Download Needle Stick Injury - Nottingham University Hospitals NHS Trust

Needle Stick Injury
Title of Guideline (must include the Guideline for the management of needlestick
word “Guideline” (not protocol,
injury in children
policy, procedure etc)
Contact Name and Job Title (author) Dr Louise Wells, Consultant Paediatrician
Directorate & Specialty
Directorate: Family Health; Specialty: Emergency
Date of submission
August 2016
Date on which guideline must be
reviewed
July 2020
Explicit definition of patient group to
which it applies (e.g. inclusion and This guideline applies to all children and young people
exclusion criteria, diagnosis)
under the age of 19 years.
Abstract
This guideline describes the management of
needlestick injury in children
Key Words
Children; Paediatrics; Needle stick; injury
Statement of the evidence base of the guideline – has the guideline been peer reviewed by
colleagues?
1a meta-analysis of randomised controlled
trials
2a at least one well-designed controlled study
without randomisation
2b at least one other type of well-designed
quasi-experimental study
3 well –designed non-experimental descriptive
studies (i.e. comparative / correlation and
case studies)
4 expert committee reports or opinions and /
or clinical experiences of respected
Yes
authorities
5 recommended best practice based on the
clinical experience of the guideline
developer
Consultation Process
Childrens Services Guideline Process
Target audience
Staff of Nottingham Children’s Hospital
This guideline has been registered with the trust. However, clinical guidelines are
guidelines only. The interpretation and application of clinical guidelines will remain the
responsibility of the individual clinician. If in doubt contact a senior colleague or expert.
Caution is advised when using guidelines after the review date.
Louise Wells
Page 1 of 10
Issued: August 2016
Document Control
Document Amendment Record
Version
V1
V2
V3
Issue Date
November 2011
November 2013
June 2016
Lead Author
Dr Louise Wells
Dr Louise Wells
Dr Louise Wells
Description
Review contact details
Review PEP
isis guidelinePEP guidelines
General Notes:
Change made in this update:



Post exposure prophylaxis (PEP) guidance has changed. This update includes the new
recommendations for this.
Contact details updates
Most recent National Guidance reviewed and their recommendations included (frequency of blood
tests and follow up included)
Statement of Compliance with Child Health Guidelines SOP
This guideline has had only minor changes made and therefore this version has not been circulated to all
for review. A previous version had been approved by circulation to senior team members.
Martin Hewitt
Clinical Guideline Lead
5th October 2016
Louise Wells
Page 2 of 10
Issued: August 2016
Needle Stick Injury In Children
HIV
HBV
HCV
vaccination
Dr Louise Wells
June 2016
Overview
Injury from discarded needles is not uncommon in children (10‐15 cases presenting to NUH
paediatric ED each year). The management of such injuries has to be realistic and based on the
best available evidence. The main risk comes firstly from hepatitis B and then hepatitis C (HBV
and HCV) transmission whereas the main public concern will frequently be with regard to
transmission of Human Immunodeficiency Virus (HIV). No data exists on the efficacy of
antiretroviral Post Exposure Prophylaxis (PEP) apart from in the health care setting. Some
Paediatricians have prescribed PEP on an individual basis when the risk of HIV is considered high.
Following exposure to blood-borne viruses, it should be remembered that the risk of transmission is
highest for Hepatitis B, then Hepatitis C and then HIV. As this document has been prepared for the
CHIVA website its focus is on HIV. However, it is important to consider risk of pregnancy and sexually
transmitted infections following high-risk sexual exposure, and any safeguarding concerns
General Measures.



Record details of the exposure incident
Assess significance of exposure
Assess infectivity of source (most will be unidentifiable)
✔ Encourage bleeding at the site of injury
✔ Wash thoroughly with disinfectant and water
✔ Cover the wound with a dressing
Blood Samples.
Blood should be obtained from the child exposed after obtaining informed consent from those
with parental responsibility. The discussion should be documented in the notes, but written
consent is not required. This should be 2mls of clotted (red top) and sent to microbiology for
serum save, HIV, hepatitis B and C serology. FBC, U and Es and LFTs should also be sent if PEP is
being considered. Storage should then be arranged with the laboratory. Clearly label the
samples as high risk with yellow stickers and biohazard bags and do not sent by chute.
The child should be tested for HIV PCR and antibodies 2 months post exposure and hepatitis
serology 2 and 6 months post exposure. Counselling will clearly be then be required if the tests
are positive as reference will then need to be made to the original stored sample. The
implications of a positive result from the pre‐exposure sample for both parents (are we bleeding
parents as routine?) and children should be discussed. Literature is available and parents should
have access to this (contact CSSU or HIV liaison nurse in ED).
If the baseline result is positive follow up testing will need to be arranged for parents. This
should be arranged with the consultant responsible and the GU clinic at NCH. The issue of
testing other members of the family will need to be addressed.
Assess Risk of Exposure.
Take a careful history and examination to assess the risk of exposure to HIV. Establish whether
exposure occurred within the last 72 hours.
Dr Louise Wells
June 2016
No Risk
 Intact skin visibly contaminated with blood or bodily fluids
Action
 Reassure parents and child
 Discharge
Low Risk


Action



Superficial injury that does not draw blood
Associated with needle/instrument not visibly contaminated with blood or bodily fluid
Counsel family about risks of HIV, HBV and HCV transmission
Recommend standard HBV immunisation: Day 0, 1 month, 6 months (or booster if
already immunised)
PEP not recommended (explain risks of HIV PEP drug side effects (see table 2) which
outweigh the extremely low risk of HIV transmission).
Moderate Risk


Skin penetrating injury that draws blood by needle/instrument contaminated with blood
or body fluid
Wound causing bleeding and produced by sharp instrument visibly contaminated with
blood
Action
 Counsel family about risks of HIV, HBV and HCV transmission
 Recommend standard HBV immunisation: Day 0, 1 month, 2 months (or booster if
already immunised)
 Discuss risks of HIV PEP (see table 2)
 Consider HIV PEP but on balance the risk of drug side effects from PEP probably
outweigh the benefit.
High Risk

Significant exposure to blood or body fluids from source known to be HIV, HCV or HBV
infected
Action
 Counsel family about risks of HIV, HBV and HCV transmission
 Recommend standard HBV immunisation: Day 0, 1 month, 2 months (or booster if
already immunised)
 Consider HBV Ig if source is a highly infectious HBV carrier and child is susceptible (see
below, under Management)
 Discuss risks of HIV PEP (see table 2)
 Recommend starting Standard HIV PEP (later modifications may be required dependent
on source's current viral load, treatment history and viral resistance).
Specific Measures.
HIV



The risk of HIV transmission following needlestick injury from a known positive source is
0.3%. This figure is based on a number of studies within the health care environment.
The risk is altered by the amount of blood inoculated, depth of wound and viral load of
the source
In rare situations the source may be known, and if the individual gives consent HIV, HBV
and HCV serology may be tested. If the source is already known to be HIV positive,
obtain details of present and past antiretroviral medications, and known resistant
mutations
In the community the risk will be substantially lower. The seroprevalance of HIV in
Nottingham is low (0.03%) and HIV is a fragile virus with its infectivity reducing rapidly
with time outside the body
Dr Louise Wells
June 2016


Two small studies following up children after sustaining needlestick injuries from
discarded syringes found no HIV infection
PEP is only recommended for needlestick injuries where the source is a known HIV
carrier. In needlestick injuries in the community PEP will rarely be recommended and
only be given in exceptional circumstances after discussion with the consultant on call
Post Exposure Prophylaxis (PEP).
The current recommendations are (www.chiva.org.uk):
1. Children aged 10 years and over and over 35kg (who are able to swallow tablets) :
raltegravir and Truvada®
2. Children aged 10 years and over with renal insufficiency: raltegravir and a fixed dose
combination of lamivudine/zidovudine
3. Children aged 6-10 years: Raltegravir and lamivudine and zidovudine
4. Children aged <6 years: Kaletra® and lamivudine and zidovudine
The doses for children are shown below, should be started ideally within an hour of exposure
(but up to 72 hours following exposure can be considered) and should be given for 28 days:
HIV PEP Drugs, Doses, Side effects and Interactions
Drug
Formulation
Dose
Side Effects
Raltegravir (RAL)
(for child >6y)
Tablet: 400mg
Chewable tablet:
25mg
Tablet:
From 25kg: 400mg BD
Chewable tablet:
11-14kg – 75 mg BD
14-20kg – 100mg BD
20-28kg – 150mg BD
28-40kg – 200mg BD
>40kg – 300mg BD
Rash, nausea, hepatitis
NB: tablet and
chewable tablet are
not bioequivalent
Zidovudine (AZT,
ZDV)
(for child <10y)
Capsule: 100mg,
250mg
Liquid: 10mg/ml
Capsule or liquid:
180mg/m2/dose BD
to a max dose of
250mg BD (max.
300mg BD when
used in combination
products)
Granulocytopenia
and/or
anaemia, nausea,
headache, myopathy,
hepatitis, neuropathy.
Lamivudine (3TC)
(for child <10y)
Tablet: 100mg,
150mg
Liquid: 10mg/ml
Tablet or liquid:
4mg/kg/dose BD to a
maximum dose of
150mg BD
Peripheral neuropathy,
nausea, diarrhoea,
headache.
Truvada® (TDF+FTC)
(for child >10y)
Combined tablet:
TDF 300mg/FTC
200mg
Combined tablet:
>35kg – 1 tablet OD
Headache, diarrhoea,
nausea, vomiting, renal
tubular dysfunction,
bone demineralisation
NB: do not use in
children with renal
impairment
Dr Louise Wells
June 2016
Lamivudine/zidovudine Combined tablet:
(for child >10y with
3TC 150mg/ZDV
renal insufficiency)
300mg
Combined tablet:
>30kg – 1 tablet BD
As for ZDV and 3TC
Kaletra® (LPV/RTV)
(for child <6y)
Liquid:
300mg/m2/dose BD
Dose in mls = (300 ×
SA)/80
Paed tablet:
15-25kg – 2 tabs BD
25-35kg – 3 tabs BD
>35kg – 4 tabs BD
Adult tablet:
>35kg – 2 tabs BD
Diarrhoea, abdominal
pain, nausea, vomiting,
headache.
Liquid: LPV 80mg/
RTV 20mg/mL
Paed tablet: LPV
100mg/RTV 25mg
(yellow)
Adult tablet: LPV
200mg/RTV 50mg
(orange)
NB: 2 adult tablets =
4 paediatric tablets =
5ml of liquid.
In the case of a known source, it may be possible to check the sensitivities of their virus to this
combination and suggest a more suitable treatment.
If you are planning on commencing PEP and the child is already on other medications please
utilise the following website or liaise with your trust pharmacist to ensure there are no
known potential drug interactions. http://www.hiv-druginteractions.org
Hepatitis B.
The risk of transmission of Hepatitis B following needlestick injury is 30% when the contact is
known to be Hep B eantigen positive and 20% when the contact is known to be Hep B sAg
positive but e antigen negative.
The risk of HBV transmission depends on:
1. Significant exposure
Percutaneous exposure (needlestick, bites or other injuries resulting in bleeding or
visible skin puncture) or muco-cutaneous exposure to blood (contamination of non
intact skin, conjunctiva or mucous membranes)
2. HBV status of the source
In most community needlestick injuries the source will be unknown and unidentifiable. If
the source is available blood should be obtained for urgent Hep B sAg testing and blood
should also be stored
3. HBV status of the exposed child
Most children will be of unknown HBV status. An initial exposure blood should be
obtained from the exposed child and stored.
An accelerated course of HBV vaccination at 0, 1 and 2 months should be arranged if significant
exposure from an unknown source occurs in a non‐vaccinated child. The first dose should be
given prior to discharge. The following 2 doses should be arranged with their GP. Blood should
be taken in 3 months and 6 months to ensure an adequate response has been mounted.
In a significant exposure from a known positive source (especially if e antigen positive), Hepatitis
B immunoglobulin should be considered, although some studies in vertical transmission have
found the additional benefit over accelerated vaccination minimal.
Dr Louise Wells
June 2016
Hepatitis C.
Hepatitis C is a blood borne transmissible viral disease. Studies show that the risk of
transmission post needlestick is as low as 0.2 to 0.4%. PEP with interferon has been shown to be
ineffective, however there is evidence that interferon alpha 2B can prevent chronic infection if
used during the initial acute illness (98% clearance in one study). Again the treatment is sensible
reassurance, a stored sample and repeat serology in 3 months and 6 months for Hepatitis C
antibodies.
Follow Up.
Prior to discharge, families embarking on HIV PEP should have the following:




An outpatient appointment, preferably within the next 72 hours to see a named clinician
with experience in prescribing antiretroviral drugs
Contact telephone numbers in case of concerns about any aspect of the HIV PEP
5 days of Antiretroviral therapy (with anti‐emetic and anti‐diarrhoeal for prn use)
A letter for their GP, with patients/parents’ consent
Outpatient Visits.
Within 72 hours:
 Review in clinic, assess adherence and toxicity
 Decide whether PEP should continue for the full four‐week course.
 Document and give baseline HIV, HBV, HCV Ab results.
 Arrange psychological support as necessary.
Day 14:
 Review in clinic, assess adherence and toxicity
 Check FBC, U&E, LFTs.
Day 28:
 Review in clinic, assess adherence and toxicity
 Check FBC, U&E, LFTs (if abnormalities on previous blood tests).
1-3 months AFTER PEP completion (8 weeks from high risk exposure)
 Follow‐up HIV testing should be undertaken with a fourth generation combined HIV
antibody/ antigen assay.
 Antibody screening for Hepatitis B and C is recommended. (Optimally 4-8 weeks after
completing the 3 doses of HBV vaccine)
References
Marcus R. Surveillance of health care workers exposed to blood from patients infected with the
human immunodeficiency virus. N Engl J Med 1988;319:1118‐23.
Centres for Disease Control and Prevention. Case‐control study of HIV seroconversion in health‐
care workers after percutaneous exposure to HIV‐infected blood – France, United Kingdom, and
United States, January 1988‐August 1994. MMWR Morb Mortal Wkly Rep 1995;44:929‐33.
Montella F, Di Sora F, Recchia O. Can HIV‐1 infection be transmitted by a “discarded” syringe? J
Acquir Immune Defic Syndr 1992;5:1274‐5.
Aragon Pena AJ, et al Hepatitis B prevention and risk of HIV infection in children injured by
Dr Louise Wells
June 2016
discarded needles and/or syringes Aten Primaria 1996;17:138‐40.
Department Of Health, HIV post‐exposure prophylaxis: Guidance from the UK Chief Medical
Officer's Expert Advisory Group on AIDS February 2004
http://www.dh.gov.uk/assetRoot/04/08/36/40/04083640.pdf
Yang YJ, et al Role of hepatitis B immunoglobulin in infants born to hepatitis B e antigen‐
negative carrier mothers in Taiwan. Pediatr Infect Dis J. 2003 Jul;22:584‐8.
Chung H, et al. Risk of HCV transmission after needlestick injury, and the efficacy of short‐
duration interferon administration to prevent HCV transmission to medical personnel. J
Gastroenterol. 2003;38:877‐9.
Elmar Jaeckel, M.D et al Treatment of Acute Hepatitis C with Interferon Alfa‐2b N Engl J Med
2001; 345:1452‐1457.
http://content.nejm.org/cgi/content/full/345/20/1452
Other Guidelines.
Children’s HIV association
http://www.chiva.org.uk
Royal Children's' Hospital Melbourne http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5231
Canadian Paediatric Society
http://www.cps.ca/english/statements/ID/id99‐02.htm
Appendix 1 ‐ Multidisciplinary units.
The following are major units which can provide advice on the management of children and
families with HIV infection. Many other units especially in London, are providing services for
children and their families.
Dr Sam Walters/ Dr Gareth Tudor‐Williams / Dr Hermione Lyall
Dept Of Paediatrics
QEQM Wing
St Mary's Hospital
Praed Street
London
W2 1NY
Dr Diana Gibb / Dr Vas Novelli / Dr Nigel Klien
Ms Clapsom (Nurse Counsellor) / Sue Trickett (Social Worker)
Great Ormond Street Hospital For Children NHS Trust
London
WC1N 3JH
Dr Mike Sharland / Wendy Faulkner (nurse)
Dept Child Health
St Georges NHS Trust
Cranmet Terrace
London
SW17 ORE
Dr Louise Wells
Tel 0207 7256 666
Tel 020 7405 9200 x5946
Tel 0208 672 1255
June 2016
Dr Jaqueline Mok
Consultant Paediatrician
Edinburgh Sick Children's NHS Trust
Community Child Health Services
10 Chalmer Crescent
Edinburgh
EH9 1TS
Tel 0131 536 0971
National AIDS Helpline
For more information about help available in your area, you can phone the National AIDS
helpline at any time. The number is 088 567123 and calls are free and entirely confidential. They
should be able to provide a variety of information including details of any support / self help
groups in your area.
Changes in this revision

Changes to HIV PEP doses as per chiva guidance
Dr Louise Wells
June 2016