Not a long ago, I received a call from a friend working in a local pediatric clinic. One of her partners had just seen a young child with an unusual rash. The diagnosis? Crusted scabies.
Sarcoptes scabiei var. hominis, the mite that causes typical scabies, also causes crusted or Norwegian scabies. These terms refer to severe infestations that occur in individuals who are immune compromised or debilitated. The rash is characterized by vesicles and thick crusts and may or may not be itchy. Because patients with crusted scabies can be infested with as many as 2 million mites, transmission from very brief skin-to-skin contact is possible, and outbreaks have occurred in health care facilities and other institutional settings.
That was the reason for my friend’s call. “What do we do for the doctors and nurses in the clinic who saw the patient?” she wanted to know.
“Everyone wore gloves, right?” I asked. There was silence on the other end of the phone.
After a quick consultation with our health department, every health care provider (HCP) who touched the patient without gloves was treated preemptively with topical permethrin. None went on to develop scabies. The experience prompted me to think about the challenges of infection prevention in ambulatory care.
Both the American Academy of Pediatrics (AAP Committee on Infectious Diseases, “Infection prevention and control in pediatric ambulatory settings,” Pediatrics 2007;20:650-65) and the Centers for Disease Control and Prevention (Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care) have published recommendations for infection prevention in outpatient settings. Both organizations emphasize the importance of standard precautions. According to the CDC, standard precautions “are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where health care is delivered.” They are designed to protect HCPs, as well as prevent us from spreading infections among patients. Standard precautions include:
• Hand hygiene.
• Use of personal protective equipment (gloves, gowns, masks).
• Safe injection practices.
• Safe handling of potentially contaminated equipment or surfaces in the patient environment.
• Respiratory hygiene/cough etiquette.
Some of these elements are likely second nature to office-based pediatricians. Hands must be cleaned before and after every patient encounter or an encounter with the patient’s immediate environment. “Cover your cough” signs have become ubiquitous in ambulatory care waiting rooms, even as we acknowledge the difficulties associated with expecting toddlers to wear masks or use a tissue to contain their coughs and sneezes.
Other elements of standard precautions may receive increased attention because the consequences of noncompliance are perceived to be dangerous or severe. For example, we know that failure to reliably employ safe injection practices (see table) has resulted in transmission of blood-borne pathogens, including hepatitis B and C, in ambulatory settings.
In my experience, the use of personal protective equipment (PPE) in the ambulatory setting is the element of standard precautions that is the least understood and perhaps the most underutilized. It’s certainly easier in the inpatient setting, where we use transmission-based precautions, and colorful isolation signs instruct us to put on gown and gloves when we visit the patient with viral gastroenteritis, or gown, gloves, and mask for the child with acute viral respiratory tract infection. In the office, we expect the HCP to anticipate what kind of contact with blood or body fluids is likely and choose PPE accordingly.
Of course, anticipation can be tricky. Gowns, for example, are only required during procedures or activities when contact with blood and body fluids is likely. In routine office-based care, these sorts of procedures are uncommon. Incision and drainage of an abscess is one example of a procedure that might warrant protection of one’s clothing with a gown. Conversely, the need for a mask might arise several times a day, as these are worn to protect the mouth, nose, and eyes “during procedures that are likely to generate splashes or sprays of blood or other body fluids.” Examination of a coughing patient is a common “procedure” likely to results in sprays of saliva. Use of a mask can protect the examiner from potential exposures to Bordetella pertussis, Mycoplasma pneumoniae, and a host of respiratory viruses.
While the AAP has been careful to point out that gloves are not needed for the routine care of well children, they should be used when “there is the potential to contact blood, body fluids, mucous membranes, nonintact skin, or potentially infectious material.” In our world, potentially infectious material might include a cluster of vesicles thought to be herpes simplex, the honey-crusted lesions of impetigo, or the weeping, crusted rash of Norwegian scabies.