Needlestick and occupational exposure

01Purpose and principlesWhat the treatment does and how it fits into care.

Exposure risk is a product of fluid, route, source infectivity and inoculum. A blood-filled hollow-bore needle penetrating deeply carries more risk than a superficial solid sharp. Mucous membranes and damaged skin provide portals of entry, whereas intact skin blocks occupational transmission. The response must therefore be fast and proportionate rather than driven by fear or job title.

Immediate care has parallel strands: safe first aid, formal incident reporting, source assessment with consent, baseline assessment of the exposed person, and time-critical prophylaxis. A baseline negative HIV test documents pre-exposure status but cannot exclude infection from the current incident. Source testing can stop unnecessary PEP when reliable, but a delayed result must not postpone an indicated first dose. PEP is generally not recommended for a treated source only when ART has been taken for at least six months, the last HIV RNA is below 200 copies/mL and was measured within the previous six months, and adherence is good. Seek expert advice for stale or uncertain data, resistance or a major inoculation.

HIV, HBV and HCV pathways differ. HIV can be prevented with a 28-day antiretroviral course begun within 72 hours. HBV prevention uses documented vaccine response and sometimes vaccine or HBIG. HCV has no vaccine, immunoglobulin or established routine PEP, so early RNA-based detection and direct-acting-antiviral linkage are central.

Key points

First aid is immediate: encourage gentle bleeding from a puncture, wash with soap and running water, irrigate eyes or mouth with water, and never suck, scrub or use bleach on the wound.
A significant occupational route is percutaneous inoculation, mucous-membrane splash or contact with non-intact skin; intact-skin contact alone is not an HIV exposure.
Potentially infectious material includes blood and visibly blood-stained fluid. Urine, saliva, vomit, sweat, tears and faeces without visible blood do not justify HIV PEP.
For an HIV-negative or status-unknown exposed person after a qualifying exposure, start indicated PEP as soon as possible, preferably within 24 hours and no later than 72 hours; do not delay the first dose for unavailable source results.
Continue the recommended three-drug HIV PEP course for 28 days, then perform guideline-timed HIV testing; review early for tolerability, renal function, interactions and adherence.
PEP is generally not recommended for a treated source only when ART has been taken for at least six months, the last HIV RNA is below 200 copies/mL and was measured within the previous six months, and adherence is good. Seek expert advice for stale or uncertain data, resistance or a major inoculation.
Hepatitis B management depends on documented vaccination and anti-HBs response plus source HBsAg; hepatitis C has no vaccine or routine antiviral PEP, so follow-up testing and rapid linkage matter.
Never test a source without informed consent or use a discarded sharp for anonymous testing; protect confidentiality and follow the occupational reporting pathway.

02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.

Percutaneous inoculationRed flag

Needlestick, scalpel injury or bite that breaks skin and involves blood creates direct access to tissue and requires urgent BBV assessment.

Mucosal splashRed flag

Blood entering an eye, mouth or nose is a qualifying route; irrigate immediately and assess source infectivity and volume.

Non-intact skin contactRed flag

Blood contacting eczema, abrasion, dermatitis or an open wound can qualify even when the worker did not feel a sharp injury.

Intact skin non-exposure

Fluid on healthy unbroken skin is removed by washing and does not by itself justify HIV PEP.

High-inoculum featureRed flag

Deep injury, hollow-bore device, visible blood and prior placement in an artery or vein increase the amount potentially transmitted.

Red flags requiring action

A deep injury, hollow-bore needle, device visibly contaminated with blood or needle previously in a vessel increases inoculum and urgency.
Blood splash to eye or mouth, or blood contacting eczema, abrasion or another break in skin, is a mucocutaneous exposure even without a needle.
Known untreated or detectably viraemic HIV in the source makes a qualifying route high priority; do not wait for full resistance information. PEP is generally not recommended for a treated source only when ART has been taken for at least six months, the last HIV RNA is below 200 copies/mL and was measured within the previous six months, and adherence is good. Seek expert advice for stale or uncertain data, resistance or a major inoculation.
The source may carry hepatitis B or C even when HIV risk is low; complete a three-virus assessment and verify hepatitis B vaccination response.
The exposed worker may be pregnant, have renal disease or take interacting medicines; tailor the regimen without delaying an indicated first dose.

03Assessment before treatmentTests and checks that guide safe selection.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Exposure description and source assessmentFirst step
Why
Record time, device, depth, fluid, route, protective equipment and source HIV, HBV and HCV information.
Interpretation and limitations
Risk cannot be inferred from a generic needlestick label; combine source infectivity with an actual portal of entry and inoculum.
02
Exposed-person baseline HIV antigen-antibody test
Why
Document pre-exposure HIV status before or at PEP initiation.
Interpretation and limitations
A negative baseline does not exclude acquisition from this incident and must never delay an indicated first dose.
03
HBV serology and vaccine record
Why
Determine HBsAg exposure management using documented vaccination and anti-HBs response.
Interpretation and limitations
Verbal recall of vaccination is weaker than a record; vaccine and HBIG decisions are source- and responder-specific.
04
HCV antibody with RNA pathway
Why
Establish baseline and detect incident HCV at the recommended follow-up interval.
Interpretation and limitations
Antibody may remain negative early; HCV RNA detects viraemia and should trigger prompt specialist treatment rather than prophylactic antivirals.
05
Renal, hepatic and pregnancy assessment
Why
Select and monitor a safe PEP regimen without losing treatment time.
Interpretation and limitations
Abnormal results usually prompt regimen adjustment or specialist advice, not abandonment of indicated prevention.

04Treatment approachPreparation, options, escalation and aftercare.

01Immediate exposure pathwayClean, report and classifyFirst stepA sharp injury or splash occurs while handling blood or body fluid at work.

1Stop the task safely, encourage gentle bleeding of a puncture, wash with soap and water or irrigate exposed mucosa, and avoid caustic chemicals.
2Report immediately through occupational health or the out-of-hours route; document fluid, route, time, device and inoculum features.
3Assess all three BBVs, source information with consent, exposed-person status and whether HIV PEP must start before further results return.

02HIV PEP pathwayTreat a qualifying HIV risk nowPercutaneous, mucosal or non-intact-skin exposure involves infectious fluid from a source with transmissible or credibly possible HIV.

1Start PEP as soon as possible, preferably within 24 hours and no later than 72 hours, after drawing baseline samples if this causes no delay.
2Provide the current recommended three-drug regimen for 28 days, check interactions and renal function, and arrange early review rather than issuing medicine without support.
3Stop or modify only on expert review when source testing, resistance, toxicity or reclassification changes the balance; complete scheduled HIV testing. PEP is generally not recommended for a treated source only when ART has been taken for at least six months, the last HIV RNA is below 200 copies/mL and was measured within the previous six months, and adherence is good. Seek expert advice for stale or uncertain data, resistance or a major inoculation.

03Hepatitis pathwaySeparate HBV prevention from HCV detectionBlood exposure creates possible hepatitis B or C transmission.

1Verify HBV vaccine doses and documented anti-HBs, test the source when consented, and give vaccine or HBIG according to the Green Book table.
2For HCV, document baseline testing and schedule early RNA and later serology according to occupational guidance because routine antiviral PEP is not recommended.
3Communicate results confidentially, manage any seroconversion promptly and review prevention or work-practice issues without blame.

05Regimens, contraindications and interactionsTreatment details and the circumstances that modify them.

Reduces the probability that a qualifying recent HIV exposure establishes systemic infection.

HIV post-exposure prophylaxis

Start the current recommended three-drug oral regimen immediately and continue for 28 days; use the specialist alternative selected for renal disease, pregnancy, interactions or source resistance.

Check baseline HIV status, renal and hepatic function, pregnancy, hepatitis B, interacting antacids and medicines; do not delay initiation while non-immediate results are pending.

Provides active and selected passive protection after occupational hepatitis B exposure.

Hepatitis B vaccine and immunoglobulin

Give vaccine booster or course and, when indicated, hepatitis B immunoglobulin at the current Green Book dose and timing for the source category and documented responder status.

HBIG does not prevent HIV or HCV; use documented anti-HBs and HBsAg information, and arrange completion plus post-vaccination testing where required.

06Complications, monitoring and follow-upAdverse effects, response and longer-term review.

Review within days to assess PEP tolerance, adherence, renal function, interactions, mental health and whether reliable source results alter the indication.
Perform HIV testing at the current post-exposure or post-PEP interval, adding HIV RNA assessment if symptoms suggest seroconversion.
Complete HBV vaccine doses and anti-HBs testing when required, and escalate if the worker is a non-responder or the source is HBsAg positive.
Use the occupational HCV schedule with early RNA testing and later serology; link detected viraemia rapidly to treatment.
Record incident analysis and safer systems while preserving worker and source confidentiality and avoiding punitive assumptions.

07Special situationsVariants, exceptions and circumstances that change the usual approach.

Route and fluid must combine

A high-risk source does not create transmission through intact skin, while an apparently small hollow-bore puncture can deliver a meaningful inoculum.

Baseline is a timestamp

Negative testing immediately after injury documents status before exposure and cannot reassure about infection acquired minutes earlier.

PEP urgency precedes certainty

When the exposure clearly qualifies, begin within the window and revise later instead of waiting for every laboratory result.

Undetectable changes the balance

Documented sustained HIV RNA below 200 copies/mL usually removes the PEP indication, but stale results or adherence uncertainty need expert review.

Three viruses need different actions

HIV uses antiretroviral PEP, HBV uses immunity-guided vaccine or HBIG, and HCV relies on detection and treatment.

08Common pitfallsFrequent interpretation and management errors.

01
Scrubbing a puncture, sucking the wound or applying bleach.
02
Calling every fluid splash a significant HIV exposure without checking route and visible blood.
03
Waiting beyond 72 hours for source results before starting indicated HIV PEP.
04
Assuming an HBV vaccine history proves protective anti-HBs response.
05
Prescribing immunoglobulin or antiviral PEP for hepatitis C.

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