Management of needlestick injuries and other accidental blood exposure
There is evidence that the risk of infection is reduced by the
use of post exposure prophylaxis with anti-retroviral drugs, by as much as
79%400. The management of needlestick injuries should be according to
local guidelines and antiretroviral drugs should be used for significant injury,
if available in the country. Recent guidelines have set out recommendations for
the use of antiretrovirals in these cases 379, 401, 402, 403, 404,
405.
First aid treatment
First aid measures should be undertaken as soon as possible
after injury. These should include decontamination of the exposure site as soon
as possible, allowing a needlestick injury or cut to bleed, washing the area
with chlorhexidine or other antiseptic and decontaminating exposed mucosa or
conjunctivae by vigorous flushing with water.
Assessment of risk following exposure
A clinical assessment should be made about the level of risk
following exposure. This is based upon the following factors:
A. THE NATURE OF THE INJURY:
|
Puncture: type of needle [hollow or
solid]
depth of penetration
volume of blood
thought to have been
injected
Laceration
Mucosal
contamination
Contamination of non intact skin
Bite |
B. THE SOURCE OF EXPOSURE:
|
Blood, blood products, body fluids, amniotic fluid, semen and
vaginal secretions are associated with transmission of HIV, while stool and
urine are not |
C. THE SOURCE PATIENT:
|
Clinical condition or available laboratory results such as viral
load |
Counselling and testing of the source patient
HIV testing should be offered to all source patients, with their
informed consent. Where such consent is not available (for example in a comatose
or anaesthetized patient), this consent should be obtained from a relative or
senior medical staff member. Where the source patient does not wish to know the
HIV result, it may be acceptable to offer to take blood for the test (for the
protection of the health care worker), without disclosing the result to the
source patient. In practice, very few patients refuse consent and most are
extremely concerned about health worker risk.
Counselling and testing of the health worker
A baseline HIV test is required for the management of the health
worker and in case of a later claim for compensation. If the health worker has
not been immunized for Hepatitis B, a test for HBV should also be undertaken at
this time.
Follow-up tests should be done at six weeks, three months and
six months. PCR testing may provide an earlier result, if available, which can
reduce the stress of waiting for many months for a test result for
seroconversion.
The injured staff member should receive follow-up counselling at
any stage during the six months that this is required. Counselling should
include advice to practise safe sex, to avoid blood donation and to consider
delaying pregnancy for six months, if this had been planned.
Post exposure prophylaxis
Post-exposure drug prophylaxis should take into account the type
and source of the injury and is not recommended for superficial needlestick
injuries or cutaneous exposure. For deeper injuries or lacerations, the use of
post exposure prophylaxis should be considered, and treatment started as soon as
possible after the injury, with the first dose of ZDV ideally taken within two
hours402.
Combination therapy, such as ZDV and 3TC (lamivudine), is
currently recommended402,403,404. The addition of a protease
inhibitor is recommended for deep exposures in the guidelines of Canada and the
USA402,403. Where viral drug resistance is less common, this may not
be as necessary. The decision to use post exposure prophylaxis must be taken by
the injured party, after discussion of the benefits and
risks.
