Needlestick injury

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.

Background

  • The risk of transmission of Blood Borne Viruses (BBV) to a needlestick recipient in a community setting is very low
  • There are no reported cases of a member of the public becoming infected by HIV, Hepatitis B or Hepatitis C following accidental injury from discarded injecting needles in the community setting
  • Follow up is essential
  • Please note that the laboratory is unable to test used syringes for evidence of infective virus under any circumstances.

Risk associated with exposure

Blood borne virus Estimated incidence in WA IV drug users* Risk of transmission with a needlestick# Calculated maximal risk of transmission
HIV 1.1 - 1.6% 0.3% 0 - 0.0048%
Hepatitis B 1.8% 30% 0 - 0.0054% 
Hepatitis C 55 - 58% 3% 0 - 1.74%

* The most likely source of discarded needles in the community
# Figures based on occupational exposure
Calculated from column 1 and 2. Maximal risk is likely to be overestimated.

Assessment

History

  • Assess risk: presence of blood in the syringe, depth of injury, site of needlestick injury
  • Assess patient's immunisation status (tetanus, hepatitis B).

Investigations

  • Take baseline serology (hepatitis B, hepatitis C and HIV)
    • This requires informed verbal consent from parent
    • Make the test for hepatitis B surface antibody (HepB-sAb) as urgent (will determine the need for Hep B immunoglobulin), results will be available within 24 hrs (except if done over the weekend – it will take longer)
  • If the identity of the needle user is known, then the source should also have their blood taken for serology (hepatitis B, hepatitis C and HIV), after obtaining informed consent.

Management

  • Contact the infectious diseases team (including after hours) to discuss the need for nPEP and to organise follow-up.
  • If the source patient is known to have a blood borne virus (BBV), the microbiologist should always be contacted.

First aid
  • If not already done, clean the exposure site with soapy water.
Tetanus prophylaxis
  • If the child has not had any vaccinations, not received a full tetanus vaccine course or has not received a booster within the last 5 years:
    • Give DTP or ADT
    • If the child is not fully immunised against tetanus, or doubt about vaccination status then also give tetanus immunoglobulin. Access via Transfusion Management Unit (Blood Bank) Ext 34015 (from PCH) or 6383 4015 (for urgent requests).
Hepatitis B Vaccination
  • If not vaccinated for Hepatitis B:
    • Give a single dose Hepatitis B vaccination in ED
    • For the next 2 vaccinations accelerate and give at 7 days and 21 days, arrange via the GP.
Hepatitis B Immunoglobulin
  • Hepatitis B immunoglobulin should be given within 72 hours, once the results are known (if the patient has HepB-sAb < 10 IU)
  • Access via Transfusion Management Unit (Blood Bank) Ext 34015 (from PCH) or 6383 4015 (for urgent requests)
Hepatitis C
  • There is no available vaccine or post exposure prophylaxis currently recommended.
HIV Prophylaxis
  • No anti-retroviral prophylaxis should be routinely prescribed unless the source of the needlestick is known to be HIV positive
  • The risk of HIV transmission from community needlesticks is extremely small (presently no published cases), and anti-retrovirals do have significant side effects.

Referrals and follow-up

  • Needlestick Discharge Information Sheet: standard letter for children with community acquired needlestick injury
  • Reults consultant to check for the results of the Hepatitis serology
  • If Hep B Ab < 10 IU/mL call and arrange return to ED to have Hepatitis B Immunoglobulin and  Hepatitis B vaccination
  • Arrange accelerated Hepatitis B vaccination course via the GP
    • GP follow up 1 week after the initial serology to communicate the results of HIV, Hepatitis C serology
  • Review at PCH Infectious Diseases outpatient clinic at 6 weeks and 3 months. Complete the Outpatient clinic referral form.
  • Follow up serology (blood tests) to be done at PCH laboratory approximately 2 weeks prior to the outpatient clinic appointments. 
    • Ensure the patient has completed pathology request forms and some take home EMLA for both tests.

Health information (for carers)

Advice to reduce the risk of transmission to close contacts until final serology at 6 months:

  • If relevant (e.g. adolescent) advise against unprotected sex/needle sharing/sharing razors
  • Do not share toothbrushes.

Endorsed by:  Director, Emergency Department   Date: Apr 2017


 Review date:  Apr 2021


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