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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.
Kevin C. King ; Ronald Strony .
Last Update: May 1, 2023 .
Needlestick injuries are frequent occurrences in healthcare settings and can lead to serious complications. While the introduction of universal precautions and safety conscious needle designs has led to a decrease in needlestick injuries, they still do occur. Awareness of needlestick injuries started to develop soon after the identification of HIV in the early 1980s. However, today the major concern after a needlestick injury is not HIV but hepatitis B or hepatitis C. Guidelines have been established to help healthcare institutions manage needlestick injuries and when to initiate post-exposure HIV prophylaxis. The Centers for Disease Control and Prevention (CDC) has developed a model that helps healthcare professionals recognize when to start antiretroviral therapy. This activity describes the evaluation and management of needlestick injuries and highlights the role of the interprofessional team in improving care for affected patients.
Identify the epidemiology of needlestick injuries. Review the risk factors for needle stick injuries. Describe the risks of contracting a blood-borne pathogen secondary to needlestick injuries.Explain the importance of improving care coordination amongst interprofessional team members to improve outcomes for patients affected by needlestick injuries.
Needlestick injuries are known to occur frequently in healthcare settings and can be serious. In North America, millions of healthcare workers use needles in their daily work, and hence, the risk of needlestick injuries is always a concern. While the introduction of universal precautions and safety conscious needle designs has led to a decline in needlestick injuries, they continue to be reported, albeit on a much smaller scale than in the past. Awareness of needlestick injuries started to develop soon after the identification of HIV in the early 1980s. However, today the major concern after a needlestick injury is not HIV but hepatitis B or hepatitis C. Guidelines have been established to help healthcare institutions manage needlestick injuries and when to initiate post-exposure HIV prophylaxis. The Centers for Disease Control and Prevention (CDC) has developed a model which helps healthcare professionals know when to start antiretroviral therapy.[1][2][3]
Needlestick injuries are an occupational hazard for millions of healthcare workers. Even though universal guidelines have decreased the risks of needlestick injuries over the past 30 years, these injuries continue to occur, albeit at a much lower rate. Healthcare professionals at the highest risk for needlestick injuries are surgeons, emergency room workers, laboratory room professionals, and nurses. The use of needles is unavoidable in healthcare, and even though every hospital has guidelines on proper handling and disposal of needles and the newest design of safety conscious needles, needlestick injuries continue to occur more often in et al. healthcare professionals like surgeons and emergency room personnel. In most cases, needlestick injuries occur chiefly because of unsafe practices and gross negligence on the part of the healthcare workers. The reality is that most needlestick injuries are preventable by following established procedures.
Needlestick injuries came to the forefront of healthcare after the discovery of the HV in the early 1980s. Since the adoption of universal precautions, the number of needlestick injuries has greatly decreased but continues to occur, but the numbers are low. Today the major threat after a needlestick injury is not HIV but acquiring hepatitis B or hepatitis C.
In the past, the majority of needlestick injuries occurred during resheathing of the needle after the withdrawal of blood from a patient. Even though this practice is now no longer recommended, there are experts in infectious disease who indicate that not resheathing the needle greatly increases the risk of needlestick injuries in house cleaners and porters who are in charge of collecting and disposing of the sharps containers. Over the years, many cases of cleaners and porters being injured by unsheathed needles have been reported. Further, this is more of a concern when healthcare workers ignore policies and discard needles directly into the plastic bags instead of the sharps containers. To prevent these injuries, many healthcare institutions have now adopted unique ways of resheathing needles. For example, in the operating room, there are now established protocols on how the nurse will pass sharp instruments and needles to the surgeon and vice versa. Another method of avoiding needlestick injuries is double gloving.
Factors that increase the risk of exposure to body fluids:
Failure to adopt universal precautions Not following established a protocol of safetyPerforming high-risk procedures that increase the risk of blood exposure such as withdrawing blood, working in the dialysis unit, administering blood
Using needles and other sharp devices that lack safety featuresWhat Organisms are Involved in Needlestick Injuries?
In reality, almost any microorganism can be transmitted following a needlestick injury, but practically only a handful of organisms are of clinical concern. The most important organisms that can be acquired after a needlestick injury include HIV, hepatitis B, and hepatitis C. All these three viruses can be acquired by a percutaneous needlestick or splashing of blood on the mucosal surfaces of the body. While HIV primarily affects the immune system, both hepatitis B and C have a predilection for the liver. Tetanus should always be considered when a needlestick injury has occurred, and the patient's vaccination history must be obtained.[4][5]
Cause and Consequence of Disease from Needlestick Injuries
Despite the high number of needle sticks that occur in healthcare settings, the majority of healthcare workers do not develop any infection. Even if the skin is punctured or there is a spill in the mucous membranes, the majority of individuals do not acquire any organisms. There has always been a concern that healthcare workers are at a very high risk of developing disease following a needlestick, but the data do not support this belief. The risk of a healthcare professional for developing any infection depends on the type of needle, the severity of the injury, the type of organism in the patient's blood, and prior vaccination status. Finally, one major determining factor in whether an infection will develop is the availability of post-exposure prophylaxis (PEP).[6][7]
HIV infection is a systemic disorder that primarily suppresses the immune system. Over time, almost every organ in the body is involved leading to a variety of symptoms. The virus has an affinity for the CD4 cells, leaving the body in a state of immunosuppression. This leads to the development of opportunistic infections, cancer, and severe wasting. Many patients will go on to develop AIDs. Luckily today Highly Active Antiretroviral Therapy (HAART) is available, and for those who remain compliant with the medication regimens, death is now a rare occurrence. In fact, most people go on to lead a normal life, but HIV is never cured.
However, after a needlestick injury developing HIV is not common at all. In fact, from 1981 to 2010, there have only been 143 possible cases of HIV that were reported among healthcare professionals. Of these only 57 of the exposed workers seroconverted to HIV. Percutaneous needlestick injury was the known cause in 84% of these cases. Other infections acquired from exposure were 9% by the mucocutaneous route and 4% by both routes.
In the United States, the majority of people who have developed HIV as a result of needlestick injuries have been nurses, laboratory workers, non-surgical physicians, and nonclinical laboratory physicians.
Several prospective studies on healthcare workers who have suffered occupational HIV exposure have been done. The data reveal that the risk of transmission from a single percutaneous needle stick or cut with a scalpel from an HIV-infected individual is about 0.3% or 3 out of every 1000 healthcare workers. However, there are several other studies that indicate that the risk of HIV actuating after a needlestick injury is a lot higher, especially in individuals who have been exposed to a higher quantity of blood and struck with a large-bore needle. Others who are at a higher risk are when they are exposed to patients with high viral titers or those patients who have just seroconverted at the time of the needlestick injury.[7]
Viral Hepatitis
Of the viruses, the most common organism acquired via a needlestick injury is hepatitis B. About 30% to 50% of individuals who do contract hepatitis B may develop jaundice, fever, nausea, and vague abdominal pain. In most individuals, these symptoms will spontaneously subside in 4 to 8 weeks. About 2% to 5% of the individuals will go on to develop chronic infection with hepatitis B. Over a lifetime, there is a 15% risk that these individuals will develop liver cancer or cirrhosis.Over twenty years ago in 1997, data from the CDC National Hepatitis Surveillance revealed that there were nearly 500 healthcare workers who acquired hepatitis B from a needlestick injury. This was a significant decline from the previously high 17,000 new cases diagnosed in 1983. A report done in 2009 reported that there were 1550 hepatitis B cases from occupational exposure, of which only 13 were related to employment in a healthcare field with exposure to blood. This decline has chiefly been attributed to the universal availability of the hepatitis B vaccine and the application of universal precautions. Before the availability of the hepatitis B vaccine, the infection rate from a needlestick ranged from 6% to 30%.
The management of an individual who has acquired hepatitis B following a needlestick injury depends on the recipient’s vaccination status. Today, hepatitis B virus immunoglobulin is available but is not recommended until serological data are obtained. In individuals who have not been vaccinated, hepatitis B immunoglobulin can prevent a full-blown infection. If the person is already infected, the immunoglobulin has been shown to produce a much milder infection. For hepatitis B immunoglobulin to be effective, it needs to be administered within the first 24 hours after exposure. It is used in combination with active immunization.
In Individuals who are not vaccinated and suffer a needlestick injury, the rapid protocol for hepatitis B vaccine is undertaken which involves intramuscular injections at times 0, 1, and 2 months followed by a booster shot at 12 months.[4]Hepatitis C
After a needlestick injury, healthcare professionals are also at risk of acquiring hepatitis C. Unfortunately the exact number of healthcare workers who have developed hepatitis C after a needlestick injury remains unknown, because of lack of follow-up. Some epidemiological studies on healthcare workers who got exposed to hepatitis C following a needlestick reveal an infection incidence of about 1.8%. However, today the actual number of hepatitis C cases has dropped significantly. In 1991, there were over 110,000 cases of hepatitis C reported, but by 1997, the numbers had dropped to 38,000. Today it is estimated that healthcare workers who suffer a needlestick injury and develop hepatitis C make up about 2% to 4% of the total number of hepatitis C cases.
After a needlestick injury, most people do not have symptoms of hepatitis C, or if they do develop symptoms, they are vague and may resemble a flu-like syndrome. Unlike hepatitis B virus, where less than 6% of adults develop a chronic infection, with hepatitis C more than 75% of adults will develop a chronic infection. About three-quarters of patients will develop acute liver disease, and of these, about 20% will go on to develop end-stage liver disease or cirrhosis. About 1% to 5% of them will develop hepatocellular cancer over the next 2 to 3 decades. While there is no post-exposure treatment for hepatitis C, there are some newer drugs that have shown promise in preventing the progression of liver damage and lowering the rates of liver cancer.[8]
Despite awareness and the introduction of universal precaution guidelines, needlestick injuries continue to occur. The exact number of needlestick injuries that occur is not known because many go unreported. In the operating room, minor needlesticks are not uncommon at all. Rough estimates indicate that in the US alone, there are nearly 600,000 needlestick injuries of which half are not reported. Needlestick injuries not only occur in hospitals but occur in every type of healthcare facility like a clinic, outpatient surgery, day surgery, urgent care center, nursing homes, and cosmetic surgery clinics.
Needlestick injuries do not occur with the same frequency in all healthcare workers. The majority of needlestick injuries occur in nurses, surgeons, emergency medical technicians, surgery technologists, and laboratory personnel. In addition, housekeeping personnel and those who clean the sharp boxes are also at high risk for needlestick injuries.[9][10][11]
Impact of Safety Devices on Needle Stick Injuries
Special safety engineered devices (SEDs) have been marketed widely in an effort to reduce the incidence of needlestick injuries. Contrary to an expected drop in needle sticks with greater use of SEDs, studies suggest that the incidence of needle sticks may have increased. Per one study published in the Netherlands in 2018, the needle stick rate prior to implementation of SEDs was 1.9 per 100 healthcare workers. After SED deployment, the incidence of needle stick injuries increased to 2.2 per 100 healthcare workers. The most common causes reported for needle sticks in the study were difficulties in operating the safety device and continued improper disposal of needles. [12]
