Needlestick injury and PEP

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🩸 Needlestick / sharps injury:
Treat every significant exposure promptly. The important blood-borne viruses are HIV, hepatitis B (HBV) and hepatitis C (HCV).

For a percutaneous injury involving blood from a person with transmissible HIV, the untreated HIV transmission risk is approximately 0.2–0.3% (about 1 in 300–500), although the actual risk depends strongly on the nature of the injury and the source viral load.

HIV PEP should be started as soon as possible, preferably within 24 hours, and should not normally be started after 72 hours.

⏱️ Immediate Actions: After a percutaneous sharps injury:

• 💧 Encourage the wound to bleed gently.
• 🧼 Wash immediately with soap and running water.
• ❌ Do not scrub, suck or use bleach or other caustic agents.
• 🩹 Dry and cover with a waterproof dressing.
• For a splash to the eyes or mucous membranes, irrigate immediately with copious water or saline.
• 🚑 Obtain urgent specialist assessment through Occupational Health, ED or the local needlestick/PEP pathway.
• 📋 Occupational exposures should be formally documented and reported according to local policy.

💡 Do not wait for source-patient blood results before starting HIV PEP if the exposure is sufficiently high risk. PEP can subsequently be stopped if assessment shows that it is unnecessary.

🧷 What Is a Significant Exposure?

• Percutaneous exposure: puncture or cut from a contaminated needle, scalpel or other sharp.
• Mucosal exposure: blood splashed into the eye, mouth or other mucous membrane.
• Exposure of non-intact skin: blood contacting broken skin, dermatitis or an open wound.
• Blood contacting intact skin does not constitute a significant blood-borne virus exposure.

⚠️ Factors Increasing Transmission Risk

• Deep injury.
• Hollow-bore needle rather than a solid needle.
• Needle previously placed in an artery or vein.
• Visible blood on the device.
• Large-volume blood exposure.
• Source patient with a high or detectable HIV viral load.

🧪 Immediate Risk Assessment

• Establish:
  • Type and depth of injury.
  • Device involved.
  • Whether blood was visibly present.
  • Time since exposure.
  • Source patient's known or suspected HIV, HBV and HCV status.
  • The exposed person's hepatitis B vaccination and antibody status.
• Where appropriate and with consent, test the source patient for blood-borne viruses.
• Baseline blood tests in the exposed person generally include:
  • HIV-1 antigen/antibody test.
  • Hepatitis B serology where immunity is not already documented.
  • Hepatitis C screening.
  • Renal function and ALT if HIV PEP is being considered.

⚠️ A baseline negative HIV or hepatitis test does not tell you whether transmission has occurred from today's exposure. It documents the person's pre-exposure status and provides a reference for subsequent testing.

💊 HIV Post-Exposure Prophylaxis (PEP)

• PEP is indicated when the exposure carries a clinically significant risk of HIV transmission.
• Start as soon as possible:
  • Preferably within 24 hours.
  • It may still be considered up to 72 hours.
  • It should generally not be initiated beyond 72 hours.
• The usual treatment duration is 28 days.
• Current UK guidance uses a three-drug antiretroviral regimen. Drug selection should follow the current BASHH/BHIVA guideline and local PEP protocol.
• Check for:
  • Renal impairment.
  • Pregnancy.
  • Drug interactions.
  • Previous antiretroviral resistance in the source patient.
• If the source is known to have HIV but has a documented sustained undetectable viral load, HIV transmission risk may be negligible and PEP may not be indicated following specialist risk assessment.

🟡 Hepatitis B

• Management depends on:
  • The source patient's HBsAg status.
  • The exposed person's vaccination history.
  • Previous anti-HBs response.
• A fully immunised person with documented immunity may require no additional treatment in many circumstances.
• An unvaccinated person with a significant exposure should usually receive an accelerated hepatitis B vaccination course.
• If the source is known to be HBsAg positive, some exposed individuals require hepatitis B immunoglobulin (HBIG) in addition to vaccination.
• Known vaccine non-responders require specialist management and may need HBIG.

🟠 Hepatitis C

• There is currently no vaccine and no recommended post-exposure antiviral prophylaxis for hepatitis C.
• Management consists of:
  • Baseline testing.
  • Appropriate follow-up testing for evidence of infection.
  • Early referral and antiviral treatment if acute HCV infection develops.
• Modern direct-acting antiviral therapy is highly effective if transmission occurs.

💊 Are Antibiotics Required?

• No — antibiotics are not routinely indicated following a needlestick injury.
• Consider antibiotics only when there is an independent indication such as:
  • Clinically infected wound.
  • Significant bite injury.
  • Other traumatic contamination where bacterial infection is a concern.
• Check tetanus immunisation status according to the nature of the wound.

🔬 Follow-Up

• Occupational exposures should be followed up by Occupational Health, ideally promptly after the event.
• For a person completing a 28-day course of HIV PEP, current UK guidance allows final HIV testing 45 days after completing PEP — approximately 10½ weeks after the exposure.
• HBV follow-up depends on vaccination status, immunity and source status.
• HCV follow-up should follow the local occupational-health or virology protocol.
• Advise the exposed person to return earlier if they develop symptoms suggestive of acute infection.

🧠 Psychological Support

• Needlestick injuries can cause considerable anxiety despite the generally low absolute risk of transmission.
• Provide clear risk information rather than either minimising or exaggerating the risk.
• Ensure access to Occupational Health, counselling or other psychological support where needed.

📌 Key Points

• 💧 Wash immediately — do not scrub or suck the wound.
• 🚑 Obtain urgent expert risk assessment.
• 🦠 Assess risk from HIV, HBV and HCV separately.
• 💊 Start HIV PEP as soon as possible, preferably within 24 hours; do not normally start after 72 hours.
• 💉 HBV is the blood-borne virus for which vaccination ± HBIG can provide post-exposure protection.
• 🟠 There is no HCV PEP; follow-up testing identifies infection so that it can be treated promptly.
• ❌ Routine antibiotics are not required.

💡 Exam Pearl
After a needlestick injury think of three separate questions:

HIV → Does this exposure require 28 days of PEP?
HBV → Is the person immune, or do they need vaccine ± HBIG?
HCV → No PEP: arrange appropriate surveillance.