An Ounce of Prevention… Never re-cap your needles Never let your sharps containers overflow The sooner it gets into the container the better Consider sliding-sheath needles Warn the patient that the stick is coming Take it slow…
Tips on Needle Safety Wear gloves A needle that pierced a glove before piercing the skin is less likely to infect Don ’ t bend the needle It will behave unpredictably if it comes out of the skin Use tissue compression… carefully Your thumbnail provides some protection
Risk of Transmission of HIV A review of 23 studies of needle stick injuries to HCWs exposed to an HIV- infected source in the era before the introduction of antiretroviral therapy found the following: HIV transmission occurred in 20 of 6135 cases (0.33 percent) One case of HIV was transmitted out of 1143 exposures (0.09 percent) on the mucosa of the healthcare worker There were no cases after 2712 intact skin exposures
Documented Seroconversion As of June 2004, 57 HCWs in the United States had acquired occupational HIV infection as indicated by seroconversion in the context of a percutaneous occupational exposure to an HIV-infected source To date, there are no confirmed seroconversions in surgeons and no seroconversions with exposures from a suture needle.
Seroconversion Continued Exposure of source blood to intact skin is considered "no risk” There are no confirmed cases of HIV transmission in HCW with skin abrasions, cuts, sores or other breaches in skin integrity, but a theoretical risk is estimated at 1/1000
Risk Factors for Seroconversion A case-control study of needlestick injuries from an HIV-infected source (involving 33 cases who seroconverted and 655 controls) found the following risk factors for acquiring HIV: Deep injury (odds ratio [OR] 15) A device visibly contaminated with the patient's blood (OR 6.2) Needle placement in a vein or artery (OR 4.3) Terminal illness in the source patient (OR 5.6)
Postexposure Management Squeeze the wound to make it bleed Wash with soap and water Alcohol is virucidal
Postexposure Management Rapid HIV tests are available on site at many facilities Post exposure prophylaxis (PEP) should be initiated within 1-2 hours of the exposure A rapid HIV test result might be back by then Zidovudine appears to reduce risk of infection by 80% but is poorly tolerated Newer 3-drug regimens are considered superior
Postexposure Prophylaxis Experts currently recommend 3-drug regimens such as: tenofovir-emtricitabine with raltegravir tenofovir-emtricitabine, atazanavir and ritonavir tenofovir-emtricitabine, darunavir and ritonavir Combination antiretroviral therapy is significantly better than zidovudine in reducing perinatal transmission rates from 8% to <2% A similar reduction is likely in PEP
DURATION OF THERAPY The recommended duration of PEP is four weeks because ZDV for this duration appeared protective in some studies; however, the optimal duration of PEP is unknown. It is biologically plausible that shorter durations of PEP would be as effective, however current guidelines strongly recommend a four week course
Monitoring HIV serology should be performed at baseline, six weeks, twelve weeks and six months following the exposure Routine monitoring of HIV viral load in an attempt to detect early infection should generally not be performed because of the risk of false positive test results. However, such testing is appropriate in patients who have symptoms suggestive of the acute retroviral syndrome.
Hepatitis B Evaluate the patient for Hep B surface antigen and the vaccine-response status of the exposed person Postexposure prophylaxis (PEP) with hepatitis B immune globulin (HBIG) and/or hepatitis B vaccine series should be considered in light of the results of these tests In those HCWs who have not been vaccinated HBIG should be administered and the Hep B vaccine series should be initiated
Hepatitis C Exposure The average incidence of seroconversion to HCV after unintentional needle sticks or sharps exposures from an HCV-positive source is 1.8 percent (range, 0-7 percent). A study from Japan reported an incidence of HCV infection of 10 percent based upon detection of HCV RNA by reverse transcriptase polymerase chain reaction
Hepatitis C Prophylaxis and Monitoring Currently, there is no proven effective preexposure or postexposure prophylaxis for persons exposed to HCV The CDC recommends that persons exposed to an HCV-positive source have the following baseline and follow-up testing Baseline testing for anti-HCV, HCV RNA, and ALT Follow-up testing for HCV RNA between four and six weeks after exposure Follow-up testing for anti-HCV, HCV RNA, and ALT between four and six months after exposure