Which Disease Can Be Transmitted When A Nurse Is Drawing Blood From A Patient With An Infection?

Continuing Education Activity

Needlestick injuries are frequent occurrences in healthcare settings and can lead to serious complications. While the introduction of universal precautions and prophylactic witting needle designs has led to a subtract in needlestick injuries, they still exercise occur. Awareness of needlestick injuries started to develop soon after the identification of HIV in the early 1980s. Still, today the major business 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 Affliction 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 intendance for affected patients.

Objectives:

Identify the epidemiology of needle stick injuries.
Review the take chances factors for needle stick injuries.
Describe the risks of contracting a blood borne pathogen secondary to a needle stick injuries.
Explain the importance of improving care coordination amid interprofessional team members to amend outcomes for patients affected by needle stick injuries.

Admission gratuitous multiple choice questions on this topic.

Introduction

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 take chances of needlestick injuries is ever a concern. While the introduction of universal precautions and prophylactic concious needle designs has led to a turn down in needlestick injuries, they continue to be reported, albeit on a much smaller scale than in the by. Awareness of needlestick injuries started to develop soon afterward the identification of HIV in the early 1980s. However, today the major concern later on a needlestick injury is non HIV but hepatitis B or hepatitis C. Guidelines have been established to help healthcare institutions manage needlestick injuries and when to initiate mail-exposure HIV prophylaxis. The Centers for Disease Control and Prevention (CDC) has adult a model which helps healthcare professionals know when to offset antiretroviral therapy.[1][2][3]

Needlestick injuries are an occupational gamble for millions of healthcare workers. Fifty-fifty though universal guidelines take decreased the risks of needlestick injuries over the past 30 years, these injuries continue to occur, admitting 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 concious needles, needlestick injuries continue to occur more oftentimes in et al. healthcare professionals like surgeons and emergency room personnel. In nigh cases, needlestick injuries occur chiefly considering of unsafe practices and gross negligence on the role of the healthcare workers. The reality is that near needlestick injuries are preventable by following established procedures.

Needlestick injuries came to the forefront of healthcare subsequently the discovery of the HV in the early 1980s. Since the adoption of universal precautions, the number of needlestick injuries have greatly decreased but continue to occur, but the numbers are low. Today the major threat after a needlestick injury is not HIV simply acquiring hepatitis B or hepatitis C.

In the past, the majority of needlestick injuries occurred during resheathing of the needle after withdrawal of claret from a patient. Even though this practice is now no longer recommended, in that location are experts in communicable diseases who betoken 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 than of a concern when healthcare workers ignore policies and discard needles directly into the plastic numberless instead of the sharps containers. To prevent these injuries, many healthcare institutions accept now adopted unique ways of resheathing needles. For example, in the operating room, there are now established protocols on how the nurse will pass shape instruments and needles to the surgeon and vice versa. Another method of fugitive needlestick injuries is double gloving.

Factors that increase the risk of exposure to body fluids:

Failure to adopt universal precautions
Non post-obit established a protocol of safety
Performing high-chance procedures that increase the gamble of claret exposure such equally withdrawing blood, working in the dialysis unit, administering claret
Using needles and other abrupt devices that lack rubber features

What Organisms are Involved in Needlestick Injuries?

In reality, most whatever microorganism can be transmitted post-obit a needlestick injury, but practically only a scattering of organisms are of clinical concern. The most important organisms that can be caused later on a needlestick injury include HIV, hepatitis B and hepatitis C. All these three viruses tin be acquired by a percutaneous needlestick or splashing of blood on the mucosal surfaces of the torso. While HIV primarily affects the immune organisation, both hepatitis B and C take a predilection for the liver. Tetanus should always exist considered when a needlestick injury has occurred, and the patient's vaccination history must be obtained.[iv][5]

Etiology

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 whatever infection. Even if the skin is punctured or there is a spill in the mucous membranes, the majority of individuals exercise non acquire any organisms. There has ever been a concern that healthcare workers are at very high chance of developing illness post-obit a needlestick, but the data do not back up this belief. The risk of a healthcare profession for developing any infection depends on the blazon of needle, the severity of the injury, blazon of organism in the patient'south claret, and prior vaccination condition. Finally, one major determining factor whether an infection will develop is the availability of post-exposure prophylaxis (PEP).[6][7]

HIV

HIV infection is a systemic disorder that primarily suppresses the immune system. Over fourth dimension, about 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 volition go on to develop AIDs. Luckily today Highly Active Antiretroviral Therapy (HAART) is bachelor, and for those who remain compliant with the medication regimens, expiry is now a rare occurrence. In fact, most people go along to lead a normal life, but HIV is never cured.

However, later a needlestick injury developing HIV is not mutual at all. In fact, from 1981 to 2022, there have merely been 143 possible cases of HIV that were reported amidst 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 U.s., the majority of people who accept developed HIV as a result of needlestick injuries take been nurses, laboratory workers, non-surgical physicians, and nonclinical laboratory physicians.

Several prospective studies take on healthcare workers who have suffered occupational HIV exposure take 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 near 0.3% or 3 out of every g healthcare workers. However, there are several other studies that betoken that the risk of HIV actuating subsequently a needlestick injury is a lot higher, especially in individuals who take been exposed to a higher quantity of blood and struck with a large bore needle. Others who are at a higher risk is when they are exposed to patients with high viral titers or from those patients who take 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 intestinal pain. In most individuals, these symptoms volition spontaneously subside in 4 to 8 weeks. Nearly 2% to 5% of the individuals volition get on to develop chronic infection with hepatitis B. Over a lifetime, at that place is a fifteen% 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 caused hepatitis B from a needlestick injury. This was a significant decline from the previously loftier 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 claret. This decline has chiefly been attributed to the universal availability of the hepatitis B vaccine and awarding of universal precautions. Before the availability of the hepatitis B vaccine, the infection charge per unit from a needlestick ranged from half dozen% to 30%.

The direction of an private who has acquired hepatitis B following a needlestick injury depends on the recipient's vaccination status. Today, hepatitis B virus immunoglobulin is available just is non recommended until serological data are obtained. In individuals who have not been vaccinated, hepatitis B immunoglobulin tin foreclose 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 exist 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 too at gamble for acquiring hepatitis C. Unfortunately the verbal number of healthcare workers who take developed hepatitis C afterwards a needlestick injury remains unknown, considering of lack of follow upwardly. Some epidemiological studies on healthcare workers who got exposed to hepatitis C post-obit a needlestick reveal an infection incidence of about 1.eight%. However, today the actual number of hepatitis C cases have dropped significantly. In 1991, there were over 110,000 cases of hepatitis C reported, simply by 1997, the numbers had dropped to 38,000. Today it is estimated that healthcare workers who endure a needlestick injury and develop hepatitis C make up near two% to 4% of the total number of hepatitis C cases.

Afterward a needlestick injury, most people practise non have symptoms from hepatitis C, or if they exercise develop symptoms, they are vague and may resemble a flu-like syndrome. Unlike hepatitis B virus, where less than vi% of adults develop a chronic infection, with hepatitis C more than 75% of adults will develop a chronic infection. Well-nigh three-quarter of patients will develop the astute liver disease, and of these, near 20% volition go on to develop finish-phase liver disease or cirrhosis. About i% to 5% of them will develop hepatocellular cancer over the next 2 to three decades. While there is no post-exposure treatment for hepatitis C, in that location are some newer drugs that have shown hope in preventing the progression of the liver damage and lowering the rates of liver cancer.[8]

Epidemiology

Despite awareness and introduction of universal precaution guidelines, needlestick injuries continue to occur. The exact number of needlestick injuries that occur are non known because many become unreported. In the operating room, minor needlesticks are non uncommon at all. Rough estimates indicate that in the Usa alone, at that place are nearly 600,000 needlestick injuries of which half are not reported. Needlestick injuries not simply occur in hospitals but occur in every blazon 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 loftier risk for needlestick injuries.[ix][10][11]

Affect 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 propose that the incidence of needle sticks may have increased. Per one study published in Netherlands in 2018, the needle stick rate prior to implementation of SEDs was one.9 per 100 healthcare workers. Later on 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]

History and Physical

History

All previous immunizations and booster shots
Any body piercings and when they were done
Any history of hemodialysis
Any prior exposure to bodily fluids and or treatment
Consummate medical history
History of hepatitis B vaccination
History of intravenous drug use
Last tetanus shot
Prior blood transfusion history
Take chances factors for HIV and viral hepatitis
Sexual history
Travel history outside the United States within the past 12 months

Physical

Most individuals with a needlestick injury do not have any obvious physical findings, except for a puncture wound. Nevertheless, a baseline concrete test of the skin, eye, lung, liver, and lymphadenopathy should be washed. This baseline examination should be made to assist in the diagnosis of whatever futurity infection.If the patient whose blood was involved in the needlestick injury is yet in the hospital, so his/her club blood work should be obtained to rule out the presence of HIV, HBV, and HCV. The injured healthcare worker should as well have complete claret work, electrolytes and baseline liver role studies. In addition, a serological profile of HIV, hepatitis B, and hepatitis C should be obtained. A pregnancy test must be washed in all women of childbearing age.

The vaccination status of a prior tetanus shot and hepatitis B must be obtained. If the patient has not had a tetanus shot within the past x years, a tetanus booster shot must be administered. In that location is no vaccine against hepatitis C. Once the initial workup is completed, the infectious disease expert should be consulted ASAP to make up one's mind the need for post-exposure prophylaxis.

Evaluation

Usually, the only evaluation is a thorough history and physical exam. Rarely, there may exist a concern of a foreign torso in which case an x-ray, ultrasound, or CT should be considered.[13][14][fifteen]

Laboratory studies include HIV and a hepatitis panel.

Evaluating for HIV: CDC 3-Step Hazard Assessment

The prerequisite for starting PEP for HIV with antiretrovirals is based on evaluating the risk by using the 3-step process developed past the CDC (2014b) and other agencies. 17-20 (Level B) equally follows:

Footstep 1 Determine the Exposure Code: One determines the exposure source which may be claret, bodily fluid or an instrument contaminated with blood (east.g., scalpel). If none, then the risk of HIV transmission is zilch. If the answer is yes, so ane has to determine the type of exposure:

If exposure occurred to intact peel, and so the risk of acquiring HIV is nil
If exposure occurred to mucous membrane or in an area of the body where the skin was not intact (e.k., ulcer), 1 should determine the book of fluid exposure - few or large drops and the duration of contact.
If the exposure was via percutaneous, then was it via a superficial abrasion or a solid needle?
What type of needle was involved? Large bore hollow needle and was information technology used to obtain claret from the patient'due south vein or artery?

Step two Condition of Patient: it is important to know the HIV status of the patient. If negative, and then PEP is non required. If the patient was HIV positive, what was the viral titer (low or loftier?) and CD4 count. If the HIV status of the patient is unknown, clinical judgment and patient's past medical history is necessary to determine the status.

Step 3 Decision on Handling: Once the above data are collected post-exposure prophylaxis is determined. In general, if the gamble of HIV exposure is depression, so there is no need for treatment, but the observation is recommended. Individuals at high run a risk for HIV exposure are offered post-exposure prophylaxis. There are e'er some cases where the risk may exist indeterminate because the patient may not be available for testing. In such cases, one should counterbalance the benefits of HAART versus the potential adverse effects.

The CDC has a PEP hotline and website bachelor that can help with direction decisions.

Visit the Non-Occupational Post-Exposure Prophylaxis (nPEP) Toolkit from the AETC National Coordinating Resource Middle

PEP Consultation Service for Clinicians

1-888-448-49119 a.m. – ii a.m. ETFor more data on the services offered through the PEPline, visit the National Clinicians Consultation Center

Handling / Direction

Hepatitis B Handling

The following iii options are available for hepatitis B vaccine in healthcare workers who already have been vaccinated:

If the patient is HBsAg positive, the recipient's serology must exist assessed. If the post-vaccination anti-HBs level is high (greater than ten mIU/mL), this is known to exist protective, and there is no need for further treatment, and a booster shot is not recommended. Notwithstanding, if the post-vaccination anti-HBs titer is depression or if there is no HPV vaccine available, the healthcare worker should be administered hepatitis B immunoglobulin.
If the patient is HBsAg negative, the healthcare workers should be observed, and his or her anti-HBs levels should be monitored
If the patient has been discharged or not available for testing, this requires a significant amount of clinical judgment. Most infectious disease experts treat such cases as if the source was HBsAg negative unless the source has a loftier risk for HBV infection (such as current or one-time 4 drug use). In this case, the assumption is made that the patient is HBsAg positive, and Mail service-exposure prophylaxis is initiated (Level B).

If the healthcare worker is not vaccinated against hepatitis B, so these are the following 3 options:

If the patient is HBsAg positive, the healthcare workers should be administered HBV immunoglobulin immediately, followed past a rapid grade of active immunization starting 14 days later.
If the patient is HBsAg negative, so there is no need to administrate hepatitis B immunoglobulin; however, the healthcare worker should strongly be recommended to get the Hepatitis B vaccine.
If the patient is not bachelor for testing, and then the healthcare workers should be managed as if he or she is HBsAg negative. If there is any suspicion about the patient's clinical status, for example, if the patient had been admitted for a complexity of intravenous drug corruption or had hazard factors for hepatitis B, then the healthcare workers must be offered Hepatitis B immunoglobulin, and active vaccination should be recommended in 14 days time. According to the CDC, vaccination should be initiated if the exposed person is unvaccinated, and treatment with HBV immunoglobulin should exist initiated if the source person is in a high-risk category (Level A).[16][17][18]

HIV Prophylaxis

Today the recommendations for postexposure prophylaxis involve the utilise of iii-antivirals. The drug treatment should be initiated as soon as possible, preferably inside hours of exposure. The elapsing of treatment is for 4 weeks.

Currently, the CDC recommends using 2 nucleoside reverse transcriptase inhibitors (NRTIs) combined with a third drug, which is usually a protease inhibitor. For case, 1 may combine Tenofovir, emtricitabine plus either dolutegravir or raltegravir. Zidovudine is no longer utilized in this drug regimen considering it has non been shown to offer any additional reward. Meet CDC guidelines for additional alternate basic regimens and alternate expanded regimens (Prophylaxis and Post Exposure Treatments).

Once a needlestick injury has occurred, the healthcare worker must seek emergency care. The site of the needlestick must be thoroughly rinsed with saline or water, and the wound must be cleaned. In most cases, there is no need to utilise antiseptic solutions to wash the expanse. Wound infections commonly practise not develop within the outset 24 hours. Post-obit the injury, there is astute pain, and and so most individuals have no other immediate symptoms. Even so, feet, panic, and anticipation are very mutual because of the fear of contracting a viral infection.

It is important to follow all state, institution and federal guidelines for reporting all needlestick exposures. In that location is also a federal police force which ensures that all employers of such injuries receive complete medical coverage, including post-exposure prophylaxis and vaccine inside a reasonable time at no toll to the employee.[19][20]

Differential Diagnosis

Rapid HIV testing

Sexual set on

Viral hepatitis

Workers compensation

Prognosis

One time a needle stick injury occurs, all healthcare workers need to follow upward with the local Occupational Health and Safety Clinic inside 12 to 72 hours. During the workup, the private must be asked to abstain from sexual intercourse until the HIV testing is negative. In fact, most infectious disease experts recommend safe sexual activity or no sex until the second confirmatory HIV exam is also negative, which is commonly 4 to 6 months. If the initial workup is negative, then the private needs to be followed up at 2 and half-dozen months. For those individuals who develop an infection following a needlestick injury, the prognosis is the same as if they had acquired the organism via whatever other route.[21][22]

Complications

When an individual is involved in a needlestick injury, it can be a traumatic experience. Fifty-fifty though most individuals never developed any infection, in that location is always the potential of acquiring a potentially serious infection similar HIV or hepatitis C. The healthcare worker has to consult with many consultants and take repeated blood work, which as well creates more stress. In many cases, needlestick injuries are non lucent, and hard decisions accept to exist fabricated on handling. In addition, the healthcare worker must cope with the fear of non knowing what volition happen, since seroconversion with HIV can take months. Plus, the treatment for HIV is not harmless. Use of HAART is associated with varying number of side effects, almost of which are unpleasant. The individual must also bargain with family unit issues and either abjure from sex or use some blazon of barrier contraception for a long period. Women may have to postpone pregnancy for many months. But the worst part is not knowing the infectious status. Fifty-fifty when there are no symptoms, non knowing is the worst part of a needlestick injury. Information technology should exist noted that if PEP is given for only a few days to those of low risk pending initial source testing results that there is minimal adventure of side furnishings.

Consultations

Consider consultation with infectious illness nurse or infectious disease specialist.

Enhancing Healthcare Team Outcomes

Fifty-fifty though about needlestick injuries practise non lead to transmission of infection, sometimes one can develop a serious lifelong chronic infection like HIV or hepatitis C. The onus is on the healthcare workers to preclude needlestick injuries in the start place. Experts suggest that no i safety policy can work all the fourth dimension and thus, i should have an all-inclusive policy that recognizes the behavior of the healthcare workers, institutional policies and safe use of sharps and other devices. A critical office of whatever preventive program is to reduce the utilize of needles whenever possible and utilize other options when bachelor. Hospital workers may also undergo continuous education and grooming on the newer devices used during dialysis and blood withdrawal. A monitoring plan is essential as it tin help eliminate potential hazard factors that are responsible for needlestick injuries to ensure that the organization is working. Today, most hospitals take an infectious illness commission that consists of a nurse, pharmacist, laboratory technologist, physician and risk management that recommends and introduces safety policies. However, because of the nurse'due south position, she or he is in a prime number position to ensure that the safe rules are being adhered to. The only way to reduce needlestick injuries is by existence enlightened, enforcing the rules and performing random audits on other healthcare workers. [23][24](Level V)

Outcomes

Although many advances accept been fabricated in the development of safer needles and sheathing devices, these devices are not fail-safe and only work in settings where the work environment is constantly monitored. Studies, notwithstanding, practice evidence that the routine use of these needleless systems leads to a marked decrease in needlestick injuries. Today the onus is on healthcare institution to educate and train their workers on the safer use of sharps and needles. It is necessary for employees to exist enlightened of the effect of needlestick and what can be washed to preclude them. Today most hospitals have instituted policies and protocols to forbid needlestick injuries past advocating the post-obit:

Establish an occupational health and safety program that primarily monitors and identifies any high-risk procedure and recommended safety maneuvers
Introduce rubber needle apply procedures, utilise of needleless devices where possible
Establish cause of all injuries that occur and how they could have been prevented
Minimize the use of needles where possible
Encourage utilize of needles with safe features
Alters any dangerous piece of work do on the floor and in the operating room
Provides healthcare professionals with educational activity in needlestick injuries, their prevention and the current management guidelines
Promotes a safety civilisation free of retribution
Encourage reporting of unsafe practices without fright of reappraisal
Conducts random audits to ensure that hospital policy and procedures are existence followed
Assesses outcomes periodically

Review Questions

Figure

Postexposure prophylaxis for HIV. Image courtesy CDC

References

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