Infectious Diseases
Question 65 of 180
A 32 year old intravenous drug user presents to the Emergency Department with a fever. Whilst performing venepuncture you sustain a needlestick injury to your left index finger. What is the most appropriate first management step for this injury?
Answer:
First aid should be carried out immediately following any exposure to blood or a body fluid. Wash the area liberally with soap and water but without scrubbing. Scrubs and antiseptics should not be used. In the case of a puncture wound or needlestick injury, encourage the wound to bleed freely but do not suck the wound. Dry the area and cover any percutaneous injury with a waterproof dressing.Occupational Needlestick Injury
Infectious Diseases
Last Updated: 12th February 2021
Any significant exposure to blood and some other body fluids or tissue has the potential to transmit blood borne viruses, the most important of which are Hepatitis B (HBV), Hepatitis C (HCV), and HIV.
Risk of transmission
The risk of becoming infected with a blood borne virus (BBV) following percutaneous or mucocutaneous exposure varies with the circumstances and the particular virus involved. Four factors are proven to increase the risk of occupationally acquired blood borne virus infection:
- Deep injury
- Visible blood on the device which caused the injury
- Injury with a needle which has been placed in a donor’s artery or vein
- High virus load in the donor’s blood e.g. in advanced stage or undiagnosed HIV infection
The risk of infection following a significant percutaneous injury is approximately:
- HBV 30% (3 in 10)
- HCV 3% (3 in 100)
- HIV 0.3% (3 in 1000)
The risk of HBV and HIV infection is significantly reduced by immunisation against Hepatitis B and the use of post-exposure prophylaxis (PEP).
Initial management
- First aid should be carried out immediately following any exposure to blood or a body fluid. Wash the area liberally with soap and water but without scrubbing. Scrubs and antiseptics should not be used. In the case of a puncture wound or needlestick injury, encourage the wound to bleed freely but do not suck the wound. Dry the area and cover any percutaneous injury with a waterproof dressing. Exposed mucous membranes, including conjunctivae, should be irrigated copiously with water, before and after removing any contact lenses.
- Following significant percutaneous or mucocutaneous exposure to blood or a body fluid, staff members should attend occupational health (in hours) or ED (out of hours). A baseline sample of clotted venous blood in a serum gel tube should be obtained from the recipient and sent to the microbiology laboratory for storage. This will only be tested, with informed consent, at a later date if subsequent follow-up tests of the recipient prove to be positive for a BBV infection.
- Information should be obtained to enable an informed assessment of the risk of blood borne virus transmission, including the nature of the exposure and any risk factors for hepatitis B, hepatitis C or HIV in the donor patient, so that the need for post-exposure prophylaxis can be ascertained.
- Where appropriate, the individual who is the source of the blood/body fluid should be approached, given an explanation of the incident and asked for informed consent to disclose their infection status or to be tested for HIV, HBV and HCV, where the status is not already known. This universal approach to source testing for BBV normalises the procedure and avoids perceived discrimination. If the donor cannot be persuaded to consent to disclosure, or if it is not safe or practicable to ask for their consent, the information may be disclosed in the public interest (e.g. if the information is needed for decisions about the continued appropriateness of post-exposure prophylaxis) – seek senior advice from the ward consultant or a consultant microbiologist.
Further management
For each of the three main blood-borne viruses, there are possible post-exposure interventions and management strategies designed to minimise the chances of the exposed worker acquiring a blood borne virus as a result of the exposure.
- Hepatitis B Virus:
- Post-exposure prophylaxis for hepatitis B may include giving one or more doses of hepatitis B vaccine with or without hepatitis B immunoglobulin depending on the level of exposure, the hepatitis B status of the donor, and the vaccination status of the recipient.
- For most people requiring post-exposure prophylaxis against hepatitis B, use a rapid immunisation schedule (given at zero, one and two months, or over 21 days if very rapid protection is needed). If immunity to hepatitis B is demonstrated following initial serology testing, do not give the remaining doses of vaccine.
- Arrange for immunoglobulin prophylaxis to be given at the same time as vaccination for people without proven hepatitis B immunity, following exposure to potentially infected blood or body fluids. If immunoglobulin prophylaxis is thought to be indicated, discuss this with a microbiologist/the local health protection unit before giving treatment. Hepatitis B immunoglobulin is given intramuscularly ideally within 48 hours of exposure, and at the same time as the first dose of vaccine.
- For an HBV-exposure incident, blood should be taken at 3 - 6 months, and tested for anti-HBs, anti-HBc or HBsAg; the precise testing regimen is dependent on the vaccination status of the recipient and the PEP administered at the time of the incident.
- Hepatitis C Virus:
- There is no post-exposure prophylaxis available for hepatitis C virus, but serial testing will be required after the exposure incident.
- Monitor the recipient for evidence of acquisition of infection with HCV over the 6 months following exposure by testing for the presence of HCV RNA and/or antibodies to HCV in samples from the recipient taken at appropriate intervals after the incident.
- For an HCV-exposure incident, blood should be taken at 6 weeks for HCV RNA testing, 12 weeks for anti-HCV and HCV RNA testing, and at 24 weeks for anti-HCV and HCV RNA testing.
- If evidence of infection is detected, the recipient should be referred immediately to an appropriate specialist for consideration of antiviral therapy, as evidence shows that treatment at this stage is very successful.
- Human Immunodeficiency Virus:
- Administration of HIV post-exposure prophylaxis is considered in some circumstances after seeking specialist advice.
- PEP must be started within 72 hours after the possible exposure to HIV, but the sooner you start PEP, the better.
- HIV post-exposure prophylaxis is a regimen of 3 anti-HIV drugs taken for 4 weeks post exposure.
- For an HIV-exposure incident, blood should be taken at 4 weeks and 12 weeks and tested for anti-HIV.
The interventions above can only be instituted after careful risk assessment of the exposure incident by appropriately trained clinical personnel. Exposed individuals should seek immediate specialist post-exposure care at a recognised specialist centre. Occupational exposures to HIV must be reported to the Health and Safety Executive (HSE).
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
