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Three Part Question

[Do all children presenting to the emergency department with non-occupational needlestick injuries] [require PEP for HIV] to [reduce HIV transmission].

Clinical Scenario

A tearful 10 year old was playing in the park and accidentaly pricked himself with a needle he found. His injury site was still bleeding when he presented to the emergency department. We wondered if HIV postexposure prophylaxis was indicated.

Search Strategy

Medline 1966-July 2006 using the OVID interface.
[blood exposure.tw or needlestick$.tw or needle?stick.tw or EXP needlestick injuries/] AND [exp. postexposure prophylaxis or postexposure prophylaxis.mp or antiretroviral$ .exp or combination therapy.exp] AND [HIV. exp or human immunodeficiency virus] AND [paeditric$.exp or infant$ or child$ or adolescent$]

Search Outcome

51 papers found, 4 papers relevant, 3 papers used

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Makwana N, Riordan FA. 2005 UK	All children referred with needlestick injury to a paediatric infectious disease clinic between August 1995-September 2003	Prospective study	Location and mechanism of childhood community needlestick injury Hepatitis B, C or HIV infection,	53 children (63% male) were referred with a NSI. Median age was 8.4 years (range 1.7-16.5 years). Most common mechanism of injury was playing with a needle found in a public place. 76% of children received the first dose of hepatitis B vaccine at presentation. The maximum time before the first vaccine was given was 14 days in one patient due to delayed presentation in hospital. No children received HIV PEP as there was no requirement as per local protocol. 40 patients (75%) attended a follow-up outpatient appointment and of these 25 (63%) had repeat serology sent at 6 months. 14 (35%) did not attend the 6 month appointment and one parent declined 6 month serology. Of the 25 pts who had serology sent, all completed 3 doses of hepatitis B vaccine. None tested positive for HIV, HBV or HCV.	A larger sample size would be needed to give more convincing results. Lack of information from those who did not attend follow-up
Babl FE 2005 USA	Children and adolescents presenting to an urban paediatric emergency (PED) department after non-occupational needlestick injury	Retrospective review American Journal of Emergency Medicine. Vol 18. No 3: May 2000	Use of HIV PEP after non-occupational needlestick injury	Over the 13 month review period 10 patients were offered HIV PEP. There was 2 and 3 yr old, and 8 adolescents. Of these 10 patients, 8 were started on HIV PEP. The regimens used for PEP varied; zidovudine, lamivudine and nelfinavir. All 10 pts were HIV negative by serology at baseline testing and all available for follow-up testing (5 of 10) remained HIV negative at 4-28 wks. Only 2 pts completed the full course of 4 wks of antiretroviral therapy.	Small sample size and the loss of some pf the patients to follow-up. Data was also limited because of lack of compliance of medication because of its adverse effects
Merchant et al 2001 USA	Children and adolescents following non-occupational needlestick injury	Retrospective review	Use of HIV PEP after non-occupational needlestick injury	Over the 13 month review period 10 patients were offered HIV PEP. There was 2 and 3 yr old, and 8 adolescents. Of these 10 patients, 8 were started on HIV PEP. The regimens used for PEP varied; zidovudine, lamivudine and nelfinavir. All 10 pts were HIV negative by serology at baseline testing and all available for follow-up testing (5 of 10) remained HIV negative at 4-28 wks. Only 2 pts completed the full course of 4 wks of antiretroviral therapy.	Small sample size Paediatrics. 2001:108: 38
Russel FM et al 2002 Australia	Children and adolescents following community-acquired needlestick injury	Prospective study	HIV,HBV,HCV transmission, use of HIV, HBV PEP after non-occupational needlestick injury	Over 32 months 50 cases of community NSI were identified. 36 were tested at least 3 months post-injury and there were no seroconversions of HIV, HBV, or HCV. No HIV PEP was given. Children who were not immune to HBV and were reviewed within 72h of injury received hepatitis B immunoglobulin i.e. 41/42 non-immune cases. 42 cases had follow-up after 3 months, 36 had blood taken. 17 had blood taken at 8 months. The remainder failed to attend. Completion of 3 doses of vaccine was achieved in 22/42 non-immune cases. Median age of injury was 6.9yrs (1.8-4.3). 32/50 were boys. 30% sustained their injury in a park, 18% in a street, 6% at the beach, and 5% in a car-park	Under –reporting of incidence, subjects lost to follow-up, small sample size

Comment(s)

HIV PEP is now a well established part of the management of HCW after occupational exposure to HIV. Use of PEP after HIV exposure in the non-occupational setting remains controversial with limited data available. There is even less information available concerning HIV PEP for children and adolescents after accidental needlestick injuries or sexual assault .

Clinical Bottom Line

The risk of acquiring HIV from a community needlestick injury, especially outside inner London, is very low. Children with these injuries should be given a course of hepatitis B vaccination. Follow up should only be offered if the parents or child cannot be reassured. HIV PEP should only be considered in those children at very high risk of contracting HIV (that is, injury from a known HIV source with presence of fresh blood on the needle and a deep, penetrating injury).These children should be offered HIV PEP and follow up.

References

1. Makwana N, Riordan FA. Prospective study of community needlestick injuries. Arch Dis Child 2005:90:523-524
2. Babl FE, Cooper ER,Damon B et al. HIV Post exposure Prophylaxis for children and Adolescents. American Journal of Emergency Medicine. Vol 18. No 3: May 2000
3. Merchant RC, Keshavatz R. HIV postexposue prophylaxis for adolescents and children. Paediatrics. 2001:108: 38
4. Russel FM, Nash MC. A prospective study of children with community-acquired needlestick injuries in Melbourne. Centre for International Child Health. 5 February 2002.