MANAGEMENT OF THE EMPLOYEE WITH A NEEDLESTICK INJURY
Accidental needle punctures are a frequent hospital problem and a threat to the health of medical personnel. The reported rate is approximately 19 sharp injuries per 100 employees annually. Many needlestick injuries are not reported; in one study, 90% went unreported. Needlestick injuries account for nearly one third of all work-related accidents in the hospital and are second only to musculoskeletal injuries as a cause of work-related illness. Of the reported needlesticks, about 90% occur among nursing personnel, housekeepers, and laboratory technicians. Registered nurses experience at least half of all needlestick injuries. The nursing activities during which most of the needlesticks occur are recapping needles, drawing blood, and administering an injection or infusion. Among housekeeping personnel, needlesticks usually result from handling trash containing improperly disposed needles. Laboratory workers report that most of the needle punctures happen while they are drawing blood and recapping needles. IV systems without needles have decreased the rate of sharp injuries. However, needlesticks still occur because compliance with these devices may be only 50%.
Serious disease and considerable cost can result from needlestick injuries. Transmission of HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) poses the greatest risk associated with accidental needlesticks for hospital personnel. Other examples of infection that can be transmitted by needlestick punctures are tetanus, tuberculosis, syphilis, malaria, and Rocky Mountain spotted fever. Postexposure prophylaxis, however, should be directed at preventing only HIV, HBV, and HCV infection, not the other illnesses. Except for HIV infection and viral hepatitis, the frequency of transmission of potentially transmissible diseases from a needle puncture is extremely low and is at the level of a case report.
Before the 1980s, the major fear of a health care provider following a needlestick was the development of hepatitis B. The risk for transmitting hepatitis B from an infected patient to a susceptible health care provider following a sharp injury was estimated to be 5% to 35%. The risk for HIV transmission after a percutaneous exposure is about 0.3% to 0.4%. The widespread use of hepatitis B vaccine and the availability of postexposure hepatitis B immune globulin (HBIG) has reduced considerably the risk and fear of acquiring hepatitis B following a sharp injury. Today, the greatest concern of health care providers is to prevent the acquisition of HIV infection as the result of a sharp injury or cutaneous or mucous membrane exposure. Hospital personnel practices have been transformed with the use of double gloving, waterproof gowns, protective eye wear, and face shields. It is estimated that between 27 and 46 HIV seroconversions occur annually per 100,000 hospital personnel at risk. Surgeons and emergency medicine physicians at large urban centers may be at even greater risk. Efforts to reduce the occupational risk for acquiring HIV infection should encompass the following measures:
Improve the reporting rates of sharp injuries.
Realize that the risk for acquiring HIV infection is lowest for cutaneous and mucous membrane exposures and highest for transfusions and IM inoculations.
Evaluate the source patient for HIV and obtain a baseline serum on the exposed health care worker.
Consider using postexposure chemoprophylactic treatment of high-risk exposures. Early initiation (within 1 to 2 hours) of prophylaxis is recommended, although failures have occurred when the drug was begun as soon as 30 minutes to 12 hours after an exposure. Zidovudine has been relatively well tolerated, but long-term effects are unknown (Table 60-1).
Table 60-1. Recommendations for chemoprophylaxis after occupational exposure to HIV, by type of exposure and source material
Direct efforts at reducing sharp injuries and developing safer devices.
Hepatitis B can be transmitted by percutaneous inoculation (needlestick), mucous membrane inoculation, sexual intercourse with an infected person, or perinatally from an infected mother to her infant. Any of these routes can be classified as critical exposure. In a hospital, needlesticks and mucous membrane inoculation are the only routes of transmitting hepatitis. Blood that is positive for HBsAg (hepatitis B surface antigen) and HBeAg (hepatitis B early antigen) is infectious even at a dilution of 10-8. The presumption is that HBsAg does not cross intact skin but enters only at the site of broken skin.
HCV is an RNA virus that can be transmitted by a needlestick or sharp injury. The rate of seroconversion is about 2% (range, 0 to 7%). One study in which the polymerase chain reaction (PCR) technique was used found a seroconversion rate of 10% after a needlestick. Infection is rare after a mucous membrane or nonintact skin exposure. A case report describes the transmission of HCV following a blood splash to the conjunctiva. Figure 60-1 outlines guidelines for managing a possible HCV exposure. If the source is positive for HCV, then the serologic status of the exposed person must be determined. A variety of tests are available to detect HCV, including antibody enzyme immunoassay (EIA) and recombinant immunoblot assay (RIBA). The sensitivity of the new EIA is about 92%. If the EIA result is positive, then an RIBA is ordered. If the RIBA result is positive, then measure the HCV RNA with PCR. The PCR result can be positive for HCV RNA in 1 to 3 weeks after an exposure. Unfortunately, results of the PCR test for HCV RNA are frequently false-positive or false-negative. Persons exposed to an HCV-positive source should at present have a baseline EIA and liver function tests, and these should be repeated at 6 months. The role of interferon for HCV seroconversion is limited. Immune globulin (IG) is not beneficial (Fig. 60-1).
Figure 60-1. Management of a possible HCV exposure. aAssess HCV status of exposed person at baseline and repeat assessment at 3 months and 6 months. HCV RNA can be detected in the blood in 1 to 3 weeks by PCR, but false-positives and false-negatives occur. bRIBA, recombinant immunoblot assay.
A number of questions must be answered relating to the management of an employee who has recently had a needlestick injury:
Has the employee had a critical exposure? Critical exposures include percutaneous punctures and mucous membrane contact. Blood-to-hand contact does not require prophylaxis unless cuts are present on the hand. The skin is an excellent barrier against hepatitis B; however, dermatologic disease is extremely common in hospital employees, and if skin disease is present, then IG prophylaxis can be recommended depending on the hepatitis status of the blood source and the hepatitis B immunity of the employee. Stool contact does not constitute critical exposure unless the stool is from a patient who has gastrointestinal bleeding.
What is the hepatitis status of the source of the inoculum? If the source is found to be HBsAg-positive, the recipient of the needlestick should receive HBIG immediately unless immune. If the source is found to HBsAg-negative, there is little risk for transmission of hepatitis B, and prophylaxis to prevent hepatitis B is not indicated. If the source is found to be HBsAg-negative and positive for anti-HBc (antibody to hepatitis B core antigen), the source is probably not infectious for hepatitis B after a needlestick. Blood that is positive for anti-HBc, however, may be infectious when it is transfused, but the inoculum is considerably smaller after a needlestick than after a transfusion. Blood that is HBsAg-positive and positive for either HBeAg or anti-HBe (antibody to HBe antigen) must be considered infectious, although the risk is far greater if the blood is positive for both HBsAg and HBeAg. Table 60-2 outlines an approach to managing persons after a percutaneous (needlestick, laceration, or bite) or permucosal (ocular or mucous membrane) exposure to blood. The therapeutic decisions are based on the HBsAg status of the source blood and the anti-HBs status of the recipient of the exposure.
Table 60-2. Recommendations for hepatitis B prophylaxis following percutaneous or permucosal exposure
What is the risk for hepatitis B following a needlestick if the blood status of the source is unknown and cannot be determined? If the source is unknown, the risk for acquiring hepatitis B is extremely low (1/2,000), and HBIG prophylaxis is unnecessary for that exposure.
What is the immune status of the recipient of the needlestick? If the serologic test on the recipient shows evidence of immunity (blood positive for anti-HBs), HBIG is unnecessary. Usually, the serologic result of the source of the blood is available before the immune status of the recipient is known. Whether HBIG is administered or not depends on the test results.
When should HBIG be administered? As soon as the results of the HBsAg test on the blood source are available, HBIG can be given if the blood source is found to be HBsAg-positive. HBIG is effective if given within 7 days of the exposure, but the sooner it is administered, the more effective it probably will be.
When should hepatitis C be suspected? Hepatitis C should be suspected if the source of the blood (donor) has a history of unexplained chronic liver disease, has received several blood transfusions, has hemophilia, is on long-term hemodialysis, or is a drug addict. Hepatitis C has been transmitted by accidental needlestick or sharp injury; the average incidence of anti-HCV seroconversion was 1.8% (range, 0 to 7%).
Is effective prophylaxis available to prevent hepatitis B after a critical exposure to HBsAg-positive blood? Both IG and HBIG are effective in postexposure prophylaxis. One study showed that clinical type B hepatitis was reduced further with HBIG than with IG (2% vs. 8%); however, subclinical infection occurred more often with HBIG prophylaxis, and overall infection occurred equally in both groups. In another report, there was no difference in the percentages of patients in whom hepatitis developed between those who received normal-titer IG and those who received HBIG. Evidence of hepatitis B appeared after postexposure prophylaxis with IG or HBIG in 7% of patients. Despite these reports, most authorities recommend HBIG for those who sustain a needlestick with blood from an HBsAg-positive donor. A second dose of HBIG is given after 1 month if the recipient of the needlestick is found to be susceptible to hepatitis B (lacking anti-HBs at the time of the needlestick exposure) and has refused hepatitis vaccine. The use of HBIG or IG is not contraindicated in pregnancy. There is also no evidence that AIDS is transmitted with either IG or HBIG.
Is IG effective in preventing hepatitis C after a needlestick exposure? Current IG lacks protective antibody against HCV.
What is the role of hepatitis B vaccine after a needlestick? The HBIG is only about 75% effective, is very expensive ($150 per dose), and provides only temporary protection. Because of these considerations, hepatitis B vaccine can be given along with HBIG after a needlestick exposure if the recipient is negative for anti-HBs. A second dose of HBIG is unnecessary if the hepatitis B vaccine is administered. The response to hepatitis B vaccine is not impaired by concurrent administration of HBIG. A dose of vaccine is repeated after 1 month and 6 months.
What is the therapy for a critically exposed recipient of blood that is HBsAg-positive who has received a single dose of vaccine? A single dose of HBIG is indicated if the recipient has received only one dose of hepatitis B vaccine. If a person has received at least two doses of hepatitis B vaccine before a needlestick, no treatment is necessary if serologic tests show adequate levels of anti-HBs.
How should a person who has received the complete hepatitis B vaccine series be managed following a percutaneous or other critical exposure to a source known to be HBsAg-positive? First, test the person for the level of anti-HBs. If the antibody level is greater than or equal to 10 sample ratio units by radioimmunoassay, no treatment is necessary. If inadequate antibody levels are found, give one dose of HBIG and a booster dose of vaccine. If the person has had adequate anti-HBs levels within the past year, no treatment is necessary. The anti-HBs titer determination is repeated if the test was performed more than 1 year before. If the exposed person is known to have inadequate antibody levels, administer one dose of HBIG and one booster dose of hepatitis B vaccine.
How many health care workers are infected yearly in the United States with HIV from an occupational exposure? About five to 10 cases occur yearly. An acute retroviral illness develops in 75% of these cases.
How long should postexposure prophylaxis be given? The guidelines suggest a 4-week treatment period, but this is arbitrary. A shorter (1- to 2-week course) with a two- or three-drug regimen may be appropriate, but data are lacking.
How long should a health care worker be monitored after exposure to detect HIV seroconversion? Ninety-five percent of seroconversions occur within 6 months. If an exposed health care worker has a possible acute retroviral illness within the first 6 months, a high-risk exposure, an illness associated with impaired antibody production, or HCV infection, then a 1-year follow-up is indicated.
When should postexposure prophylaxis be administered? Preferably, start antiretroviral drugs within 1 to 2 hours. Indications for therapy are based on the type of exposure and source material.
A flowchart of therapy to prevent HBV, HCV, and HIV infection for the person who sustains a needlestick injury is presented in Fig. 60-2. (N.M.G.)
Figure 60-2. Recommended therapy to prevent HBV, HCV, and HIV infection after an exposure.
Bell DM, Gerberding JL. Human immunodeficiency virus (HIV) postexposure management of health care workers. Am J Med 1997;102:1–126.
The entire issue is devoted to HIV postexposure management. The Public Health Service suggests that an exposed health care provider be followed for 6 months (e.g., 6 weeks, 12 weeks, and 6 months) to detect HIV seroconversion.
Cardo DM, et al. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. N Engl J Med 1997;337:1485–1490.
Factors associated with an increased risk for HIV transmission include deep injury, injury with a device that is visibly contaminated with blood, procedures that involve inserting a needle into the source patient’s artery or vein, and a terminally ill source patient.
Centers for Disease Control and Prevention. Update: provisional Public Health Service recommendations for chemoprophylaxis after occupational exposure to HIV. MMWR Morb Mortal Wkly Rep 1996;45:468–472.
Prophylaxis was associated with a 79% decreased risk for HIV seroconversion.
Centers for Disease Control and Prevention. Immunization of health care workers: recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR Morb Mortal Wkly Rep 1997;46(RR18):3–10, 14–17, 22–23.
Centers for Disease Control and Prevention. Evaluation of safety devices for preventing percutaneous injuries among health care workers during phlebotomy procedures, Minneapolis-St. Paul, New York City, and San Francisco, 1993–1995. MMWR Morb Mortal Wkly Rep 1997;46:21–25.
Injuries associated with phlebotomy account for 39% of cases of HIV seroconversion. Use of safety devices can decrease the sharp injuries related to phlebotomy.
Centers for Disease Control and Prevention. Evaluation of blunt suture needles in preventing percutaneous injuries among health care workers during gynecologic surgical procedures, New York City, March 1993–June 1994. MMWR Morb Mortal Wkly Rep 1997;46:25–29.
Blunt rather than curved suture needles were associated with fewer sharp injuries.
Centers for Disease Control and Prevention. Recommendations for follow-up of health care workers after occupational exposure to hepatitis C virus. MMWR Morb Mortal Wkly Rep 1997;46:603–606.
Guidelines for the management of an HCV exposure.
Centers for Disease Control and Prevention. Public Health Service guidelines for the management of health care worker exposures to HIV and recommendations for postexposure prophylaxis. MMWR Morb Mortal Wkly Rep 1998;47(RR7):1–33.
Guidelines for HIV postexposure prophylaxis.
Dienstag JL, et al. Hepatitis B vaccine in health care personnel: safety, immunogenicity, and indicators of efficacy. Ann Intern Med 1984;101:34.
Ninety-seven percent of vaccine recipients responded to three doses of vaccine.
Folin AC, Nordström GM. Accidental blood contact during orthopedic surgical procedures. Infect Control Hosp Epidemiol 1997;18:244–246.
Blood exposure occurred in 11% of orthopedic procedures, mostly with skin contamination (79%) and percutaneous injury (13%).
Gerberding JL, et al. Risk of exposure of surgical personnel to patients’ blood during surgery at San Francisco General Hospital. N Engl J Med 1990;322:1788.
Parenteral exposures occurred in 1.7% of operations. Risk was greatest with procedures lasting more than 3 hours, blood loss exceeding 300 mL, and major vascular and intraabdominal gynecologic surgery.
Hoofnagle JH, et al. Passive-active immunity from hepatitis B immune globulin. Ann Intern Med 1979;91:813.
Efficacy of HBIG documented.
Ippolito G, et al. The risk of occupational human immunodeficiency virus infection in health care workers. Arch Intern Med 1993;153:1451.
The rate of seroconversion was 0.25% after percutaneous exposure and 0.09% after mucous membrane contamination. The rate of seroconversion after HIV contamination of nonintact skin is even lower than with a mucous membrane exposure.
Knodell RB, et al. Efficacy of prophylactic gamma globulin in preventing non-A, non-B posttransfusion hepatitis. Lancet 1976;1:557.
Gamma globulin may be effective in reducing the severity of posttransfusion hepatitis C. Its value in preventing hepatitis C secondary to a needlestick is unknown. Gamma globulin used today has no role in the prevention of hepatitis C.
Lawrence LW, et al. The effectiveness of a needleless intravenous connection system: an assessment by injury rate and user satisfaction. Infect Control Hosp Epidemiol 1997;18:175–182.
Use of a needleless IV connection system was associated with about a 50% reduction in needlesticks.
L’Ecuyer PB, et al. Randomized prospective study of the impact of three needleless intravenous systems on needlestick injury rates. Infect Control Hosp Epidemiol 1996;17:803–808.
Needlestick injuries can occur despite the availability of needleless devices.
Mangione CM, Gerberding JL, Cummings SR. Occupational exposure to HIV: frequency and rates of underreporting of percutaneous and mucocutaneous exposures by medical house staff. Am J Med 1991;90:85.
Only 30% of sharp injuries were reported by the house staff.
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Testing of source blood is unnecessary in injuries caused by needles from peripheral IV lines and distal ports of central lines unless blood is seen.
McCormick RD, et al. Epidemiology of hospital sharps injuries: a 14-year prospective study in the pre-AIDS and AIDS eras. Am J Med 1991;91(Suppl3B):301S–307S.
Injuries occurred during disposal of used procedure trays (20%), administration of parenteral drugs (16%), surgery (16%), blood drawing (13%), and recapping of used needles (10%).
Management of Hepatitis C. NIH Consensus Statement 1997;15:1–41.
Review of hepatitis C.
Noguchi S, et al. Early therapy with interferon for acute hepatitis C acquired through a needlestick. Clin Infect Dis 1997;24:992–994.
Case reports of a short course of interferon used to treat two patients in whom HCV infection developed after a needlestick.
O’Neill TM, Abbott AV, Radecki SE. Risk of needlesticks and occupational exposures among residents and medical students. Arch Intern Med 1992;152:1451.
Only 9% of exposures were reported. Residents and students cited being too busy as the main reason for not reporting.
Patel N, Tignor GH. Device-specific sharps injury and usage rates: an analysis by hospital department. Am J Infect Control 1997;25:77–84.
Reported injury rates per 100,000 devices. Injury rates were 11.1/100,000 for butterfly needles and 8.5/100,000 for IV catheters.
Petrosillo N, et al. The risks of occupational exposure and infection by human immunodeficiency virus, hepatitis B virus, and hepatitis C virus in the dialysis setting. Am J Infect Control 1995;23:278–285.
In this dialysis unit, a seroprevalence survey revealed HIV antibody (0.1%), HBsA (5.1%), and HCV antibody (39.4%).
Puro V, Petrosillo N, Ippolito G. Risk of hepatitis C seroconversion after occupational exposures in health care workers. Am J Infect Control 1995;23:273–277.
Risk for HCV seroconversion after a hollow-bore needlestick was 1.2% and 0 after mucous membrane contamination.
Resnic FS, Noerdlinger MA. Occupational exposure among medical students and house staff at a New York City Medical Center. Arch Intern Med 1995;155:75–80.
Half of the surgical house officers, 27% of students, and 20% of medical house staff noted an exposure (sharp injury, mucous membrane, or broken skin) to a patient’s blood within the past 6 months.
Ridzon R, et al. Simultaneous transmission of human immunodeficiency virus and hepatitis C virus from a needlestick injury. N Engl J Med 1997;336:919–922.
A rare example of delayed HIV seroconversion 9.5 months after a needlestick. Most cases (95%) of HIV seroconversion occur within 6 months.
Tokars JI, et al. Surveillance of HIV infection and zidovudine use among health care workers after occupational exposure to HIV-infected blood. Ann Intern Med 1993;118:913.
Rate of seroconversion after percutaneous exposure to HIV-infected blood was 0.36%. Failures of zidovudine prophylaxis have occurred.