Chapter 4. Infection Control in the Office

Infection control is a critical component of pediatric practice in the outpatient setting. Children seen in an office for sick visits frequently have infections that may be transmitted to other patients or staff. In addition, as the delivery of complex medical care continues to shift from the hospital to the outpatient setting, careful attention to infection control practices in the office has become increasingly important. Clinicians should understand the epidemiology and modes of transmission of common pediatric infections. In addition, office practitioners must be familiar with regulations that apply to infectious diseases, including requirements for purchasing safety devices for staff, reporting diseases to public health agencies, and cleaning and disinfection in the office environment to prevent the transmission of infections.

There are three primary modes of transmission by which microorganisms can be spread between patients and health care workers: contact, droplet, and airborne. (Additional routes of transmission, including common vehicle and vector-borne transmission, will not be reviewed here.) The Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee issue national guidelines and recommendations for preventing and controlling health-care-associated infections.1 These guidelines apply to both inpatient and outpatient settings, and they serve as the source for the application of transmission-based precautions in health care settings.

Many common infections encountered in pediatric practice are transmitted by direct or indirect contact. Direct contact refers to person-to-person spread of an organism through direct physical contact. Indirect contact refers to spread that occurs by means of contact with a contaminated intermediate object (often fomites such as stethoscopes, bed linens, etc.), including the hands of health care workers; this route is the most important means of transmission of infections in health care settings.

Transmission via the droplet route occurs when large droplets are generated as an infected person coughs, sneezes, or talks. These droplets are propelled a short distance (generally less than 3 ft), and are deposited on the eyes, nasal mucosa, or mouth of a susceptible host.

Airborne transmission occurs when small droplet nuclei, dust particles, or skin squames containing microorganisms are transmitted to a susceptible host by air currents. Infections that are transmitted by the airborne route may be spread to others who are quite distant in space from the source infection.

Table 4–1 reviews the primary modes of transmission for many common infections that may be encountered in a pediatric practice. Each of these modes of transmission requires a unique strategy to prevent the spread of infection (see “Isolation Precautions in the Outpatient Setting”).

Because contact with contaminated hands of health care workers is the primary means of transmission of infections in the health care setting, hand hygiene is the single most important method of preventing the spread of infections. Numerous studies in health care facilities have demonstrated the effectiveness of hand hygiene in reducing health-care-associated infections.2–8 Several limitations of traditional handwashing with soap and water (including the need for access to sinks and the 15 seconds of vigorous rubbing required for optimal effect) have contributed to poor compliance with hand-hygiene practices in health care settings.7,9–11 Alcohol-based hand sanitizers have several advantages, including increased killing of many organisms compared with soap and water; no requirement for access to running water; and less time required for proper use. In 2002, CDC endorsed alcohol-based hand sanitizers as the preferred products for decontaminating the hands of health care workers.12 This recommendation applies to office practice as well; providers should have alcohol-based hand sanitizers available for use in their clinics or office spaces, in addition to sinks (for use when hands are visibly soiled or for particular organisms against which soap and water are more effective, such as Clostridium difficile).

Several aspects of the design of an ambulatory care facility can impact the transmission of infectious diseases. Detailed information about current recommendations can be found in the most current version of the Guidelines for Design and Construction of Healthcare Facilities from the American Institute of Architects.13

Waiting areas should be designed in a fashion that allows for spatial separation of patients with potentially communicable diseases. Contact between healthy children and those with active infections should be minimized to the extent possible.14 During influenza season, persons in the waiting area (including patients and family members or guardians) should ideally be instructed to practice components of respiratory hygiene and cough etiquette as recommended by CDC.15 Office providers should post visual alerts containing instructions about how to prevent the spread of infections from coughing, and tissues and hands-free disposal receptacles should be provided. In addition, waiting areas should have easy access to hand-hygiene agents (either alcohol-based sanitizers or sinks with soap and water). Children who present with illnesses that may be transmitted by the airborne route should be immediately placed into an examination room with the door closed. Examination rooms should always contain a sink, and an alcohol-based hand sanitizer should be easily accessible.

Because of occupational exposures, health care workers are potentially at risk of acquiring several bloodborne viral infections, including human immunodeficiency virus (HIV), hepatitis B, and hepatitis C. The Occupational Safety and Health Administration (OSHA) mandates that health care providers in the outpatient setting adhere to the Bloodborne Pathogen Standard,16 and the Joint Commission specifies that infection-control policies and procedures be consistent across the inpatient and outpatient arenas within a facility.17 It is, therefore, incumbent on outpatient providers to understand issues around preventing transmission of these bloodborne pathogens.

The frequency of sharps injuries can be drastically reduced by the use of safety devices. “Safety” versions of needles and other devices are now widely available. These safety devices use technologies such as retractable needles to reduce the likelihood of a sharps injury. OSHA requires that health care facilities use devices with engineered sharps injury protections.16 Outpatient practices should regularly review their inventory of devices and actively replace products with safety versions where applicable. Devices of particular interest in the outpatient setting include needles used for administration of immunizations, other injectable medications, or phlebotomy; safety versions of all of these devices are currently available.

When needlestick injuries do occur, every outpatient practice needs to have in place a process for managing exposed employees. As a routine, the risk of the particular exposure for transmitting bloodborne pathogens must be assessed, and employees should be counseled about risks and about the decision to take antiretroviral medications as postexposure prophylaxis for HIV. In addition, procedures must be in place to arrange for testing source patients for HIV and hepatitis B and C. Recommendations for management of these scenarios are available from CDC.18,19 Since most exposed personnel will be adults, many pediatric office providers choose to contract with an adult provider or other resource for assistance in managing exposures.

Prompt reporting of communicable diseases is the foundation of public health surveillance and disease control. Information obtained through disease reporting is crucial to alert the public to potential health concerns, monitor disease trends and identify high-risk groups. As of January 2007, there were 63 reportable diseases in the United States at a national level; these diseases are reported weekly in Morbidity and Mortality Weekly Report (www.cdc.gov/mmwr), and are summarized annually by CDC in the “Summary of Notifiable Diseases in the United States.” Reporting of these diseases is regulated by individual states. Although the details may differ from state to state, every state has regulations mandating that specified diseases or conditions be reported to local or state public health agencies. All health care providers are responsible for knowing these regulations and for reporting diseases according to their local or state guidelines. In general, certain infections with high mortality or large public health implications (such as meningococcal infections, measles, or smallpox) must be reported immediately; other infections (such as pertussis, varicella, or invasive Group A streptococcal infection) may in some cases be reported in a slightly less emergent fashion (e.g., 1–2 business days). While clinical laboratories have their own reporting requirements, individual providers are also responsible for reporting these conditions. Providers should also be clear about which infections are reported to local boards of health and which are reported directly to the state department of public health. For details about regulations for your own state, refer to your local and state public health agencies.

Many features of the office environment have infection-control implications, and providers should be familiar with requirements pertaining to processes for storage and disposal of regulated products or waste.

Vaccine storage is a key component of an outpatient pediatric practice. While some vaccines (such as varicella) can be stored frozen (5°F or lower), many others including diphtheria/tetanus/acellular pertussis, measles/mumps/rubella, and pneumococcal conjugate vaccine are refrigerated prior to use. Refrigerated vaccines must be stored in the range of 36–46°F to maintain their efficacy. CDC recommends continuously monitoring the temperature of any refrigerator used to store vaccines, since unanticipated failure of cooling could compromise the efficacy of a vaccine if administered to patients.20 Office practices should keep a log of temperatures on the refrigerator at all times.

Storage of medications and patient specimens must comply with OSHA standards. Medications must be stored in a separate refrigerator from patient specimens (such as urine or other body fluids that could be potentially infectious). Refrigerators used for specimen storage should be clearly marked by the use of a biohazard sticker on the outside of the refrigerator.16

OSHA regulations require that sharps and medical waste be disposed of in the appropriate manner.16 Designated puncture-proof sharps containers must be available as close as is practical to the location where needles or other devices capable of causing injury will be used. The containers must be closable and labeled or color-coded. The containers must not be overfilled with disposed sharps in order to avoid needles sticking out of the opening. Practices frequently choose to contract with a company to empty their sharps containers on a regular basis. Medical waste (sometimes referred to as “infectious waste”) is a term used to describe waste that is potentially infectious or hazardous (for instance, linens contaminated with blood). In general, facilities must define which waste is infectious and develop protocols for separating infectious waste from noninfectious waste. Procedures should be in place for proper labeling, storage, and disposal of infectious waste (e.g., red waste containers with a biohazard label). A more complete review of medical waste management is available for providers who are responsible for developing waste management programs for outpatient facilities.21

Office providers must be responsible for ensuring that appropriate cleaning and disinfection measures are in place to prevent the transmission of infections within the office. Many different contaminated devices have been implicated in the transmission of infections.22–24 Following a brief review of disinfection and sterilization principles, several specific items commonly present in outpatient practices will be addressed. Several excellent published reviews of disinfection and sterilization are available for readers who are interested in more details.25–29

Sterilization is the complete destruction of all forms of microbial life, including fungal and bacterial spores. Sterilization is accomplished by physical and chemical processes (e.g., steam under pressure, liquid chemicals, etc.). Disinfection eliminates many or all pathogenic organisms, with the exception of spores. Disinfection is usually performed using liquid chemicals or wet pasteurization. The same chemical may act as a sterilant with prolonged exposure time (e.g., 6–10 h), but only as a disinfectant at shorter exposure times (e.g., less than 45 min). Cleaning refers to the removal of all foreign material (e.g., organic matter) from an object, usually through the use of water with detergents or enzymatic products.27 It is important to note that cleaning of equipment must precede sterilization or disinfection.

Whether a patient care item requires cleaning, disinfection, or sterilization is based on the associated risk of transmission of infection given its intended use. In general, items are divided into three categories: critical, semicritical, or noncritical.29Table 4–2 reviews the distinction between these categories and summarizes the appropriate disinfection and sterilization procedures for each group of items.

In the office setting, providers most commonly use noncritical reusable medical equipment, such as stethoscopes and blood pressure cuffs. These items pose little risk of infection to the patient because they only come into contact with intact skin, which functions as a barrier to most microorganisms. The same is true of examination tables and office floors. These items should be disinfected using low-level disinfectants approved by the Environmental Protection Agency, such as quaternary ammonium compounds. Ambulatory facilities should establish a regular schedule for cleaning and disinfection of these items (generally at least daily in addition to when items are soiled). Single-use items such as otoscope specula should be discarded after use; reprocessing of single-use items places the liability on the facility instead of on the manufacturer and, therefore, requires extensive oversight to ensure adequate disinfection and preserved function of equipment.

Multidose vials have been associated with multiple outbreaks in outpatient clinics30; if single-dose vials cannot be used because of cost or availability, careful attention must be paid to proper use of multidose vials and appropriate infection-control precautions.

Toys pose a unique challenge in the pediatric ambulatory setting. Toys can serve as fomites in the transmission of infection among patients. Facilities can reduce the risk of transmission by purchasing toys that are easily cleaned or disinfected. Hard, smooth objects made of plastic lend themselves more easily to cleaning procedures than furry stuffed animals or complex games with grooves and ridges that can harbor bacteria or viruses and are difficult to clean. No published standards exist to regulate cleaning of toys in health care settings; however, offices should establish cleaning policies that call for toys to be cleaned on a routine basis (often daily in addition to after exposure to secretions or to patients with certain known infections).

Isolation precautions for patients with communicable diseases are a critical part of infection control within the hospital setting, and Healthcare Infection Control Practices Advisory Committee guidelines1 provide recommendations for isolation precautions for specific infections or clinical syndromes. These recommendations also apply to ambulatory health care settings, and providers should be aware of measures to reduce the transmission of infections within the office.

Methicillin-resistant Staphylococcus aureus (MRSA) infections have been a part of health care since the 1960s, and their frequency began to rise notably in the 1980s. Initially, most patients with MRSA infections had risk factors for resistant infections, such as frequent contact with health care facilities. Since the mid-1990s, there has been a well-documented rise in the rate of community-acquired MRSA (CA-MRSA) infections in adults and children across the United States31–33; at some centers, up to 60–80% of pediatric MRSA infections are now community-acquired. Since these patients are frequently seen in the office setting for concerns such as skin and soft tissue infections, the office practitioner must be cognizant of infection-control measures in the clinic to reduce the likelihood of transmission of MRSA to other patients. Gloves should be worn for contact with any patient with known or suspected MRSA infection. Offices must ensure that an adequate supply of gloves is available at all times, and that they are easily accessible to providers at the point of entry into an examination room. Gowns should be available for encounters in which extensive contact with the patient is anticipated, in order to decrease contamination of clothing. Strict attention to hand hygiene, preferably with an alcohol-based hand sanitizer, is also critical.

C. difficile is another infection that has been seen traditionally in hospitalized patients but has become more prevalent in the community in recent years.34,35C. difficile is a spore-producing organism that is also transmitted by contact. If a patient with known or suspected C. difficile infection is seen in clinic, gloves should be used for contact with the patient. After examining such a patient, hand hygiene should be performed using soap and water rather than an alcohol-based agent, as alcohol has poor activity against spore-forming organisms and therefore is not the preferred method of hand decontamination for this infection.12,36

The most common infections seen by pediatricians in the outpatient setting are viral respiratory and gastrointestinal infections, including respiratory syncytial virus (RSV) and rotavirus (among others). These viral infections are also transmitted by contact, and in the hospital setting would require gown and glove use. During the winter and spring when these infections comprise a majority of sick visits to an office, implementing appropriate infection-control measures can seem overwhelming. It is important for practitioners to understand the infectivity of these organisms and their potential for transmission.

Rotavirus is present in high titers in the stool of infected patients, and is shed for an average of 4 days during infection (although the virus may persist for weeks in some cases).37 The virus can survive on environmental surfaces for several weeks, and contamination of various items (such as toys and patient charts) in the health care setting is well documented.38

RSV is also primarily transmitted by contact, as documented in a classic study by Hall and Douglas.39 Volunteers caring for infants with RSV were divided into three groups: “cuddlers,” who held and provided care for the infants; “touchers,” who did not touch the infant but had extensive contact with the environment, which had been contaminated with patient secretions; and “sitters,” who sat by the crib but did not touch the patient or the environment. RSV infection developed in 5 of 7 cuddlers, 4 of 10 touchers, and 0 of 14 sitters. RSV is usually shed for 3–8 days during infection,40 and the virus can survive for up to 6 hours on environmental surfaces.41

Because of the nature of transmission of these common viral infections, office practitioners should be vigilant about ensuring strict attention to hand hygiene in the office and appropriate cleaning and disinfection of contaminated surfaces. In addition, glove use in the office setting when seeing patients who have infections that are transmitted by contact may help to reduce contamination of the hands with infectious organisms.

Clinicians who see patients in an ambulatory setting are asked frequently to answer questions regarding infection-control implications of infectious diseases. Providers should be knowledgeable about potential criteria for excluding children from school or out-of-home child care, as well as methods to prevent infection in staff members and criteria for exclusion from work when staff members become ill.

As of 1999, more than 7.5 million children younger than 5 years of age were enrolled in out-of-home child care.4 Attendance at child care places children at high risk of acquiring contagious diseases,42–51 because children readily exchange secretions and staff members face daunting challenges in environmental sanitation.52,53 The most common infections encountered in the child care setting include viral respiratory and gastrointestinal infections (rotavirus is the most frequent cause of gastroenteritis in child care), enteric bacteria such as Shigella and E. coli O157:H7, hepatitis A, parasites such as Giardia and cryptosporidium, and encapsulated bacteria (such as Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae).

In the child care setting, the most common routes of transmission of infections include fecal–oral, droplet, and person-to-person contact. In most situations, common sense hygienic practices will decrease the risk of illness transmission. Mild illness is common among children younger than 5 years, and most children need not be excluded from child care for mild respiratory tract illness. Exclusion is recommended when doing so is likely to decrease the risk of secondary cases. Table 4–3 summarizes some illnesses for which exclusion from child care is reasonable.54 Examples of illnesses that generally do not require exclusion include rash without fever or behavioral change; parvovirus B19 infection in immunocompetent hosts; cytomegalovirus infection; and HIV or chronic hepatitis B infection in most cases. Each child care center is likely to have its own list of illnesses for which exclusion is required, and written procedures for hand hygiene, environmental sanitation, and managing illness in children and staff members should be in place. Consultation with local and state public health agencies is also recommended when deciding about whether to exclude an ill child from child care, as most states have laws about isolation of persons with specific communicable diseases.

Health care workers who are exposed to or contract selected illnesses should also be restricted from work to decrease the risk of transmission to patients or other staff members. State and local public health regulations should be consulted when creating exclusion policies. Table 4–4 provides a list of illnesses that generally require health care worker exclusion from patient care activities.55,56 Decisions about work restriction for specific illnesses are made based on the epidemiology of the particular infection and its mode of transmission. Providers should ensure that policies encourage personnel to report their illnesses and that wages are provided during periods of required exclusion even if workmen's compensation laws do not require reimbursement.

Many infections to which health care workers may be exposed can be prevented by vaccination. Office practitioners should be familiar with published recommendations for vaccination of health care workers.55,57–59Table 4–5 reviews these recommended vaccines. Review of vaccination status and mandatory immunization of employees should be part of a comprehensive occupational health program for all health care facilities. These activities should occur at the time of hire for new employees and as part of an annual review for current employees, since new vaccines may be added to the list of recommended immunizations and selected vaccines (such as influenza) must be delivered annually.

Tuberculosis (TB) screening for health care workers should also be done based on the risk classification of the facility, according to published CDC guidelines.60 Outpatient health care settings are currently classified as low risk if fewer than three TB patients were seen during the preceding year, and medium risk if more than three TB patients were seen during the preceding year. For low-risk settings, health care workers should undergo TB screening at hire and then only need additional screening if an exposure to TB occurs. In contrast, for medium-risk settings, annual TB screening of health care workers should be performed. Clinics that are part of a larger health care setting might fall under different risk classification criteria based on the types of services provided and frequency of TB visits, and each facility should review the CDC guideline to determine its own risk classification and recommendations for screening.

Infection control in the outpatient setting is complex and requires constant vigilance by providers as well as systematic attention to high-risk activities. Emphasis should be placed on proper hand hygiene, in addition to other fundamental principles to prevent the transmission of infections, including isolation precautions and surface disinfection. Clinicians should be familiar with appropriate regulations and should be aware of relevant literature to guide infection-control practices. Providers who have questions about infection-control issues should consult available resources, including infection-control practitioners at affiliated health care facilities, as well as local and state public health officials.