The American Academy of Pediatrics (AAP) Committee on Infectious Diseases and Committee on Practice and Ambulatory Medicine have issued recommendations for infection control in physicians' offices. The recommendations appear in the June 2000 issue ofPediatrics.
Outpatient facilities have been identified as vectors for transmission of infectious agents among patients, including outbreaks of measles and tuberculosis. Despite this, there are no comprehensive national guidelines for infection control in an outpatient setting. The AAP has laid out guidelines for the delivery of health care, standard precautions that should be taken in the physician's office, office design, disinfection and antimicrobial use. Because third-party liability cases involving infectious diseases have been successfully prosecuted, the AAP believes these guidelines should help minimize physicians' risk and liability. The AAP guidelines, coupled with the standard precautions for hospitalized patients of the Centers for Disease Control and Prevention (CDC), which were modified by the AAP for children, are appropriate for most patient encounters. The AAP stresses that the single most important precaution that can be taken to avoid the transmission of infection is hand washing.
Hand Washing and Delivery of Health Care
Hand washing is the most important method that can be used to prevent transmission of infectious agents. Hands should be washed before and after contact with patients, body fluids and dirty materials; between dirty and clean procedures on the same patient; after removing gloves; before and after performing invasive procedures; after using the restroom; and whenever hands are visibly soiled.
Liquid soap in pump dispensers is ideal. For routine use, it is not necessary to use antibacterial soaps. Pump dispensers are more sanitary than bars of soap, and they are disposable. The dispensers should be replaced regularly. If the dispensers are refilled, then they should be rinsed and washed before refilling to avoid contamination. Use of soap and a sink is preferred to the use of waterless hand cleansers. The best method for routine hand washing is to cover the hands with soap and vigorously rub for at least 10 seconds. To dry the hands, paper towels are preferred.
If hand lotions are provided, they should also be available in pump dispensers that are replaced or cleaned regularly. Hand lotions should not be petroleum-based because this may cause deterioration of latex gloves.
The accompanying table on page 788 summarizes the standard precautions recommended by the CDC and modified by the AAP for children. Precautions must be taken routinely, because it cannot be determined whether a child harbors an infectious agent. Standard precautions include wearing gloves, cleaning skin surfaces and environmental surfaces and using sharps containers to dispose of needles.
Gloves should be available for all health care workers. They should be worn when the worker will come in contact with blood, body fluids, secretions and excretions, or with items that have been contaminated with these fluids. It is not necessary to wear gloves when performing routine well-child care, such as wiping a nose or changing a diaper. When gloves are removed, the hands should be washed to avoid contamination that can occur as the gloves are removed. Masks, face shields, protective eye-wear or water-impermeable gowns may be worn as warranted by the circumstances.
Skin surfaces should be thoroughly cleaned when blood or other body fluids have contaminated the surface. Environmental surfaces should be cleaned with a detergent, then with a bleach solution. The bleach solution, which should be freshly prepared before use, comprises a bleach–water mixture in a 1:64 ratio (1/4 cup bleach to 1 gallon of water). The bleach must be in contact with the surface for at least 30 seconds. Gloves should be worn while cleaning.
Sharps containers should be available in all areas where injections are given. The containers should be placed out of the reach of children and should not be overfilled. State and local regulations provide guidelines for the removal and incineration of the filled containers. In addition, a policy should be in place for health care workers who receive needlestick injuries; federal law requires that all needlestick injuries be logged.
|Hands should be washed before and after each patient encounter.|
|Hands and other body surfaces should be washed immediately and thoroughly if contaminated with blood or other body fluids.|
|Hands should be washed after removal of gloves.|
|Barrier precautions to prevent skin and mucous membrane exposure|
|Gloves should be worn for contact with blood, body fluids, mucous membranes, nonintact skin, and items or surfaces contaminated with body fluids; gloves need not be used for routine care of well children, including wiping a nose and changing diapers.|
|Gloves should be worn when performing venipuncture and other vascular access procedures.|
|Masks and protective eyewear or face shields should be used during procedures that are likely to generate droplets of blood or body fluids.|
|Water-impermeable gowns or aprons should be worn during procedures that are likely to generate splashes of blood or other body fluids.|
|Handling of sharp instruments|
|Needles should not be recapped, bent, broken, removed by hand from syringes or manipulated by hand.|
|Sharp instruments, including needles, should be placed in puncture-resistant containers for disposal.|
|Disposal containers should be as close as practical to areas of use.|
|Disposal containers should be out of the reach of children.|
|Reusable sharp instruments should be placed in puncture-resistant containers for transport to processing areas.|
|Safer medical devices should be used as soon as such devices are proved to be beneficial and cost-effective.|
|Equipment should be available for use in areas in which the need for resuscitation is predictable.|
|Mouth-to-mouth resuscitation should be avoided.|
Offices should be designed so that the tools required for the prevention of infection are readily available. In addition, surfaces such as floors should be cleaned daily, and examination rooms should be cleaned between patients. Sinks should have soap dispensers and disposable towel dispensers near them. Faucet aerators should not be used; these have been linked to contamination with Pseudomonas species and other bacteria. Restrooms should be cleaned daily and whenever visibly soiled. At least one restroom should have a diaper changing area; disposable paper towels and a receptacle for dirty diapers and soiled paper towels should be provided.
Disposable paper covers should be used in the examination rooms to cover the examination tables. If contamination is visible, and if diapers have been changed, the area should be cleaned thoroughly. After removing visible soil, a fresh 1:64 bleach–water mixture should be applied for two minutes, then rinsed and dried.
The waiting and reception areas should also be regularly cleaned and maintained. These sites are often opportunities for patient-to-patient transmission of infection. To minimize transmission of infection, crowding should be avoided, waiting times should be as short as possible and children's toys should not be shared. There is no benefit to segregating sick and well patients in separate waiting areas. Immunocompromised patients and those known to have an infectious disease, such as measles, should not wait in the general waiting area but should be escorted immediately to an examination room.
Toys should be disposable or washable; it is best to clean them between uses to avoid transmission of infection. Toys contaminated with body fluids should be removed from the waiting area immediately. It is not necessary to clean toys with antibacterial agents; the best way to clean them is to run them through a dishwasher at the end of the day. This decreases microbial contamination and eliminates organic material deposited on the toy.
Personal and diagnostic equipment found in physicians' offices may also be contaminated with infectious agents. Tools such as stethoscopes should be cleaned regularly with a paper towel, soap and water, or an alcohol wipe. Any tool or piece of equipment that becomes contaminated with blood should be disinfected. Equipment that is rarely cleaned, such as pens, charts and computer keyboards, may also be a source of contamination. The best way to avoid spreading the contamination is to regularly wash the hands. Whenever feasible, disposable supplies should be used.
Sterilization and Disinfection
Levels of cleaning can be divided into the following categories: sterilization, disinfection, cleaning and antisepsis. Sterilization destroys all forms of microbial life. Disinfection reduces, but does not eliminate, microbes. Cleaning simply removes foreign material. Antisepsis is the process used to decontaminate skin.
All equipment should be cleaned regularly and stored where it will not become contaminated. Instruments that penetrate the patient must be sterile. Sterilization is most often performed by autoclave. The distilled water used with steam autoclaving should reach a temperature of 121°C to 132°C (249.8°F to 269.6°F) for 20 minutes for unwrapped instruments and 30 minutes for small packs. Packs that have been sterilized should be dated and stored in a clean, dry area. Materials wrapped in muslin can only be stored safely for a few months. Plastic-wrapped packs can be stored safely for one year.
High-level disinfection is used for instruments that come into contact with mucous membranes. They may be cleaned by boiling (placing them in boiling water for at least 20 minutes) or by chemical disinfection with glutaraldehyde, hydrogen peroxide or bleach. The solution used in disinfection should be prepared according to the manufacturer's directions. Usually a 2 percent solution of glutaraldehyde, a 6 percent solution of hydrogen peroxide or a 1:64 bleach–water solution are used. Only 2 percent glutaraldehyde is approved for use in hospitals.
Intermediate-level disinfection is accomplished with ethanol and isopropanol, iodine and iodophors, phenols and phenolics, and 1:64 bleach–water solution.
Low-level disinfection is appropriate for instruments that do not touch mucous membranes, such as bedpans, table tops and blood pressure cuffs. Phenols and phenolics, quaternary ammonium compounds, 1:500 bleach–water solutions, and iodine and iodophors are used in low-level disinfection.
Antiseptics are chemical agents used on the skin or tissue. These include isopropyl alcohol, chlorhexidine gluconate, iodine and iodophors. Alcohol is the preferred skin preparation for immunizations and venipuncture for blood collection. Most skin preparation agents should be allowed to dry to ensure that surface bacteria are killed. Tincture of iodine, which is active on contact, is the preferred skin preparation for invasive procedures, such as insertion of catheters.
Contamination of antiseptics has been associated with outbreaks of infections and false-positive findings on blood culture. To prevent contamination, bottles should be dated and should not be refilled. They should also be discarded if not used within three months. When feasible, single-use pads of iodine and alcohol should be used, thus eliminating the need for bottles.
Use of Antimicrobial Agents
Overuse and inappropriate use of antimicrobial agents have led to the emergence of antibiotic-resistant microorganisms, an increasing problem worldwide. An important aspect of infection control is diagnosing infection and instituting antibiotic therapy carefully. The CDC and AAP have provided guidelines for the use of antibiotics. Hand washing before and after contact with patients known to be colonized with resistant bacteria, including methicillin-resistantStaphylococcus aureus and vancomycin-resistant Enterococcus species, is appropriate. No guidelines for managing patients harboring antibiotic-resistant micro-organisms in office settings have been published.
Summary of AAP Infection Control Policies
All health care professionals should wash their hands before and after patient contact.
Standard precautions should be used in dealing with all patients.
Contact between infected, contagious children and uninfected children should be minimized.
Skin should be prepared with alcohol for immunization and routine venipuncture. Skin should be prepared with 1 or 2 percent tincture of iodine or povidone iodine for incision, suture and collection of blood for culture.
Needles and sharps should be disposed of in puncture-proof units that should be available near the areas used for injection or venipuncture and placed out of the reach of children.
Standard guidelines for sterilization, disinfection and antisepsis should be followed.
Judicious use of antimicrobial agents is essential to limit the emergence and spread of drug-resistant bacteria.