Hollow-Bore Needlestick in the Intensive Care Unit
A 29-year-old ICU nurse sustains a hollow-bore needlestick while recapping a syringe after drawing blood from a 58-year-old patient admitted with altered mental status and a history of injection drug use. The needle penetrated the nurse's single glove and skin, drew blood, and the wound is moderately deep. The nurse completed a three-dose hepatitis B vaccine series as a student but has never had an anti-HBs titer checked. The source patient is confused and cannot provide consent for HIV or hepatitis testing; state law permits source testing without consent in occupational exposures. The source patient has a history of HCV infection treated 3 years ago with sustained virologic response, but no recent RNA. The exposure occurred 45 minutes ago. The nurse is tearful and asks whether to start HIV medications.
1. What immediate wound care and risk assessment should be performed, and how should source testing proceed?
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Wash the wound with soap and water; do not use bleach or caustic agents, and do not squeeze the wound. Assess the exposure: hollow-bore needle, visible blood, moderate depth, and a source with injection drug use all increase risk for HIV and hepatitis B and C. The glove reduces inoculum but does not eliminate risk. Obtain the source patient's HIV antibody/antigen test, HBV surface antigen, and HCV antibody with reflex RNA as permitted by state law. Because the patient cannot consent, use the occupational exposure pathway and document the legal basis and the clinician who authorized testing. Test the nurse at baseline for HIV, HBV, and HCV, and check anti-HBs because vaccination history without a titer does not prove immunity. Do not delay HIV post-exposure prophylaxis while waiting for source results when the exposure is high-risk; start and reassess when results return.
2. Should HIV post-exposure prophylaxis be started? If so, what regimen and monitoring are appropriate?
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Yes. The exposure is a moderate-depth hollow-bore needlestick with visible blood from a source with injection drug use, which is a substantial risk even though HIV status is unknown. Start a three-drug regimen as soon as possible, ideally within 2 hours and no later than 72 hours after exposure. A commonly used regimen is tenofovir disoproxil fumarate plus emtricitabine plus dolutegravir; alternatives include raltegravir, depending on local protocol, pregnancy status, and drug interactions. Obtain baseline CBC, renal and hepatic function, HIV testing, and pregnancy testing if applicable, and review interactions with the nurse's other medications. Prescribe a 28-day supply with follow-up at 2 weeks for tolerance and adherence. If the source is later confirmed HIV-negative, stop prophylaxis. If the source is HIV-positive with resistant virus, adjust the regimen with expert consultation. Document the risk assessment and shared decision-making.
3. How should hepatitis B and hepatitis C be managed for this nurse?
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For hepatitis B, check the nurse's anti-HBs. If the source is HBsAg-positive and the nurse's anti-HBs is below 10 mIU/mL or unknown, give hepatitis B immune globulin and a vaccine booster, then complete revaccination if indicated. If the nurse is a known responder with anti-HBs of 10 mIU/mL or higher, no post-exposure prophylaxis is needed. If the source is HBsAg-negative, no hepatitis B prophylaxis is required, but update vaccination status. For hepatitis C, there is no recommended post-exposure prophylaxis. The source has a history of sustained virologic response, which lowers concern but does not replace testing; obtain HCV RNA. Test the nurse at baseline and follow up with HCV RNA at 2 to 4 weeks and again at 4 to 6 months, or per local protocol. Counsel the nurse about symptoms and about avoiding blood donation until follow-up is complete. Document all counseling and follow-up appointments.