Needlestick and Occupational PEP

One pathway for a needlestick, covering HIV, HBV and HCV together · v1.5

  • Enter the route of the exposure and the time since it happened.
  • Then enter the source serology and the exposed worker's hepatitis B vaccination status, renal function and pregnancy status.
  • You get the risk for HIV, hepatitis B and hepatitis C assessed together, and one post-exposure prophylaxis plan with the baseline tests due.
  • Do not wait on the source laboratory result where the exposure is high risk. The first dose goes in inside 72 hours, and the plan is revised when the serology returns.

  • Non-occupational exposure. Sexual exposure, sexual assault and injecting drug use follow a different pathway and are assessed elsewhere.
  • Paediatric dosing. Every regimen printed is the adult NACO dose.
  • Treatment of an infection that has already been transmitted. This is prophylaxis and the baseline testing that goes with it.
  • Exposures that are not to blood or body fluid: rabies after an animal bite and tetanus after a contaminated wound have modules of their own.
  • The 2025 USPHS follow-up schedule. The testing printed here is NACO 2021: baseline, 6 weeks, 3 months and 6 months.

1. Exposure Details

2. Source Patient Serology

If the source is unknown, a needle found in the laundry for instance, select Unknown in those fields. Do not delay PEP while waiting for laboratory results when the exposure is high-risk.

3. Exposed Person (HCW) Status

Pathophysiology & Clinical Pearls

1. Mnemonic for Immediate First Aid: "WASH"

  • W - Wash the area thoroughly with soap and flowing water.
  • A - Avoid squeezing or milking the wound. Do NOT apply bleach or caustic agents.
  • S - Source testing. Draw blood from the source patient for HBsAg, HIV and Anti-HCV immediately.
  • H - HIV PEP & HBIG evaluation, inside the 72-hour window.
Clinical caution, the squeeze: The instinct after a needlestick is to squeeze the finger and bleed it out. There is no evidence that squeezing reduces the risk, and caustic agents such as bleach and undiluted alcohol damage the tissue. Wash with soap and running water, and use nothing else.

2. Pathophysiology: Why HBIG + Vaccine?

In a high-risk exposure (Unvaccinated HCW + Positive Source), the Hepatitis B vaccine alone is too slow, because the virus replicates before active immunity develops. Both are given, one to cover the gap and one to close it:

  • HBIG (Hepatitis B Immune Globulin): Provides immediate, passive neutralising antibodies that bind to the HBsAg on the viral envelope, preventing hepatocyte entry. This protection fades in a few weeks.
  • HBV Vaccine: Initiates the endogenous T-cell and memory B-cell response for long-term active immunity.
  • Administration rule: If giving both, give them in different limbs (left deltoid and right deltoid, for instance). Given at the same site, the passive HBIG antibodies may bind the vaccine antigen and blunt the vaccine response.

3. Transmission Risk After a Hollow-Bore Needlestick

These are the baseline transmission probabilities without treatment, from a positive source, and they are the figures to counsel a colleague with. They are often taught as the rule of 3s.

Pathogen Untreated Transmission Risk Post-Exposure Efficacy
Hepatitis B (HBV) ~30% (Highest Risk) HBIG + vaccine is 85 to 95% effective if given within 24 to 72 hours (HBIG is of uncertain value after 7 days).
Hepatitis C (HCV) about 2% (1.8%) No active PEP available. Monitor HCV RNA; treat with Direct-Acting Antivirals (DAAs) if infection occurs (Cure rate >95%).
HIV ~0.3% Triple-therapy ART PEP for 28 days reduces risk by >80% if started within 72 hours.

4. NACO Guidance: HIV PEP Regimen

The National AIDS Control Organisation (NACO) standard for adult PEP is a 28-day course of a three-drug regimen. The preferred regimen is Tenofovir (TDF) 300 mg + Lamivudine (3TC) 300 mg + Dolutegravir (DTG) 50 mg once daily. Where the source is on treatment with a detectable viral load, or has known resistance, the first dose is still given now and the regimen is reviewed with an expert within 24 hours.

  • Pregnancy: NACO and WHO both recommend dolutegravir-based regimens for pregnant women. The neural tube defect risk turned out to be far smaller than the first reports suggested.
  • Renal impairment: Tenofovir disoproxil fumarate (TDF) is nephrotoxic. Below an eGFR of 50 mL/min, NACO replaces it with zidovudine (AZT) 300 mg twice daily, with lamivudine (3TC) dose-adjusted for the creatinine clearance and dolutegravir unchanged.
Abbreviations Ag/Ab (Antigen/Antibody) · ALT (Alanine Aminotransferase) · anti-HBs (Antibody to Hepatitis B Surface Antigen) · anti-HCV (Hepatitis C Antibody) · ART (Antiretroviral Therapy) · ARV (Antiretroviral) · AZT (Zidovudine) · DAAs (Direct-Acting Antivirals) · DTG (Dolutegravir) · eGFR (Estimated Glomerular Filtration Rate) · HBIG (Hepatitis B Immunoglobulin) · HBsAg (Hepatitis B Surface Antigen) · HBV (Hepatitis B Virus) · HCV (Hepatitis C Virus) · HCW (Healthcare Worker) · HIV (Human Immunodeficiency Virus) · IM (Intramuscular) · NACO (National AIDS Control Organisation) · PEP (Post-Exposure Prophylaxis) · RNA (Ribonucleic Acid) · TDF (Tenofovir Disoproxil Fumarate) · Vax (Vaccine) · WASH (Wash, Avoid Squeezing, Source Testing, HIV PEP and HBIG) · WHO (World Health Organization) · 3TC (Lamivudine)
References
  1. National AIDS Control Organisation (NACO), Ministry of Health and Family Welfare, Government of India. National Guidelines for HIV Care and Treatment. 2021.
  2. World Health Organization. WHO updated recommendations on HIV clinical management: recommendations for a public health approach. Geneva: WHO; 7 January 2026.
  3. Schillie S, Vellozzi C, Reingold A, et al. Prevention of Hepatitis B Virus Infection in the United States: Recommendations of the ACIP. MMWR Recomm Rep. 2018;67(1):1-31.
  4. Weng MK, Doshani M, Khan MA, et al. Universal Hepatitis B Vaccination in Adults Aged 19-59 Years: Updated Recommendations of the ACIP, United States, 2022. MMWR Morb Mortal Wkly Rep. 2022;71(13):477-483.
  5. Kuhar DT, Henderson DK, Struble KA, et al. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol. 2013;34(9):875-892. [Superseded by the 2025 US Public Health Service update]
  6. Moorman AC, de Perio MA, Goldschmidt R, et al. Testing and Clinical Management of Health Care Personnel Potentially Exposed to Hepatitis C Virus: CDC Guidance, United States, 2020. MMWR Recomm Rep. 2020;69(6):1-8.
  7. Singh A, Kumar H, Tandon N. Guidelines for vaccination in normal adults in India. J Assoc Physicians India. 2016;64(Suppl):S1-S5.
How to Cite This Tool

DOIhttps://doi.org/10.5281/zenodo.22401618

AMA Style:Umakanth S. Needlestick and Occupational PEP. Version 1.5. MEDiscuss Clinical Decision Support System. Published 2026. Accessed . https://mediscuss.org/cdss/occupational-exposure-pep. doi:10.5281/zenodo.22401618

Vancouver Style:Umakanth S. Needlestick and Occupational PEP [Internet]. Version 1.5. MEDiscuss.org; 2026 [cited ]. Available from: https://mediscuss.org/cdss/occupational-exposure-pep. doi:10.5281/zenodo.22401618

Disclaimer and scope
Disclaimer: This decision-support system is written for healthcare professionals. It does not substitute clinical judgment, and the treating physician retains absolute responsibility for every diagnostic, dosing and therapeutic decision. The algorithms are built on the evidence as it stands, and the evidence moves. Verify the output against your current institutional protocol, and against the patient in front of you.
© 2026 MEDiscuss.org. All rights reserved. Provided free of charge for clinical use. Unauthorised reproduction or redistribution is strictly prohibited.
Category Immunisation & ProphylaxisPathway
Specialties Internal Medicine, Infectious Diseases
Status Essential

Written and maintained by

Dr Shashikiran Umakanth

Last revised 24 August 2026

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