Should you give PEP after an unknown stick?

In the May issue of HEH, we reported on an effort to reduce sharps injuries by using disposal containers with a better design. A reader subsequently posed a question: Would you administer post-exposure prophylaxis to an employee who receives a sharps injury from an unknown source, such as a sharp protruding from a container?

We asked Ronald H. Goldschmidt, MD, director of the National HIV/AIDS Clinicians' Consultation Center (Warmline, PEPline, Perinatal HIV Hotline) and professor and vice chair of Family and Community Medicine at the University of California, San Francisco, to share his advice.

Each situation needs to be assessed, Goldschmidt says. "Was the needle possibly from a patient with HIV or hepatitis? That requires the best possible clinical judgment. Obviously a needlestick in an HIV unit is very different from a needlestick in an Alzheimer's unit for the elderly."

Another factor is how long the needle has been in the sharps container. "HIV deteriorates very quickly with time," says Goldschmidt, so the risk diminishes over days and even hours. Another consideration: What type of needle was it? Was it visibly bloody? PEP might be appropriate in the case of a needlestick from an unknown source with a freshly bloody needle in a busy emergency department, he says.

Even if the risk is very small, a worried health care worker might request PEP. Because you can't say the risk is zero, "under those circumstances you'd go ahead and start PEP," he says. Starting PEP promptly is important, but PEP can always be discontinued based on a reevaluation, he says.