Needle stick Injury: Blood borne Pathogen Exposure

I. Step 1: Initial Management

A. Wash wounds with copious soap and water
B. Flush exposed mucous membranes with water
II. Step 2: Evaluate Source of Exposure
A. Avoid testing discarded needles or syringes
B. Test known source
1. Hepatitis B Surface Antigen
2. Hepatitis C Virus Antibody
3. HIV Test
4. Liver Function Tests
a. Aspartate Aminotransferase
b. Alanine Aminotransferase
c. Alkaline Phosphatase
C. Assess risk of exposure if source unknown
1. Hepatitis B Risk
III. Step 3: Evaluate Exposed Patient
A. Assess Hepatitis B Immune Status
1. Prior vaccination
2. Vaccine response
B. Initial labs
1. Anti-HCV RNA
2. Hepatitis B Surface Antibody
3. Hepatitis B Surface Antigen
4. HIV Test
5. See labs specific to HIV Postexposure Prophylaxis
C. Follow-up labs
1. Anti-HCV RNA
a. Consider testing at 2, 4 and 8 weeks after exposure
b. Repeat at 4-6 months after exposure
2. HIV Test
a. Repeat at 6 months after exposure
IV. Step 4: Management of the exposed patient
A. Postexposure Prophylaxis
1. See HIV Postexposure Prophylaxis
2. See Hepatitis B Postexposure Prophylaxis
B. Prevent transmission of possible infections
1. Use protection from Sexually Transmitted Disease
2. Consider Immunization of close contacts
Per-cutaneous HIV exposure risk: 3 per 1000 injuries
I. Indications for post-exposure prophylaxis
A. Occupational HIV exposure (needle stick)
B. Non-occupational HIV exposure
1. Isolated high risk exposure within last 72 hours
2. Exposure to HIV positive or high risk sexual partner

II. Protocol: Medications

A. Start within hours of exposure (under 24 to 48 hours)
B. Triple Therapy for 4 weeks

III. Protocol:
A. Source Status
1. HIV-Positive Class 1 (asymptomatic, viral load <1500)
a. Percutaneous exposure: three drug prophylaxis
b. Mucous membrane or non-intact skin: 2 drug protocol
2. HIV-Positive Class 2 (symptomatic, AIDS, high load)
a. Percutaneous exposure: three drug prophylaxis
b. Mucous membrane or non-intact skin: 2 drug protocol
3. Source with Unknown HIV Status or unknown source
a. No prophylaxis usually needed
b. Consider two drug protocol if high risk setting
4. HIV Negative Source: No prophylaxis needed
 Protocols below intended for healthcare worker exposure

I. Protocol: Known HBsAg Positive Source

A. Unvaccinated exposed patient
1. Hepatitis B Immunoglobulin (HBIG) 0.06 ml/kg and
2. Hepatitis B Vaccine
B. Exposed patient with known response to vaccine
1. No treatment
C. Exposed patient with known failed response to vaccine
1. Patient has not yet completed second 3-dose series
a. Hepatitis B Immunoglobulin (HBIG) 0.06 ml/kg and
b. Hepatitis B Vaccine (complete second 3-dose series)
2. Patient has completed two prior 3-dose series
a. Hepatitis B Immunoglobulin (HBIG) 0.06 ml/kg
b. Second Hepatitis B Immunoglobulin dose
D. Exposed patient with unknown response to vaccine
1. Test for antibody to HBsAg
2. Adequate antibody (HBsAg Positive): No treatment
3. Inadequate antibody (HBsAg Negative)
a. Hepatitis B Immunoglobulin (HBIG) 0.06 ml/kg and
b. Hepatitis B Vaccine booster dose
II. Protocol: Known HBsAg Negative Source
A. Administer Hepatitis B Vaccine Series if unvaccinated
B. No treatment otherwise needed
III. Protocol: UnKnown HBsAg Source Status
A. Unvaccinated exposed patient
1. Hepatitis B Vaccine Series
B. Exposed patient with known response to vaccine
1. No treatment
C. Exposed patient with known failed response to vaccine
1. Treat source as HBsAg positive if high risk
D. Exposed patient with unknown response to vaccine
1. Test for antibody to HBsAg
2. Adequate antibody (HBsAg Positive): No treatment
3. Inadequate antibody (HBsAg Negative)
a. Hepatitis B Vaccine initial and booster dose
b. Recheck titer in 1 to 2 months
Vaccination and Treatment
antibody response
status of exposed
workers/ who get prick

HBsAg positive Source HBsAg Unknown Source

negative
Source
Unvaccinated  HBIG x 1 and Initiate HB Initiate HB vaccine
 initiate HB vaccine vaccine series
series series

Previously vaccinated

Known responder No treatment No No treatment

( anti-HBs 10 - 100 treatment
mIU/mL).

Known non-responder*  HBIG X 1 and No If known high risk

is a person with  initiate treatment source, treat as
inadequate levels of revaccination HBsAg positive source
serum antibody to or HBIG X 2
HBsAg (I.e., anti-HBs
<10 mIU/mL).

Antibody response Test exposed person No Test exposed person

unknown for anti-HBs treatment for anti-HBs
1. If adequate, no 1. If adequate, no
treatment is treatment is
necessary. necessary.

2. If inadequate*, If inadequate*,
 administer vaccine  administer vaccine
and HBIG x 1 booster and recheck
and vaccine booster. titer in 1-2
months.