My own office had a powerful reminder about the importance of standard precautions last year when we were referred a young infant with recurrent fevers and a mostly dry, peeling rash. As we learned in medical school, the mucocutanous lesions of congenital syphilis can be highly contagious. In accordance with AAP recommendations, all HCPs who examined this child without the protection of gloves underwent serologic testing for syphilis. Fortunately, there were no transmissions!
Published data about infectious disease exposures and the transmission of infectious diseases in the outpatient setting, either from patients to health care workers or among patients, are largely limited to outbreak or case reports. A 1991 review identified 53 reports of infectious disease transmission in outpatient settings between 1961 and 1990 (JAMA 1991;265(18): 2377-81). Transmission occurred in medical and dental offices, clinics, emergency departments, ophthalmology offices, and alternative care settings that included chiropractic clinics and an acupuncture practice. A variety of pathogens were involved, including measles, adenovirus, hepatitis B, atypical mycobacteria, and Streptococcus pyogenes. The authors concluded that many of the outbreaks and episodes of transmission could have been prevented “if existing infection control guidelines,” including what we now consider standard precautions, had been utilized. Many reports published in the intervening 25 years have come to similar conclusions.
So why don’t HCPs yet follow standard precautions, including appropriate use of PPE? The reasons are complex and multifactorial. We’re all busy and lack of time is a common complaint. Gowns, gloves, masks, and alcohol hand gel aren’t always readily available. Some HCPs may not be knowledgeable about the elements of standard precautions while others may not understand the risks to themselves and their patients associated with nonadherence. Finally, some organizations have not established clear expectations related to infection prevention and compliance with AAP and CDC recommendations.
Several years ago, at the very beginning of the H1N1 influenza epidemic, a colleague of mine working in a pediatric practice saw a patient complaining of fever, lethargy, and myalgia. Not surprisingly, the patient’s rapid influenza test was positive. My colleague recalls that she was handed the result before she ever walked into the room – without any PPE – to see the patient.
“This was different than my usual routine at the hospital,” she told me. The expectation at the hospital was gown, gloves, and masks for any patient with influenza or influenzalike illness. At the office though, there was no such expectation, and providers did not routinely wear masks, even when seeing patients with respiratory symptoms. My colleague wasn’t reckless or rebellious. She was simply conforming to the culture in that office, and following the behavioral cues of more senior physicians in the practice. Subsequently, she developed severe influenza infection requiring a prolonged hospital stay.
It’s time to change the culture. As a first step, perform a quick audit in the office, using the AAP’s “Infection prevention and control in pediatric ambulatory settings” as a guide.
Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Kosair Children’s Hospital, also in Louisville. She had no relevant financial disclosures.