Clinical Practice Guidelines

Needle stick injury


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    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  • See also 

    Background 

    Community acquired needlestick injuries (CA-NSI) in children are a cause of significant parental anxiety.  It may reassure healthcare workers, parents, and patients, that there are no published reports of an incidental CA-NSI in a child, such as might occur on the beach or in a park, leading to transmission of a blood borne virus such as hepatitis B, hepatitis C, or HIV.

    Assessment 

    History 

    • Details of incident – time, date, place
    • Details of injury – location on body, superficial or deep
    • Source (the person who used the needle) known or unknown?
    • What kind of needle/syringe?
    • What, if any, first-aid has been provided?
    • Was there visible blood on/in the needle/syringe?
    • Immunisation history (specifically tetanus and hepatitis B)
    For the following scenarios featuring risk factors for blood borne virus transmission from a needle-stick, discuss with a senior clinician and consider referral to the Infectious Diseases fellow (during hours) or on-call consultant (after hours):

    • Source known to be infected with a blood borne virus.
    • Needlestick injury from a deliberate assault.
    • Deep, large volume injection with hollow bore needle.
    • Personal history of injecting drug use (adolescents).

    Investigations  

    • Take blood and request hepatitis B surface antibody (serum gel tube) and to store serum.
    • Do not routinely request investigations for hepatitis C or HIV.
    • Source known: it is important that efforts are made to test the person who used the needle for blood borne viruses as for an occupational injury (i.e hepatitis B and C, and HIV serology). We do not test the syringe.
    • Investigate specific injuries as clinically indicated. 

    Acute management 

    Investigate and manage injured patients as clinically indicated and then proceed to consider specific management in relation to the risk from needlestick injury. 

    First Aid – Initial thorough washing of site with soap and water. 

    Post-exposure prophylaxis - immunised patient

    Tetanus:

    Hepatitis B:

    • Hepatitis B vaccine is routinely administered to Australian children as part of the National Immunisation Program (NIP).
    • To review the current NIP schedule go to Mike South app ( http://www.mikesouth.org.au/immunisation/AUSIMMWELCOME.html]
    • In immunised patients, unless there has been a previous documented anti-HBs antibody level > 10 mIU/mL, check anti-HBs antibody level.  Make sure to label the pathology slip with ‘URGENT: Needlestick’ so that serology will be performed on the same day.  
    • Administer hepatitis B booster vaccination to all patients with anti-HBs < 10 mIU/mL. Monovalent Engerix-B paediatric formulation or H-B-Vax II 0.5 mL IM.
    • If hepatitis B serology is not available at the time of discharge from the emergency department, ensure results are followed up within 72 hours. Hepatitis B booster vaccines can be given by the LMO.

    Hepatitis C:

    • No post-exposure prophylaxis is available for hepatitis C. 

    HIV:

    • Only the highest risk needlestick injuries are offered HIV post-exposure prophylaxis which consists of 2-3 anti-retroviral medications administered for 28 days. For these scenarios, consult with the Infectious Diseases fellow during hours or consultant through switchboard after hours to discuss. 

    Post-exposure prophylaxis - unimmunised patients

    Ideally, post-exposure prophylaxis should be provided as the first part of a comprehensive plan for catch-up vaccinations. Consider referral to the RCH or MMC Immunisation service for all unimmunised children.

    At minimum:

    • Offer hepatitis B immunoglobulin within 72 hours. This can be ordered outside the hospital from the Australian Red Cross Blood Service ph no 9694 0200.  
      • <30 kg: 100 IU IM injection.
      • >30 kg: 400 IU IM injection.
    • Offer Hepatitis B vaccination (3 dose-schedule).
      • 0.5 mL IM (hepatitis B containing vaccine eg: Infanrix hexa, monovalent Engerix-B paediatric formulation or H-B-Vax II).
      • Within 7 days, and at 1 and 6 months after first dose.
      • Can be given at same time but different limb from immunoglobulin. 

    Follow up

    • Reassure patients and carers that the risk of viral transmission from community-acquired needlestick injuries in children is exceedingly low.
    • Provide unimmunised patients with written information in relation to further catch-up doses of hepatitis B and tetanus vaccines (at minimum). They may choose to have their GP administer these vaccinations or else, at RCH, may attend the Immunisation Clinic.
    • Refer to the Infectious Diseases outpatient clinic to provide an opportunity for questions and to plan follow-up investigations and vaccinations, if required.

    Information specific to RCH

    • Hepatitis B immunoglobulin can be ordered from the blood bank at RCH on x55829. 
    Emergency department management of community-acquired needlestick injury

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