The patient was a 24-year-old woman, a surgical nurse, seen in the clinic for evaluation of a needle puncture wound to the hand. Earlier in the day, while assisting in a frantic attempt to revive a man with cardiac arrest, she sustained a deep puncture wound to her right palm from a needle that had accidentally dropped into the bedclothes. The needle was visibly contaminated with blood. She immediately washed her hand thoroughly with soap and water, applied an antiseptic, and dressed the puncture site with a loose adhesive bandage.
She was married, with one 14-month-old child.There was no history of blood transfusion or injected-drug abuse. She had donated blood the previous month, and it was not rejected. Her tetanus immunization was up to date, but she had not been immunized against hepatitis B.
Two days after the clinic visit, tests for antibody in the cardiac arrest patient's blood revealed that he had a chronic viral infection.
1. What were the main diagnostic considerations?
2. What risk of infection did the patient face?
3. What measures could be taken to reduce the risk? How much time could expire before preventive measures became ineffective?
4. What was the nurse's prognosis?
1. The viruses of concern are hepatitis B virus (HBV), human immunodeficiency virus (HIV), and hepatitis C virus (HCV). Each of these could be transmitted to the nurse by a needle stick and cause serious illness.
2. There are an estimated 750,000 to 1 million carriers of HBV in the United States.They typically have large amounts of circulating infectious virus, so that even a tiny amount of their blood can transmit the disease.The risk of infection from a needle puncture wound when the blood originates from a hepatitis B virus carrier is estimated to be 10% to 35%.The AIDS-causing human immunodeficiency virus (HIV) infects approximately 1 million Americans.The blood of these persons is also potentially infectious, but the risk of transmission by a needle stick is considerably lower than the risk for hepatitis B, averaging about 0.4%.The lower risk results from smaller amounts of circulating infectious virus in HIV-infected individuals.The risk is probably higher early in HIV disease, during the acute infection, and later, when AIDS develops, because much higher levels of circulating infectious virus are then present.
Hepatitis C virus transmission by blood accounts for most cases of post-transfusion hepatitis.Transmission from surgeon to patient has been documented, presumably by the multiple pricks from surgical needles that often penetrate the surgeons' gloves during major surgery.The risk of transmission by needle stick from an HCV-positive individual is about 1.8%.The number of new hepatitis C virus infections in the United States each year has been estimated at between 150,000 and 170,000, but the mode of transmission is unknown in most cases.
Other viruses, such as cytomegalovirus (CMV) and Epstein-Barr virus (EBV), can be transmitted by blood.The risk from a needle stick injury is unknown but is probably much lower than from the viruses already mentioned.
Obviously, all blood should be considered potentially infectious.
3. In the case of needle puncture wounds that expose a person to HBV, hepatitis B immune globulin (HBIG) is given as soon as possible after the wound occurs. HBIG is gamma globulin obtained from individuals that have a high titer of antibody against HBV. At the same time, active immunization is started with hepatitis B vaccine.These measures must be initiated within 7 days of the injury to be effective.This nurse, as with all persons at high risk of blood exposure, should have already been immunized with hepatitis
B vaccine; then, no other preventive measures would need to be taken.
Those exposed to HIV by needle punctures should be given zidovudine (AZT), plus one or more other anti-HIV medications, immediately and for 4 weeks.There is probably little protective effect if therapy is delayed beyond 2 hours.
There is no proven preventive measure for HCV exposure. Approaches similar to those for HBV may become available in the future.
4. Preventive measures for hepatitis B exposure are highly effective, reducing the risk of infection by 75% or more. Also, the already relatively low risk from needle puncture wound for HIV exposure can probably be reduced by 75% to 80% with preventive medication.The patient's prognosis for remaining free of infection was good.The small chance of becoming infected and the long incubation period of these diseases, however, add up to considerable worry. Every effort should be made to avoid needle puncture wounds in the first place.
Table 27.7 give the main features of Pasteurella multocida bite wound infections.
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