Needlestick injury from an unknown-source patient at night

What went wrong

1. Recapping caused the injury. Recapping is the commonest mechanism of sharps injury; the needle should have been left in a rigid sharps container at the point of use, or a safety-engineered device used.
2. Wearing a glove is not protection against a penetrating injury - it reduces inoculum but does not prevent it.
3. Hard squeezing and spirit are not recommended. Vigorous squeezing can traumatise tissue and push contamination deeper; spirit, bleach and scrubbing damage the skin and increase inflammation without proven benefit.

Correct immediate care

• Encourage gentle bleeding under running water - do not milk or squeeze hard.
• Wash thoroughly with soap and water.
• Dry and cover with a waterproof dressing; a simple antiseptic is acceptable but not mandatory.
• Do not use bleach or inject anything into the wound.
• Irrigate splashes to eyes or mouth with water or saline.

Then, without delay: report to the nearest emergency or duty doctor, enter the incident in the accident book, and begin the risk assessment. The clock matters - HIV post-exposure prophylaxis is most effective the sooner it starts, and the aim is within 2 hours and certainly within 72 hours. The source patient's blood should be sent for HIV, hepatitis B surface antigen and hepatitis C antibody with appropriate consent or, if he lacks capacity, under the local emergency testing policy.

HIV

• This is a percutaneous, hollow-bore, blood-contaminated injury from a source of unknown status in a high-prevalence emergency setting - a recognised exposure.
• Start a 28-day three-drug regimen as soon as possible, ideally within 2 hours and no later than 72 hours, without waiting for the source result if the source cannot be tested rapidly. A standard regimen is tenofovir plus lamivudine (or emtricitabine) plus dolutegravir or raltegravir.
• Baseline bloods first: HIV antibody, hepatitis B and C serology, full blood count, renal and liver function, pregnancy test if relevant.
• If the source is later confirmed HIV-negative, stop the regimen; if positive, complete 28 days with adherence and toxicity monitoring.

Hepatitis B

• Her vaccination history is unknown, so she must be managed as potentially unprotected.
• Take blood for HBsAg, anti-HBs and anti-HBc, but do not wait for results: give hepatitis B immunoglobulin and start or complete an accelerated vaccination course (0, 1 and 2 months, booster at 12 months).
• If anti-HBs is subsequently above 10 mIU/mL from previous vaccination, the immunoglobulin was unnecessary but harmless.
• There is no post-exposure prophylaxis for hepatitis C; management is early detection and curative direct-acting antiviral treatment.

Documentation

• Record the date and time of exposure, device, depth, glove use, source details, the risk assessment, staff member's vaccination status, advice given, prophylaxis started and follow-up dates - in the incident report and occupational health record.
• The exposure must be reported even though it was caused by her own practice; confidentiality of the source patient must be preserved.

Follow-up schedule

• HIV testing at baseline, 6 weeks, 3 months and 6 months (a 4th-generation assay at 4–6 weeks may allow earlier discharge).
• Hepatitis C PCR at 4–6 weeks and 6 months (or 12 weeks with a sensitive assay).
• Hepatitis B serology at 1–2 months to confirm response to vaccination.
• Review for drug toxicity at 2 weeks if on HIV prophylaxis.

Fitness to work She may complete the shift if she is clinically well, the wound is dressed and she can work safely - but she should be relieved from direct patient contact long enough to attend the emergency department now, and occupational health must see her the next working day. She should be told that HIV prophylaxis commonly causes nausea and fatigue and that adherence support is available; she must not donate blood during follow-up. Reassure her that the overall transmission risk per needlestick is low while still taking it seriously.