Infection Control and Barrier Precautions - 4 Contact Hours

A registered nurse is starting an IV line. The first attempt is unsuccessful, and as the IV catheter is removed, the stylet punctures the nurse’s forefinger. Blood was visible on the stylet before the puncture occurred. The nurse was wearing gloves. The stylet punctured the tip of the finger, and it did not enter a large vein.

After discarding the IV catheter and placing a dressing over the insertion site, the nurse washes the area with soap and water, covers it with an adhesive bandage, and immediately goes to the hospital’s emergency department (ED). The time from the injury until he arrived in the ED was approximately 15 minutes.

A rapid human immunodeficiency virus (HIV) test is done, and testing for Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) is done, as well.  The nurse is 33 years old; he has no past medical history, does not take any prescription medications, and has no risk factors for HBV, HCV, or HIV. He has been fully vaccinated against HBV.

The patient is a 65-year-old male who has been admitted for the treatment of heart failure. He does not have any factors that would now, or would have in the past, increase his risk of being infected with HBV, HCV, or HIV. The patient agrees to be tested for HBV and HCV but refuses to be tested for HIV.

The nurse’s rapid HIV test is negative, his HBV and HCV test are negative, and his HBSAb titer is ≥ 10 mlU/ml. The patient’s HBV and HCV tests are negative.

The ED physician summarizes the situation for the nurse.

1. He is fully immunized against HBV, so there is no need for further testing or treatment.

2. Because the source is negative for HCV and does not have risk factors for the disease, no further testing is needed. If the nurse develops signs and symptoms of hepatitis, he should seek medical attention.

3. This was a percutaneous injury from a hollow needle that was visibly stained with blood; those are risk factors for the transmission of HIV. However, the injury was shallow, it did not enter a large vein, and it is unlikely - but not impossible - that the source is infected with HIV. The nurse is young, and there are no contraindications to post-exposure prophylaxis (PEP) for HIV for him. PEP for HIV is most effective when given within hours of exposure. If determined that the source is HIV-negative, PEP can be stopped.

4. There are no universally accepted guidelines for the use of HIV PEP in situations like this; the decision to use PEP is made on a case-by-case basis, considering the type of injury, the factors of the exposure that are for and against transmission, and the patient’s personal preference. The patient decides to be treated.