DTM&H is a member of the following medical societies: American College of Emergency Physicians, American College of Occupational and Environmental Medicine, American Medical Association, American Society of Tropical Medicine and Hygiene, Physicians for Social Responsibility, Southeastern Surgical Congress, Southern Association for Oncology, Southern Clinical Neurological Society, and Wilderness Medical Society
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

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