eMedicine Specialties > Emergency Medicine > Infectious Diseases

Needle-stick Guideline: Treatment & Medication

Author: Brenda Cosens, RN, Director, Developmental Disabilities Provider Services, Metrocare Services, Incorporated
Coauthor(s): Robert E Suter, DO, MHA, Professor, Division of Emergency Medicine, University of Texas at Southwestern Medical School
Contributor Information and Disclosures

Updated: Aug 18, 2009

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.

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.

Hepatitis B vaccine (Recombivax HB, Engerix-B)

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

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.

Lamivudine (3TC, Epivir)

Thymidine analog that inhibits viral replication.

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