Needlestick Injuries

Introduction | Aetiology and Risk Factors | Clinical Presentation | Diagnosis and Immediate Actions | Management and Treatment | Prevention | When to Refer | References

Introduction

Needlestick injuries occur when a needle or other sharp object accidentally penetrates the skin. These injuries pose a significant risk of transmission of bloodborne pathogens, including hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). Needlestick injuries are a common occupational hazard in healthcare settings but can also occur in other environments. Immediate and appropriate management is crucial to reduce the risk of infection.

Aetiology and Risk Factors

Needlestick injuries can result from a variety of situations, particularly in healthcare settings:

• Inappropriate Handling of Needles: Recapping needles, improper disposal, or handling needles without using safety devices can increase the risk of injury.
• Accidental Injuries: Needlestick injuries can occur during medical procedures, such as drawing blood, administering injections, or suturing, especially when working quickly or under stress.
• Improper Disposal: Injuries can occur when needles are disposed of inappropriately or when someone accidentally comes into contact with improperly discarded needles, such as in public areas.
• Reusing Needles: Reusing needles, particularly in low-resource settings, significantly increases the risk of needlestick injuries and transmission of bloodborne pathogens.
• Handling Sharp Instruments: Injuries can also occur with other sharp instruments such as scalpels, lancets, or glass ampoules.

Clinical Presentation

The clinical presentation of a needlestick injury is typically straightforward:

• Immediate Pain: A sharp pain or pricking sensation at the site of injury.
• Visible Wound: There may be a small puncture wound, sometimes with slight bleeding.
• Psychological Impact: Anxiety and concern about the risk of infection, particularly if the source of the needle is unknown or known to be from a patient with a bloodborne infection.

Diagnosis and Immediate Actions

The diagnosis of a needlestick injury is based on the reported incident. Immediate actions are crucial to minimise the risk of infection:

• Immediate Washing: Wash the injury site immediately with soap and water. Avoid scrubbing the wound, which can increase tissue damage.
• Encourage Bleeding: If the injury involves a needle stick, gently squeeze around the wound to encourage bleeding, which may help flush out any contaminants.
• Avoid Using Antiseptics: Do not use alcohol or antiseptic agents on deep wounds as these may cause tissue damage.
• Report the Incident: Report the needlestick injury to the appropriate supervisor or occupational health department as soon as possible to initiate the necessary follow-up procedures.
• Document the Incident: Record details of the incident, including the type of needle, the circumstances of the injury, and information about the source patient if known.

Management and Treatment

The management of needlestick injuries involves assessing the risk of infection, administering prophylactic treatments if necessary, and providing follow-up care:

1. Risk Assessment

• Source Patient Testing: If the source of the needle is known, assess the patient's HIV, HBV, and HCV status through testing if it is not already known. This will guide further management.
• Risk Categorisation: Evaluate the risk based on the type of injury, the source patient's infection status, and the depth of the injury.

2. Post-Exposure Prophylaxis (PEP)

• HIV PEP: If the source patient is HIV-positive or if there is a high risk of HIV transmission, start HIV post-exposure prophylaxis as soon as possible, ideally within 1-2 hours of the exposure. PEP typically involves a 28-day course of antiretroviral therapy (ART).
• HBV Prophylaxis:
  • Vaccination: If the exposed individual has not been vaccinated against hepatitis B, administer the HBV vaccine series. If the individual is unvaccinated or incompletely vaccinated and the source is HBsAg-positive, administer hepatitis B immunoglobulin (HBIG) in addition to the vaccine.
  • Booster Dose: If the exposed individual is already vaccinated but with an incomplete series or unknown response, consider administering a booster dose.
• HCV Management: There is currently no prophylaxis for hepatitis C; however, early identification and treatment of acute HCV infection can improve outcomes. Regular monitoring of HCV RNA is recommended following exposure.

3. Follow-Up and Monitoring

• Baseline Testing: Perform baseline blood tests for HIV, HBV, and HCV in the exposed individual.
• Follow-Up Testing: Follow-up testing is typically done at 6 weeks, 3 months, and 6 months post-exposure to monitor for seroconversion.
• Counselling and Support: Provide psychological support and counselling to address anxiety and stress related to the injury and the potential risk of infection.

Prevention

Preventive measures are crucial in reducing the risk of needlestick injuries in healthcare settings:

• Use of Safety Devices: Utilise needles with safety features, such as retractable needles or needle guards, to minimise the risk of injury.
• Proper Disposal: Dispose of needles immediately after use in designated sharps containers. Never recap needles after use.
• Training and Education: Regularly train healthcare workers on the safe handling of needles and sharps, including the correct disposal methods.
• Universal Precautions: Follow standard infection control practices, including wearing gloves and other protective equipment when handling needles or other sharp instruments.
• Immunisation: Ensure that all healthcare workers are up-to-date with their hepatitis B vaccination and have documented immunity.

When to Refer

Referral to a specialist or occupational health may be necessary in the following situations:

• High-Risk Exposure: If the needlestick injury involves a high-risk source, such as a known HIV-positive or hepatitis-infected patient, referral to an infectious disease specialist for further management may be necessary.
• Psychological Impact: If the injured person experiences significant anxiety or psychological distress following the injury, referral to counselling or psychological services may be appropriate.
• Complications: If complications such as infection or seroconversion occur, referral to a specialist for further management and treatment is required.

References

1. British Association of Occupational Health (2024) Guidelines for the Management of Needlestick Injuries. Available at: https://www.bohrf.org.uk (Accessed: 26 August 2024).
2. National Institute for Health and Care Excellence (2024) Needlestick Injuries: Diagnosis and Management. Available at: https://www.nice.org.uk/guidance/ng110 (Accessed: 26 August 2024).
3. British National Formulary (2024) Post-Exposure Prophylaxis for Bloodborne Viruses. Available at: https://bnf.nice.org.uk/ (Accessed: 26 August 2024).