Needle-stick Guideline Treatment & Management
- Author: Brenda Cosens, RN; Chief Editor: Rick Kulkarni, MD more...
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.
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. 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).
- 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.
- Postexposure prophylaxis recommendation
- 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.
Consult an infectious disease specialist if risks and/or benefits of drug treatment cannot be easily defined.
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