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Needle-stick Guideline Treatment & Management

  • Author: Brenda Cosens, RN; Chief Editor: Rick Kulkarni, MD  more...
 
Updated: May 11, 2014
 

Prehospital Care

See the list below:

  • If the exposure is mucosal or the wound is large enough to irrigate, irrigate with copious amounts of saline or other clean fluid.[6]
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Emergency Department Care

See the list below:

  • Irrigate and clean wound.
  • The need for tetanus and/or hepatitis B prophylaxis is based on medical history.[9] 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).[6]

  • 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.
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Consultations

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

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Contributor Information and Disclosures
Author

Brenda Cosens, RN Branch Director, Encompass Home Health

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.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eric L Weiss, MD, DTM&H Medical Director, Office of Service Continuity and Disaster Planning, Fellowship Director, Stanford University Medical Center Disaster Medicine Fellowship, Chairman, SUMC and LPCH Bioterrorism and Emergency Preparedness Task Force, Clinical Associate Professor, Department of Surgery (Emergency Medicine), Stanford University Medical Center

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 Oncology Association of Practices, Southern Clinical Neurological Society, Wilderness Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

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, Society for Academic Emergency Medicine

Disclosure: Received salary from WebMD for employment.

Additional Contributors

William G Gossman, MD, FAAEM Associate Clinical Professor of Emergency Medicine, Creighton University School of Medicine; Chairman, Department of Emergency Medicine, Creighton University Medical Center

William G Gossman, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

References
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  5. 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. 1997 Nov 20. 337(21):1485-90. [Medline].

  6. 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. 1998 May 15. 47(RR-7):1-33. [Medline].

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  8. Butsashvili M, Kamkamidze G, Kajaia M, Kandelaki G, Zhorzholadze N. Circumstances surrounding the community needle-stick injuries in Georgia. J Community Health. 2011 Dec. 36(6):1050-2. [Medline].

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

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

  11. 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. August 2008. 57(RR-6):1-19. [Full Text].

  12. 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].

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