---

Needlestick Injury in Healthcare Workers: Complete Step-by-Step Management Guide

---

PART 1: IMMEDIATE ACTIONS (First 5-10 Minutes)

Step 1 - Wound Decontamination (Do This First, Before Anything Else)

• Needlestick/cut: Remove glove, wash the area thoroughly with soap and water. Do not squeeze, milk, or suck the wound - this does not reduce transmission risk and may increase it.
• Mucous membrane exposure (eye splash): Irrigate copiously with clean water, saline, or sterile irrigant for several minutes.
• Skin (intact or non-intact) splash: Wash thoroughly with soap and water.
• Contact of blood/body fluid with intact, undamaged skin: No further workup needed - intact skin is a complete barrier; this does not constitute an at-risk exposure for HIV, HBV, or HCV.

---

PART 2: REPORT AND ESCALATE IMMEDIATELY

Step 2 - Report to Occupational Health/Emergency Department

• Report the exposure immediately - time is critical for PEP initiation (< 72 hours for HIV PEP; ideally within 2 hours).
• Contact your institution's Occupational Health Service or go to the Emergency Department if after hours.
• In the US, expert 24/7 consultation is available via the PEPline: 1-888-448-4911 (or http://nccc.ucsf.edu/clinician-consultation/pep-post-exposure-prophylaxis/).
• Document all details: date, time, type of device, depth of injury, visible blood on needle, type of procedure being performed, and source patient information.

---

PART 3: CHARACTERIZE THE EXPOSURE

Step 3 - Assess the Type and Severity of Exposure

• HIV via needlestick from known HIV+ source: ~0.3% per exposure
• HBV (source HBeAg+, recipient non-immune): 37-62% per exposure - the highest risk
• HCV via needlestick: ~1.8-2% per exposure
• Mucous membrane HIV exposure: ~0.09%
• Intact skin exposure: essentially zero for all three

---

PART 4: TEST THE SOURCE PATIENT (AND THE EXPOSED HCW)

Step 4 - Source Patient Testing

• HIV: Rapid HIV antigen/antibody combination test (4th generation) - result in ~20 minutes
• HBV: HBsAg (hepatitis B surface antigen) - if unknown status; comprehensive triple screen (HBsAg, HBcAb, HBsAb) is now preferred per 2025 guidelines
• HCV: Anti-HCV antibody ± HCV RNA if antibody positive or if source is high-risk

Step 5 - Baseline Testing of the Exposed Healthcare Worker (HCW)

• HIV antigen/antibody combination test (4th generation)
• HBsAg, anti-HBs, anti-HBc (HBV status)
• Anti-HCV antibody + HCV RNA
• CBC, renal function (creatinine), LFTs (baseline before starting ARVs)
• Pregnancy test if applicable (influences drug selection)

---

PART 5: SCENARIO-BY-SCENARIO MANAGEMENT

---

SCENARIO A: SOURCE PATIENT IS HIV-POSITIVE (or Unknown Status)

A1 - Source HIV Status Unknown and Testing Not Possible

• Use shared clinical decision-making to decide whether to initiate PEP.
• Key considerations:
  1. Severity of exposure (large-volume blood, deep percutaneous)
  2. Route of inoculation (hollow-bore needle vs. solid needle)
  3. Epidemiologic likelihood of the source being HIV-positive (e.g., patient from high-prevalence setting, known IVDU, etc.)
• Do not test needles or other sharp instruments for HIV - there is no approved method and results are unreliable.
• Err toward starting PEP in higher-risk scenarios - it can always be stopped if the source tests negative.

When to Initiate HIV PEP

• Yes, start PEP if: high-risk percutaneous exposure (hollow needle with visible blood, deep injury), source is high-risk or known HIV+, or source is unknown in a high-prevalence setting.
• Consider not starting PEP if: exposure was very low-risk (superficial scratch, solid needle, no visible blood), source tests HIV-negative by rapid test, or exposure was with intact skin only.
• Start as soon as possible - within 2 hours is ideal, within 72 hours is the outer limit. PEP started after 72 hours has no proven benefit.

Preferred HIV PEP Regimens (2025 PHS Guidelines)

• If source patient is known to have drug-resistant HIV: consult an HIV expert before selecting a regimen.
• If the HCW is already on PrEP: use shared decision-making - expert consultation is strongly recommended.
• If the HCW is pregnant: certain agents (e.g., efavirenz) should be avoided; consult HIV specialist immediately.

Follow-up Testing After HIV Exposure

• Baseline, then 4-6 weeks, 3 months, and 6 months post-exposure (some centers now follow to 4 months if source is HCV+, due to rare delayed seroconversion).
• If the HCW takes PEP: repeat HIV testing at 4-6 weeks, 3 months, and 6 months.
• If PEP is declined/not indicated: baseline and 6-week testing minimum.

---

SCENARIO B: HEPATITIS B VIRUS (HBV)

HBV Management Table (from Yamada's Gastroenterology, 7th ed.)

• HBIG should be given within 24 hours of exposure (definitely within 7 days) for maximum benefit.
• Hepatitis D (delta virus) post-exposure recommendations are the same as for HBV (Yamada's Gastroenterology).
• There is no specific antiviral treatment recommended for acute HBV in the setting of needlestick PEP - HBV generally self-resolves in adults (~90-95% clearance rate).

---

SCENARIO C: HEPATITIS C VIRUS (HCV)

• Neither immunoglobulin nor antivirals are recommended as PEP after needlestick exposure to HCV.
• The management is monitoring and early treatment if infection occurs.

HCV Post-Exposure Monitoring Protocol (Goldman-Cecil Medicine):

• If HCV RNA becomes detectable at any point - the HCW has been infected.
• Treat immediately with direct-acting antivirals (DAAs) for 8 weeks:
  • Sofosbuvir 400mg + Velpatasvir 100mg (fixed-dose, once daily) - pan-genotypic
  • OR Glecaprevir 100mg + Pibrentasvir 40mg (3 pills once daily) - pan-genotypic
• Treatment of acute HCV is preferred over waiting - it achieves higher cure rates and prevents chronic infection (20-50% would spontaneously clear, but 50-80% will develop chronic HCV if untreated).
• Cure assessment: HCV RNA at 12 and 24 weeks post-treatment (late relapses have been reported).

---

SCENARIO D: NEEDLE FOUND IN SHARPS CONTAINER / COMPLETELY UNKNOWN SOURCE

• This is a common and challenging scenario.
• No cases of HIV transmission from "found needles" outside healthcare settings in the US have been documented.
• Within healthcare settings, found needles have been implicated in only two cases of transmission over two decades.
• PEP is generally not recommended for low-risk "found needle" scenarios.
• Use shared decision-making considering:
  1. Severity of the injury
  2. Route (percutaneous vs. superficial)
  3. Amount of potentially infectious material present
  4. Epidemiologic likelihood of HIV exposure (setting, patient population)
• If the HCW is very anxious or insists, expert consultation via PEPline (1-888-448-4911) is appropriate.

---

PART 6: SPECIAL ADDITIONAL ORGANISMS TO CONSIDER

• Syphilis (Treponema pallidum): Baseline RPR/VDRL; can consider single-dose benzathine penicillin 2.4 MU IM if source is high-risk or known syphilis.
• HTLV-I/II: Consider testing in high-prevalence areas; no PEP available.
• Viral hemorrhagic fevers (e.g., Ebola - in relevant settings): Post-exposure prophylaxis should be considered for high-risk exposures in unvaccinated persons (monoclonal antibody treatments; oral ribavirin for Lassa/CCHF); evacuate and manage per institutional/public health protocols.
• CMV, EBV: Generally not transmitted by needlestick in immunocompetent HCWs; no PEP.
• Malaria: Considered in endemic settings if patient had active parasitemia - can treat presumptively.

---

PART 7: COMPLETE FOLLOW-UP SCHEDULE SUMMARY

---

PART 8: PSYCHOLOGICAL SUPPORT

• Informed the absolute risk of HIV transmission per needlestick is low (~0.3%).
• Offered counseling or psychological support.
• Reassured about confidentiality of testing and treatment.
• Encouraged to report rather than hide exposures.

---

PART 9: DOCUMENTATION AND REPORTING

• Complete an incident report per institutional policy.
• In the US, OSHA Bloodborne Pathogen Standards require that exposures be documented and followed.
• In many jurisdictions, needlestick injuries must be reported to occupational health registries.

---

QUICK DECISION SUMMARY

---

• 2025 PHS Guidelines (PMC Full Text) - the most current occupational HIV PEP guidelines
• UCSF NCCC PEP Quick Guide (Oct 2025) - updated October 2025 for all three bloodborne pathogens
• National HIV Curriculum - Occupational PEP - comprehensive clinical review
• PEPline (US): 1-888-448-4911 (24/7 expert consultation)

---

• Goldman-Cecil Medicine International Edition, pp. 3381-3394 (HIV in healthcare workers, management after needlestick)
• Goldman-Cecil Medicine International Edition, p. 1659 (HCV needlestick: no PEP, monitoring + DAA if infected)
• Yamada's Textbook of Gastroenterology, 7th ed., Table 86.8 (HBV post-exposure prophylaxis table)
• Tintinalli's Emergency Medicine, pp. 2419-2421 (Needlestick injuries - risk estimates and management overview)
• 2025 US Public Health Service Guidelines for Occupational HIV Exposure and PEP (PMID/PMC12616222) - published September 2025 in Infection Control and Hospital Epidemiology
• Weber DJ et al., Infect Dis Clin North Am 2026 Jun - Evaluation and Management of Occupational Exposures and PEP [PMID 41820134]

---

Hepatitis B vs C: Modes of Transmission, Natural History, Outcomes & Mnemonics

---

SECTION 1: MODES OF SPREAD - HEPATITIS B (HBV)

HBV Transmission Routes (Most to Least Common by Incidence)

---

SECTION 2: MODES OF SPREAD - HEPATITIS C (HCV)

HCV Transmission Routes (Most to Least Common by Incidence)

---

SECTION 3: KEY DIFFERENCES IN TRANSMISSION AT A GLANCE

---

SECTION 4: NATURAL HISTORY - HEPATITIS B

A. Acute HBV Infection Outcomes (Adult-Acquired)

B. Age-Dependent Chronicity Rate (Critical Concept)

C. Natural History of Chronic HBV (Untreated)

1. Immune Tolerant Phase - High HBV DNA (>10⁸ IU/mL), HBeAg+, normal ALT, minimal inflammation. Lasts decades in perinatally acquired HBV. High risk of transmission.
2. Immune Active / Immune Clearance Phase - Rising ALT, falling HBV DNA, inflammation. Hepatic damage occurs here. HBeAg seroconversion happens.
3. Inactive Carrier Phase - After HBeAg seroconversion; HBeAg negative, anti-HBe positive, low HBV DNA (<2000 IU/mL), normal ALT, minimal histological activity. 70-80% of patients reach this phase.
4. HBeAg-Negative Hepatitis (Reactivation Phase) - HBeAg negative, but active hepatitis due to pre-core or core promoter mutant virus; fluctuating HBV DNA and ALT.

D. Long-Term Complications of Chronic HBV (Untreated)

E. With Treatment (Treated HBV)

• Nucleos(t)ide analogues (entecavir, tenofovir): suppress HBV DNA to undetectable, normalize ALT, reduce cirrhosis risk by ~50-70%, reduce HCC risk by ~40-70%
• HBsAg clearance (functional cure): rare, ~1-3% per year even on treatment; remains the goal
• Treatment does NOT eradicate cccDNA - lifelong suppression is usually needed
• Regression of established cirrhosis is possible with long-term viral suppression
• No curative treatment yet - functional cure (HBsAg clearance) is achievable in a minority

---

SECTION 5: NATURAL HISTORY - HEPATITIS C

A. Acute HCV Infection Outcomes

B. Natural History of Chronic HCV (Untreated)

C. With Treatment (Treated HCV - DAAs)

• DAAs (sofosbuvir-based, glecaprevir/pibrentasvir) achieve Sustained Virologic Response (SVR) in >95% of patients - effectively a cure
• SVR = HCV RNA undetectable at 12 weeks post-treatment - defined as cure
• After SVR: no further viral transmission, regression of fibrosis/inflammation, significant reduction in HCC risk
• HCC risk after SVR in cirrhotics: drops by ~70%, but residual risk remains (~1-2%/year) - surveillance must continue
• Cirrhosis can partially regress after SVR
• Treatment course: 8 weeks for most patients (including acute HCV); 12 weeks if cirrhotic

---

SECTION 6: COMPARISON TABLE - OUTCOMES SIDE BY SIDE

---

SECTION 7: EASY MNEMONICS

---

MNEMONIC 1: HBV Chronicity by Age - "90-20-5 Rule"

"90 babies, 20 children, 5 adults"

• 90% → neonates/perinatally acquired
• 20-60% → children under 5 (remember as "20")
• <5% → immunocompetent adults

---

MNEMONIC 2: HBV Acute Outcomes - "65-30-5 Rule" (or use the Robbins diagram above)

"65% Silent, 30% Yellow, 5% Chronic, 0.5% Fail"

• 65% = subclinical/silent (anicteric)
• 30% = icteric hepatitis
• 5-10% = chronic infection (adult)
• 0.1-0.5% = fulminant hepatic failure

---

MNEMONIC 3: HCV Outcomes - "80-20-20-4 Rule"

"80% don't know, 20% clear it, 20% (of chronic) get cirrhosis, then 4% HCC/yr"

• ~80% = asymptomatic acute infection
• ~20-45% = spontaneous clearance
• 55-85% = chronic infection
• 15-30% = cirrhosis at 20 years
• 2-4%/year = HCC once cirrhotic

---

MNEMONIC 4: HBV Phases - "IT-IC-IN-RE" (like "Inactive-Reactivate")

IT - IC - IN - RE

• IT = Immune Tolerant (HBV DNA high, ALT normal, no damage - "Tolerating the virus")
• IC = Immune Clearance (fighting the virus - ALT rises, damage occurs)
• IN = INactive Carrier (virus sleeping, low DNA, normal ALT)
• RE = REactivation (HBeAg-neg hepatitis, mutant virus wakes up)

---

MNEMONIC 5: HBV vs HCV Transmission - "SIPS vs SPIT"

S - Sexual contact I - IV drug use / Injection P - Perinatal (mother-to-child) - #1 globally S - Sharps/blood (occupational, transfusion)

S - Sharps/blood/IVDU - #1 by far P - Percutaneous (needlestick, tattoo) I - Intranasal drug use (shared straws) T - Transfusion (historical, now rare)

---

MNEMONIC 6: HBV vs HCV - "WHO CLEARS IT?"

"B for BAD at clearing; C for CAN clear"

• HBV (B = BAD at clearing when caught young): Neonates rarely clear it (90% chronic) - the immune system is too immature
• HCV (C = CAN clear sometimes): 15-45% spontaneously clear with an intact immune response

---

MNEMONIC 7: The "FIVE F's" of Fulminant Hepatitis - Who is at Risk?

Fulminant risk is high when: Five scenarios = HDV + HBV co-infection (most feared), underlying chronic liver disease, HBV + HCV, immunosuppression, pregnancy (Hepatitis E, not B/C)

---

MNEMONIC 8: Remembering Chronicity Numbers

• HBV (B): 90% perinatal, 5% adult
• HCV (C): 85% (55-85%) of acute HCV becomes chronic

---

SECTION 8: QUICK VISUAL SUMMARY CARD

                    HBV ACUTE INFECTION
                           ↓
         ┌─────────────────┼────────────────────┐
      ~65% Silent      ~30% Icteric         ~0.5% Fulminant
       (recover)       (mostly recover)     (death/transplant)
                    95-99% resolve
                         5-10% → CHRONIC
                                  ↓
                    ┌─────────────┴──────────────┐
                 70-80%                        20-30%
             Inactive Carrier              Chronic Hepatitis
                    ↓                           ↓
           Spontaneous                    15-40% CIRRHOSIS
           clearance (1-2%/yr)                  ↓
                                         2-3%/yr HCC

---

                    HCV ACUTE INFECTION
                           ↓
              ┌────────────┴───────────────┐
           15-45%                       55-85%
      Spontaneous Clearance         CHRONIC HCV
                                         ↓
                              20 yrs: 15-30% CIRRHOSIS
                                         ↓
                                   2-4%/yr HCC
                            (DAA Treatment = >95% cure)

---

• Robbins & Kumar Basic Pathology, Fig. 14.9 - HBV outcomes flowchart (diagram reproduced above)
• Harrison's Principles of Internal Medicine, 22nd ed. (2025), pp. 1648-1669 - Complications and sequelae of viral hepatitis
• Mulholland & Greenfield's Surgery, 7th ed., pp. 3881-3907 - HBV/HCV clinical features and epidemiology
• Yamada's Textbook of Gastroenterology, 7th ed. - HBV post-exposure management
• Goldman-Cecil Medicine International Edition - HCV natural history, treatment with DAAs
• WHO Global Hepatitis Report 2024 - 240 million chronic HBV, 1.1 million deaths/year
• PMC11168840 (2024) - "Revisiting the natural history of chronic hepatitis B" - Clin Liver Dis
• WHO Guidelines on Hepatitis B and C Testing (NBK442290) - chronicity rates by age
• PMID 41839199 (2026, Lancet Gastroenterol Hepatol) - Systematic review on natural history of chronic HBV