SN5 SHORT NOTE 5M ★ High-yield

Describe needlestick injury and its post-exposure management.

Microbiology · 2nd Professional — Para-Clinical

The Risk

A sharps or needlestick injury is percutaneous inoculation, or contact of broken skin or mucous membrane, with blood or another potentially infectious body fluid. It is the commonest occupational exposure in healthcare.

Virus	Risk per percutaneous exposure to a positive source	Prevention
Hepatitis B	Up to 30% (about 6 to 30%, higher if the source is HBeAg positive) — roughly 100 times more transmissible than HIV	An effective vaccine exists; this is the one that is entirely preventable in advance
Hepatitis C	About 1.8% (1 to 3%)	NO vaccine and NO effective post-exposure prophylaxis; monitoring, with early treatment if infection occurs
HIV	About 0.3% percutaneous; about 0.09% for mucous membrane exposure — much lower than is generally feared	Post-exposure prophylaxis, which is highly effective

Factors increasing risk — a deep injury, visible blood on the device, a hollow-bore needle (which carries more blood than a suture needle), a needle that was in the source's artery or vein, and a high viral load in the source
Commonest circumstances — recapping needles, disposal-related injuries, handling used sharps left on trolleys or beds, injury during suturing, and injuries to housekeeping and waste staff from improperly discarded sharps — a group at high risk and frequently overlooked
Under-reporting is the norm, particularly among doctors and surgeons, and it is the main obstacle to prophylaxis being given in time

CLINICAL PEARL

Hepatitis B is the greatest risk and the only one you can eliminate before it happens. It is about a hundred times more transmissible than HIV, yet attention and anxiety after a needlestick focus almost entirely on HIV. A healthcare worker who is vaccinated and has documented anti-HBs above 10 mIU/mL is protected, needs no hepatitis B prophylaxis after any exposure, and has removed the largest component of occupational risk permanently. Every student should be vaccinated and have the antibody titre checked.

Immediate Management

1. First aid immediately — wash the wound with soap and running water
irrigate mucous membranes and eyes copiously with water or saline.
Do not squeeze, scrub, or apply bleach, alcohol or antiseptic to the wound, and do not suck it — these damage tissue and do not reduce transmission → 2.
Report immediately to the designated officer — delay is the main reason prophylaxis fails → 3.
Assess the exposure — the fluid involved, the route, the depth, and the device → 4.
Assess the source — test for HBsAg, anti-HCV and HIV with consent, using a rapid test where available → 5.
Assess the exposed person — hepatitis B vaccination status and anti-HBs titre, and baseline HIV, HCV and liver function → 6.
Give prophylaxis as indicated — and for HIV, within hours, ideally within 2 and certainly within 72 → 7.
Counsel, follow up and document

Virus	Post-exposure action
Hepatitis B	If the exposed person is vaccinated and a known responder (anti-HBs above 10) — nothing is needed. If unvaccinated or a non-responder, and the source is positive or unknown — hepatitis B immunoglobulin plus the vaccine course, started within 24 hours and certainly within 7 days
Hepatitis C	NO immunoglobulin and NO prophylaxis. Baseline and follow-up anti-HCV, with HCV RNA at 4 to 6 weeks; if seroconversion occurs, early direct-acting antiviral treatment cures over 95%
HIV	PEP with a three-drug regimen — in India commonly tenofovir, lamivudine and dolutegravir — for 28 days, started as soon as possible, ideally within 2 hours. The first dose should not wait for formal counselling or for the source result. Follow-up testing at 6 weeks, 3 months and 6 months
Tetanus	Consider prophylaxis for a contaminated injury

Prevention and Applied Aspects

Never recap a needle; if recapping is unavoidable, use the one-handed scoop technique. Recapping remains the commonest single cause of injury
Dispose of the sharp yourself, immediately, at the point OF use, into a puncture-proof container that is sealed at three-quarters full — never pass a used sharp to another person and never leave one on a trolley or bed
Use safety-engineered devices where available — retractable needles, needleless connectors, blunt suture needles — and needle destroyers, which are widely used in India
Adopt the "hands-free" or neutral zone technique in theatre, placing sharps in a designated tray rather than passing them hand to hand; and announce sharps
Vaccinate against hepatitis B and check the response — this is the most important single measure, and every medical and nursing student should be vaccinated before clinical contact
Report every exposure, however trivial it seems and however senior the person; under-reporting by doctors is well documented and denies them prophylaxis and follow-up they may need
Universal precautions protect against all three viruses at once, and are applied to every patient rather than to those known to be infected — because most infectious sources are not known to be infectious at the time
Do not delay PEP for the source result; start it and stop it later if the source proves negative, since effectiveness falls sharply with every hour

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