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Needlestick, Emergency Medicine

Basics

Description

- General prevention: - Universal precautions - Avoid recapping of needles - Wear gloves: Decreases amount of blood exposure by 50% - Double gloving - Follow body " “substance isolation protocols. - Hepatitis B virus vaccination

- Infectiousness of various body fluids for HIV: - Plasma/serum: 10 " “5,000 ppm - CSF: 10 " “1,000 ppm - Semen: 10 " “50 ppm - Vaginal secretions, urine, saliva, tears, breast milk: <1 ppm

- Factors affecting risk: - Viral load - Actual injection volume - Type and size of needle - Portal of entry (depth of inoculation) - Duration of contact - Level of disease in source patient - Host susceptibility - Barriers (e.g., through gloves)

- CDC guidelines: For more severe percutaneous exposure, if source patient is: - HIV negative: No prophylaxis - Unknown source: Consider basic regimen - Patient with risk factors: Consider basic regimen - HIV positive, low viral load: Recommend expanded regimen 3 drugs - HIV positive, high viral load: Recommend expanded regimen ≥3 drugs

- CDC alternative expanded regimen: Basic regimen and: - Atazanavir (ATV) ‚ ± ritonavir (RTV) or - Fosamprenavir ‚ ± ritonavir (RTV) or - Indinavir (IDV) ‚ ± ritonavir (RTV) or - Saquinavir (SQV) + ritonavir (RTV) or - Nelfinaviror - Efavirenzor - Consider others after expert consultation: These include abacavir, delavirdine, zalcitabine, nevirapine, enfuvirtide.

- Counseling to prevent secondary infection: - Safer sex advice - Avoid becoming pregnant - Do not donate blood/tissue. - Do not breast-feed.

- Hepatitis B virus: - Known HBsAg-positive source: - Complete vaccination confirmed by titer: No prescription - Unvaccinated: Hepatitis B immune globulin ASAP, begin hepatitis B virus vaccine series. - Nonresponder to vaccine: Hepatitis B immune globulin ASAP, may repeat in 30 days; consider revaccination with 3-dose series. - Unknown responder to vaccine with inadequate titer: Hepatitis B immune globulin ASAP, vaccine booster

  • Mechanisms of exposure to blood or body fluid:PercutaneousMucous membraneSkin
  • General prevention:Universal precautionsAvoid recapping of needlesWear gloves: Decreases amount of blood exposure by 50%Double glovingFollow body " “substance isolation protocols.Hepatitis B virus vaccination
  • Risk factors:Risk of seroconversion from a single needlestick exposure without prior immunization:Hepatitis B virus: 37 " “62% from HBsAg-positive and HBeAg-positive source, 23 " “37% from HBsAg-positive and HBeAg-negative sourceHepatitis C virus: 1.8%HIV: Blood 0.3%, mucous membrane 0.09%Infectiousness of various body fluids for HIV:Plasma/serum: 10 " “5,000 ppmCSF: 10 " “1,000 ppmSemen: 10 " “50 ppmVaginal secretions, urine, saliva, tears, breast milk: <1 ppmFactors affecting risk:Viral loadActual injection volumeType and size of needlePortal of entry (depth of inoculation)Duration of contactLevel of disease in source patientHost susceptibilityBarriers (e.g., through gloves)

Diagnosis

Signs and Symptoms

History

Exposure to blood or body fluid: ‚

  • Date, time, circumstances, details of exposure, source
  • Immunizations

Diagnosis Tests & Interpretation

Women with body fluid exposure who are considering antiviral therapy must have serum or urine pregnancy testing. ‚

Lab

To be done with occupational health if possible: ‚

  • Baseline serology for HIV (enzyme immunoassay, western blot), hepatitis B virus, hepatitis C virus (anti-HCV), ALT. Assess adequacy of hepatitis B virus vaccination.HIV-Ab, HCV-Ab, HBsAg, HBsAb titer
  • Obtain consent from source patient for HIV (consider rapid HIV-antibody test), hepatitis B virus, hepatitis C virus (anti-HCV) testing.

Imaging

Not applicable unless concerned for retained tissue foreign body ‚

Differential Diagnosis

Principally concerned with transmission of hepatitis B virus, hepatitis C virus, and HIV ‚

Treatment

Pre-Hospital

  • Pre-hospital personnel should always maintain universal precautions to prevent needlestick or other body fluid exposure.
  • Patients with exposure should be evaluated within hours for prophylactic therapy.

Initial Stabilization/Therapy

  • Copious cleaning, wound care
  • Direct and immediate referral to occupational health, when available, to ensure strictest confidentiality in lab testing and treatment
  • In the ED, after hours, patients with needlestick exposure must be triaged with high priority. It is important to initiate prophylactic therapy quickly after exposure.

Ed Treatment/Procedures

  • If referral to occupational health is unavailable, initiate prophylactic therapy in ED.
  • Tetanus prophylaxis if necessary
  • HIV:Begin basic vs. expanded antiretroviral prophylaxis regimen after considering HIV status of source and severity of exposure. Some organizations advocate only the expanded 3-drug regimen. Treat for 28 days.CDC guidelines: For less severe percutaneous exposure, if source patient is:HIV negative: No prophylaxisUnknown source: Consider basic regimenPatient with risk factors: Consider basic regimenHIV positive, low viral load: Recommend basic regimenHIV positive, high viral load: Recommend expanded regimen ≥3 drugsCDC guidelines: For more severe percutaneous exposure, if source patient is:HIV negative: No prophylaxisUnknown source: Consider basic regimenPatient with risk factors: Consider basic regimenHIV positive, low viral load: Recommend expanded regimen 3 drugsHIV positive, high viral load: Recommend expanded regimen ≥3 drugsCDC guidelines: For less severe mucous membrane or nonintact skin exposure, if source patient is:HIV negative: No prophylaxisUnknown source: No prophylaxisPatient with risk factors: No prophylaxisHIV positive, low viral load: Consider basic regimenHIV positive, high viral load: Recommend basic regimenCDC guidelines: For more severe mucous membrane or nonintact skin exposure, if source patient is:HIV negative: No prophylaxisUnknown source: Consider basic regimenPatient with risk factors: Consider basic regimenHIV positive, low viral load: Recommend basic regimenHIV positive, high viral load: Recommend expanded regimen ≥3 drugsCDC preferred basic regimen:Zidovudine (AZT) + lamivudine (3TC); sold as combination drug Combivir; orTenofovir DF (TDF) + emtricitabine (FTC);Zidovudine (AZT) + emtricitabine (FTC); orLamivudine (3TC) + tenofovir DF (TDF); orCDC alternative basic regimen:Lamivudine (3TC) + stavudine (d4T); orEmtricitabine (FTC) + stavudine (d4T) orLamivudine (3TC) + didanosine (ddI) orEmtricitabine (FTC) + didanosine (ddI)CDC preferred expanded regimen: Basic regimen and:Lopinavir/ritonavir (Kaletra)CDC alternative expanded regimen: Basic regimen and:Atazanavir (ATV) ‚ ± ritonavir (RTV) orFosamprenavir ‚ ± ritonavir (RTV) orIndinavir (IDV) ‚ ± ritonavir (RTV) orSaquinavir (SQV) + ritonavir (RTV) orNelfinavirorEfavirenzorConsider others after expert consultation: These include abacavir, delavirdine, zalcitabine, nevirapine, enfuvirtide.Counseling to prevent secondary infection:Safer sex adviceAvoid becoming pregnantDo not donate blood/tissue.Do not breast-feed.
  • Hepatitis B virus:Known HBsAg-positive source:Complete vaccination confirmed by titer: No prescriptionUnvaccinated: Hepatitis B immune globulin ASAP, begin hepatitis B virus vaccine series.Nonresponder to vaccine: Hepatitis B immune globulin ASAP, may repeat in 30 days; consider revaccination with 3-dose series.Unknown responder to vaccine with inadequate titer: Hepatitis B immune globulin ASAP, vaccine boosterKnown HBsAg-negative source:Vaccinated: No prescriptionUnvaccinated: Begin hepatitis B virus vaccine seriesUnknown source:Complete vaccination confirmed by titer: No prescriptionUnvaccinated: Begin vaccine series. If high-risk exposure, consider hepatitis B immune globulinNonresponder to vaccine: Hepatitis B immune globulin ASAP with revaccination 3-dose series. If high-risk exposure, repeat hepatitis B immune globulin in 30 days.Unknown responder to vaccine with inadequate titer: Vaccine booster and recheck titer in 1 " “2 moHepatitis C virus:Use of immunoglobulins or antivirals (interferon, ribavirin) inconclusive as prophylaxis, but possibly beneficial if initiated early when infection evident

Medication

  • HIV:Zidovudine:300 mg PO BID or 200 mg PO TIDSide effects: GI symptoms, headache, fatigue, myalgias, marrow suppression, seizureZidovudine should be taken in conjunction with lamivudineLamivudine:300 mg PO QD or 150 mg PO BIDSide effects: GI symptoms, headache, fatigue, neuropathy, congestion, cough (caution with trimethoprim/sulfamethoxazole)Combivir (combination zidovudine + lamivudine) (300 mg + 150 mg tab):1 tablet PO BIDSide effects: See side-effect profiles of zidovudine and lamivudineEmtricitabine:200 mg/d POSide effects: Rash, hyperpigmentationEmtricitabine must be taken in conjunction with efavirenz and zidovudineTenofovir DF:300 mg/d POSide effects: GI symptoms, headache, fatigue, neuropathy, dizzinessTenofovir must be taken in conjunction with efavirenz and emtricitabineDidanosine:<60 kg 250 mg/d PO as delayed-releaseSide effects: Pancreatitis, GI symptoms, lactic acidosis, neuropathyStavudine:60 kg 40 mg PO BID orIf wt <60 kg, then 30 mg PO BIDSide effects: Peripheral neuropathy, GI symptoms, headache, pancreatitis, elevated liver function tests, neutropenia, anemiaLopinavir/ritonavir (Kaletra) (200 mg + 50 mg cap):2 capsules PO BIDSide effects: GI symptoms, hyperlipidemiaAtazanavir:400 mg/d POIf used with tenofovir, then decrease to 300 mg/d PO and add ritonavir 100 mg/d POSide effects: Be wary with medications that prolong PR interval, hyperbilirubinemiaFosamprenavir:1,400 mg PO BIDIf used with ritonavir, then decrease to 1,400 mg/d PO or 700 mg PO BIDSide effects: GI symptoms, rash, drug interactions, depressionIndinavir:800 mg + ritonavir 100 mg PO BID, in combination with (lamivudine + zidovudine) or (emtricitabine + zidovudine) or(lamivudine + tenofovir) or (emtricitabine + tenofovir);If used with ritonavir, then decrease to 800 mg PO BIDSide effects: Nephrolithiasis, hyperbilirubinemia, GI symptomsSaquinavir:1,000 mg + ritonavir 100 mg PO BIDSide effects: GI symptoms, hepatitisNelfinavir:1,250 mg PO BIDSide effects: Potential carcinogenic and teratogenic warning, GI symptoms, weakness, rashEfavirenz:Alternate expanded regimen for HIV postexposure prophylaxis: 600 mg PO in combination with (lamivudine + zidovudine) or(emtricitabine + zidovudine) or (lamivudine + tenofovir) or (emtricitabine + tenofovir)Side effects: Stevens " “Johnson syndrome, rash, sleep disruption, dizziness, psychiatric, teratogenFor some of the antiretroviral agents, the oncogenic and teratogenic effects are unknown.NRTIs and NtRTIs can result in lactic acidosis with hepatic steatosis.All can have serious drug interactions that lead to significant harm or death.
  • Hepatitis B:Hepatitis B immune globulin: 0.06 mL/kg IMHepatitis B virus booster: Unit-dose vial

Follow-Up

Disposition

Admission Criteria

Admission not necessary ‚

Discharge Criteria

Manage as outpatients with appropriate follow-up in occupational medicine clinic ‚

Additional Reading

  • Beltrami ‚ EM, Williams ‚ IT, Shapiro ‚ CN, et al. Risk and management of blood-borne infections in health care workers. Clin Microbiol Rev. 2000;13:385 " “407.
  • Panlilio ‚ AL, Cardo ‚ DM, U.S. Public Health Service, et al. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR Recomm Rep. 2005;54(RR-9):1 " “17.
  • U.S. Public Health Service. Updated U.S. Public Health Service Guidelines for the management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. MMWR Recomm Rep. 2001;50(RR-11):1 " “52.
  • National Clinicians ' Post-Exposure Prophylaxis Hotline: Phone (888) 448-4911; Available at Http://www.nccc.ucsf.edu. Accessed on January 29, 2013.
  • Centers for Disease Control and Prevention (CDC). Update: Influenza activity " “United States, September 30-December 1, 2007. MMWR Morb Mortal Wkly Rep. 2007;56(49):1287 " “1291.

Codes

ICD9

  • V01.79 Contact with or exposure to other viral diseases
  • V07.8 Other specified prophylactic or treatment measure
  • V15.85 Personal history of contact with and (suspected) exposure to potentially hazardous body fluids

ICD10

  • Z20.5 Contact with and (suspected) exposure to viral hepatitis
  • Z20.6 Contact w and (suspected) exposure to human immunodef virus
  • Z77.21 Contact w and exposure to potentially hazardous body fluids

SNOMED

  • 417981005 exposure to blood and/or body fluid (event)
  • 444491009 Exposure to viral hepatitis (event)
  • 444356002 exposure to Human immunodeficiency virus (event)