Needle-stick Guideline

Concern regarding the management of occupational exposure to human immunodeficiency virus (HIV) was heightened when it was realized that HIV is transmitted through bodily fluids. Despite this concern, the risk of hepatitis is actually a greater occupational threat.[1]

The major pathogens of concern in occupational body fluid exposure are HIV, hepatitis A, hepatitis B, and hepatitis C.[1, 2, 3, 4, 5] 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 central nervous system.

The rate of occupational transmission from the blood of an HIV-positive source is believed to be 0.3% for a percutaneous exposure and 0.09% for a mucous membrane (nose, eye, mouth) exposure.[6, 7] For an exposure to intact skin, there is no risk of transmission if removed in timely fashion via washing. The rate of transmission from a hepatitis B–positive source to a nonimmunized host is 6%-24% and 1%-.8% (range, 0%-7%) for exposure to hepatitis C.[3] Hepatitis B infectivity depends on the hepatitis B e antigen (HBeAg) status of the source. If HBeAg-positive, the rate of transmission can be up to 30% but, when negative, is 1%-6%.

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

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.

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

Laboratory studies in the source patient (if available) are as follows:

• HIV testing
• Hepatitis B antigen
• Hepatitis C antibody
• Aspartate aminotransferase/alanine aminotransferase (AST/ALT) and alkaline phosphatase levels

Laboratory studies in exposed individuals/health care worker include the following:

• Hepatitis B surface antibody
• HIV testing at time of incident and again at 6 weeks, 3 months, and 6 months
• Hepatitis C antibody at time of incident and again at 2 weeks, 4 weeks, and 8 weeks

The following are laboratory studies to be performed prior to initiating retroviral therapy:

• Pregnancy test
• CBC count with differential and platelets
• Serum creatinine/BUN levels
• Urinalysis with microscopic analysis
• AST/ALT levels
• Alkaline phosphatase level
• Total bilirubin level

Patients with an occupational exposure should seek treatment as soon as possible, as studies have shown the efficacy of postexposure HIV prophylaxis is highest when initiated within the first 72 hours of exposure.[8]  However, it is recommended to initiate this preventative therapy as soon as possible as some efficacy can start to diminish within 2 hours post-exposure.[9]

Wash wounds with warm water and soap.

If the exposure is mucosal, including to the eyes, or if the wound is large enough to irrigate, irrigate with copious amounts of saline or other clean fluid.[7]

No evidence supports routine use of bleach, antiseptics, or disinfectants to clean exposed areas.

Irrigate and clean the wound.

Assess the need for tetanus and/or hepatitis B prophylaxis is based on medical history.[10] 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.

Follow all federal (Occupational Safety and Health Administration [OSHA]), state, and institutional guidelines for reporting such exposures. Federal law requires covered employers to ensure that all medical evaluations and procedures, vaccines, and postexposure prophylaxis are made available to the employee within a reasonable time and at a reasonable location and at no cost to the employee.[11]

CDC three-step risk assessment

Assess necessity for HIV or chemoprophylaxis (antiretrovirals) based on an assessment of the risk by using the 3-step process developed by the Centers for Disease Control and Prevention (CDC).[12]

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 recommendations are discussed below.

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.

Recommended 28-day prophylaxis

For adults, the backbone regimen is a combo pill of tenofovir 300 mg daily plus emtricitabine 200 mg (Truvada) daily plus either raltegravir (Isentress) 400 mg BID or dolutegravir (Dovato) 50 mg daily.  

Zidovudine is no longer recommended in the preferred PEP regimen because it is not believed to offer any clear advantage in efficacy over the tenofovir formulation and has significantly higher rates of treatment-limiting adverse effect.[13, 8, 14, 15] See https://stacks.cdc.gov/view/cdc/38856.

Assess need for hepatitis B/C prophylaxis

Hepatitis B measures are as follows:

• Previously vaccinated with known response to vaccine: No therapy required.
• Previously vaccinated without known response to vaccine: Send anti-HepBs titer; administer prophylaxis (one dose of HBIG); booster is required
• Unvaccinated: Provide one dose of HBIG and initiate vaccination series

There is no known effective postexposure prophylaxis for hepatitis C. The risk of HCV infection after exposure is approximately 1.8%. Testing should occur within 48 hours of exposure, and the typical guidelines for management and treatment of hepatitis C should be followed.[16]

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

Clinicians who are treating exposed patients can also consult the National Clinicians Post-Exposure Prophylaxis Hotline (PEPline) at 1-888-448-4911 for advice (available 11AM-8pm EST) on managing any occupational exposure to HIV, hepatitis B, and/or hepatitis C.

Other resources available for consultation include the following[17] :

• Clinical Consultation Center (CCC) for PEP may be reached by calling 1-888-448-4911 for occupational exposure. The CCC is part of the AIDS Education and Training Centers and is located at the University of California.   
• Antiretroviral Pregnancy Registry - Address: 301 Government Center, Wilmington, NC 28405; telephone: 800-258-4263; fax: 800-800-1052
• FDA (for reporting unusual or severe toxicity to antiretroviral agents) - Telephone: 800-332-1088; address: MedWatch, The FDA Safety Information and Adverse Event Reporting Program, Food and Drug Administration, 5600 Fishers Lane, Rockville, MD 20852
• The CDC’s Cases of Public Health Importance (COPHI) coordinator (for reporting HIV infections in HCP and failures of PEP) - Telephone: 404-639-2050
• HIV/AIDS Treatment Information Service

When indicated, medications are used to prevent disease transmission.

Class Summary

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

Diphtheria & tetanus toxoids (Tenivac)

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 (HyperTET S/D)

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.

Class Summary

Nucleoside reverse transcriptase inhibitors inhibit the enzyme that allows for reproduction of the virus. Therefore, these drugs work to prevent viral replication.

Tenofovir DF (Viread)

Tenofovir is an antiretroviral agent used in the treatment of acquired immunodeficiency syndrome (AIDS). It inhibits the activity of HIV reverse transcriptase by competing with the natural substrate deoxyadenosine 5’-triphosphate and, after incorporation into DNA, by DNA chain termination

Common side effects include nausea, vomiting, diarrhea, and asthenia, but can have more significant effects, leading to hepatotoxicity or renal failure.

Emtricitabine (Emtriva)

Emtricitabine is a synthetic nucleoside cytosine analogue. It competes with deoxycytidine-5’-triphosphate and is incorporated into viral DNA, causing chain termination.

Significant side effects are rare, other than GI upset. Can cause lactic acidosis. Manufactured as a combination pill with tenofovir and marketed as Truvada.

Class Summary

These agents prevent insertion of a DNA copy of the viral genome into host cell DNA. They are indicated for HIV-1 infection combination therapy in treatment-experienced adults with evidence of viral replication and drug-resistant HIV-1 strains.

Raltegravir (Isentress)

Raltegravir prevents integration of the proviral gene into human DNA by inhibiting the catalytic activity of integrase.

Dolutegravir (Tivicay)

Inhibits the strand transfer step of HIV-1 integration necessary for the HIV replication cycle by binding to the integrase active site.

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.

If postexposure prophylaxis is recommended, the full 28-day course must be completed. Studies have shown that compliance with the recommendations is poor, likely owing to the side effect profile.[18]

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

Universal precautions[19]

Life-long infection

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 Medscape Reference topic.

• HIV Disease

• Hepatitis A

• Hepatitis B

• Hepatitis C

• Tetanus

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 eMedicineHealth's Infections Center. Also, see eMedicineHealth's patient education article Tetanus.