Occupational Needle-Sticks & HIV PEP
Comprehensive emergency protocol for occupational healthcare worker bloodborne pathogen exposures and needle-stick injuries. Covers percutaneous transmission risks for Hepatitis B, Hepatitis C, and HIV ('Rule of 3s'), the strict 72-hour window for post-exposure prophylaxis (PEP), CDC preferred 3-drug 28-day antiretroviral regimens (Biktarvy vs. Dolutegravir + Truvada), and complete Hepatitis B vaccination and HBIG algorithms.
Resuscitation Quick Actions • First 2 Minutes
Immediate Wound Care
Wash needle-stick or puncture site with soap and water for 5 minutes; flush mucous membranes with copious sterile saline; DO NOT milk or squeeze wound (does not decrease transmission and increases micro-trauma).
Transmission Probability 'Rule of 3s'
Hepatitis B (HBeAg+ source) ~ 30%; Hepatitis C ~ 3%; HIV ~ 0.3% (3 in 1,000 percutaneous) and 0.09% (mucous membrane).
HIV PEP Timing
Must start within 72 hours of exposure; 28-day course of 3-drug antiretroviral therapy; dispense a 3-7 day starter pack directly in the ED.
Preferred HIV PEP Regimen
Biktarvy (Bictegravir/Emtricitabine/Tenofovir alafenamide) 1 tablet PO daily x 28 days OR Dolutegravir 50 mg PO daily PLUS Truvada (Tenofovir DF/Emtricitabine) 1 tablet PO daily.
Hepatitis B PEP
If exposed worker is unvaccinated or known non-responder -> Administer Hepatitis B Immune Globulin (HBIG 0.06 mL/kg IM) + first dose of Hep B vaccine series within 24 hours.
Hepatitis C
NO effective post-exposure prophylaxis exists; obtain baseline HCV Ab and RNA PCR; if seroconversion occurs at 4-6 weeks, refer for curative Direct-Acting Antivirals (DAAs).
Bottom-Line Clinical Pearl
Occupational HIV Post-Exposure Prophylaxis (PEP) must be initiated as soon as possible after exposure, ideally within 2 hours, and no later than 72 hours. Administer the first dose immediately in the emergency department using modern single-tablet 3-drug regimens (Biktarvy or Dolutegravir + Truvada) for 28 days. Never squeeze or milk a puncture wound.
The risk of bloodborne viral transmission following a percutaneous hollow-bore needle injury from a known infected source patient follows the classic 'Rule of 3s':
| Pathogen | Percutaneous Transmission Risk (Hollow-Bore Needle) | Mucous Membrane Transmission Risk | Post-Exposure Prophylaxis (PEP) Availability |
|---|---|---|---|
| Hepatitis B Virus (HBV) | ~ 30% (if source is HBeAg positive); ~ 1-6% if HBeAg negative | Clinically significant | HIGHLY EFFECTIVE: Hepatitis B Immune Globulin (HBIG) + Hepatitis B Vaccine series initiated within 24 hours (reduces transmission by > 90%). |
| Hepatitis C Virus (HCV) | ~ 1.8% to 3.0% | Extremely rare (< 0.1%) | NO POST-EXPOSURE PROPHYLAXIS AVAILABLE. Immunoglobulin and antivirals are NOT recommended for prophylaxis. Perform baseline HCV Ab and HCV RNA; repeat RNA at 4-6 weeks; curative direct-acting antivirals (DAAs) achieve > 98% cure if transmission occurs. |
| Human Immunodeficiency Virus (HIV) | ~ 0.3% (approximately 1 in 330 percutaneous exposures) | ~ 0.09% (approximately 1 in 1,000 splash exposures) | HIGHLY EFFECTIVE: 3-drug antiretroviral PEP regimen started within 72 hours and continued for 28 days reduces transmission by > 81-90%. |
Immediate First-Aid Rule: Never Squeeze or Milk the Wound
Immediately wash contaminated puncture wounds with gentle soap and water for 5 minutes. Flush eyes or mucous membranes with copious saline or tap water. DO NOT squeeze, milk, or apply tourniquets to the puncture site, and DO NOT instill caustic antiseptics (bleach, alcohol, iodine). Squeezing induces local tissue hyperemia and micro-tears that actually increase viral uptake into regional capillary beds.
CDC guidelines mandate initiating PEP as rapidly as possible—ideally within 2 hours, and strictly within a 72-hour window. Provide a 3-to-7 day starter pack directly from the emergency department to ensure no doses are missed while awaiting outpatient pharmacy fulfillment:
| Regimen Category | Medications & Exact Adult Dosing | Clinical Advantages & Pregnancy Considerations |
|---|---|---|
| Preferred Single-Tablet Regimen (First-Line) | Biktarvy: Bictegravir 50 mg/Emtricitabine 200 mg/Tenofovir alafenamide (TAF) 25 mg — 1 tablet PO once daily with or without food for 28 days. | Single daily tablet; superior patient compliance; lowest rates of nausea and GI side effects; minimal renal/bone toxicity due to TAF backbone. |
| Preferred Multi-Tablet Regimen | Dolutegravir (Tivicay) 50 mg PO once daily PLUS Truvada (Tenofovir DF 300 mg/Emtricitabine 200 mg) 1 tablet PO once daily for 28 days. | Potent integrase strand transfer inhibitor (INSTI) with high barrier to resistance; standard global reference regimen. |
| Alternative/Pregnancy Regimen | Dolutegravir 50 mg PO daily PLUS Truvada 1 tablet PO daily OR Raltegravir (Isentress) 400 mg PO BID PLUS Truvada 1 tablet PO daily. | Safe and approved across all trimesters of pregnancy. Tenofovir disoproxil fumarate (TDF) and emtricitabine have extensive safety data in pregnancy. |
| Exposed Healthcare Worker HBV Status | Source Patient HBsAg Positive | Source Patient HBsAg Negative | Source Patient Unknown/Untestable |
|---|---|---|---|
| Documented Vaccinated RESPONDER (anti-HBs >= 10 mIU/mL) | NO TREATMENT REQUIRED (complete immune protection) | NO TREATMENT REQUIRED | NO TREATMENT REQUIRED |
| Documented Vaccinated NON-RESPONDER (anti-HBs < 10 mIU/mL after 2 complete series) | Administer HBIG (0.06 mL/kg IM) x 2 doses (1st dose immediately, 2nd dose 1 month later) OR HBIG x 1 + start new vaccine series | NO TREATMENT REQUIRED | Treat as if source is HBsAg positive: Administer HBIG (0.06 mL/kg IM) x 2 doses |
| UNVACCINATED or Incompletely Vaccinated | Administer HBIG (0.06 mL/kg IM) ONCE immediately within 24 hours + INITIATE 3-DOSE HEP B VACCINE SERIES (Days 0, 1 month, 6 months) at separate anatomic site | Initiate and complete the 3-dose Hepatitis B vaccine series | Initiate and complete the 3-dose Hepatitis B vaccine series |
| Vaccinated with UNKNOWN Response/Titer | Test exposed worker for anti-HBs STAT: If >= 10 mIU/mL -> no treatment. If < 10 mIU/mL -> administer HBIG x 1 dose + vaccine booster | NO TREATMENT REQUIRED | Test exposed worker for anti-HBs: If < 10 mIU/mL, administer 1 vaccine booster dose and recheck in 1-2 months |
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