• 
• 

Three Part Question

[In patients with needlestick injury] how does [emergency intervention with prophylactic medication against HIV] [change the risk of distress or infection]?

Clinical Scenario

Tearful nineteen year old university student accidentally walked into IVDA 6 hours ago at a party and has puncture wound to hand from needle projecting from user's pocket. Needle and user not available.

Search Strategy

Medline 1966-12/2000 using the OVID interface.
[blood exposure.tw or needlestick$.tw or needle?stick.tw or EXP needlestick injuries/] AND [maximally sensitive RCT filter] AND [prophyla$.tw] UK Department of Health (www.doh.gov.uk): [needlestick.tw]

Search Outcome

Medline: 18 papers found of which 5 irrelevant and 14 of insufficient quality for inclusion. UK DoH: 11 papers found of which 9 irrelevant and 2 given honorable mention.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Cardo DM et al, 1997, USA	33 HIV+ve healthcare workers and 665 HIV-ve controls from voluntary reporting 87-94	Multicentre unblinded Retropective Case-control(Level III)	Likelihood that cases had taken HIV prophylaxis,Risk factors for cross-infection	Estimated reduction in odds of HIV with zidovudine: 0.81[NNT approx = 411]	High suspicion of selection bias, unknown confounders, various protocols used

Comment(s)

The only attempted RCT found by this search, that of HIV prophylaxis vs placebo, was abandoned by authors of paper 1 after tiny recruitment rate. With the available published evidence scarce, expert opinion was sought at the UK Department of Health, and two related guidelines found (2,3). These suggest needlestick may be a "medical emergency" and A&E departments should offer "immediate 24 hour access to advice, drugs and support" for staff with significant (ie percutaneous) exposure, and referral to specialists in HIV treatment for patients who are not staff. No published evaluation of guidelines was found on this search of the indexed literature.

Clinical Bottom Line

A patient like the one above should be offered management in A&E by a protocol including: 1. assessment including risk factors, 2. relief of distress by addressing concerns, 3. urgent referral for further specialist investigation and treatment. 4. at least urgent Zidovudine and HepB Immunoglobulin unless specialist review is imminent.

References

1. Cardo DM, Culver DH, Ciesielski CA, et al. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. Centers for Disease Control and Prevention Needlestick Surveillance Group. N Engl J Med 1997;337(21):1485-90.
2. UK Health Departments. Guidance for clinical healthcare workers: Protection against infection with blood-bourne viruses. Recommendations of the Expert Advisory Group on AIDS and the Advisory Group on Hepatitis. 1998
3. UK Health Departments. HIV Post-exposure prophylaxis: guidance from the UK Chief Medical Officers' Expert Advisory Group on AIDS. 2000