Consistent handwashing, staff immunizations, and common sense are the keys to preventing and controlling infections in an office practice, said Dr. Jerome O. Klein, a professor of pediatrics at Boston University.

Physicians in office practice have two obligations: to prevent patients from acquiring infections from sick health care workers and to prevent health care workers from acquiring infections from patients, Dr. Klein said in an interview.

He presented a review of infection prevention pointers at a conference on infectious diseases held in Cambridge, Mass.

Hand hygiene is a mainstay of any effective plan to both prevent and control infections in pediatric ambulatory care settings, Dr. Klein said at the meeting sponsored by the university.

“Handwashing before and after seeing a patient should be automatic, and any of the soap or cleansing products will be satisfactory,” he said. The handwashing technique and the type of cleanser used are less important than the consistency of the handwashing.

Encourage a “no hand jewelry” policy during patient care, although such a policy is difficult to implement. “There is a residue of dirt, germs, and grime underneath a ring that cannot be accessed by the wash,” he said.

In addition, Dr. Klein emphasized the importance of following a standardized policy for the use of gloves and gowns in pediatric ambulatory care settings. The American Academy of Pediatrics recommends that health care workers wear gloves for contact with any body fluids including blood, secretions, excretions, and nonintact skin, and when they perform venipunctures.

Gowns and masks or protective eyewear should be worn for any procedures where there is a chance that blood or other fluids might splash.

The American Academy of Pediatrics' Committee on Infectious Diseases published a policy statement on infection prevention and control in pediatric ambulatory care settings in September 2007 (Pediatrics 2007;120:650–65). The statement includes guidelines for many aspects of infection prevention and control ranging from cough etiquette and proper waste disposal to managing possible exposure to bloodborne pathogens.

In addition, the statement includes guidelines for when to restrict health care workers from patient care and when they should be restricted from the facility. Dr. Klein highlighted five common infections as examples:

▸ Staphylococcal skin infections. Restrict the worker from direct patient care until he or she has been treated for 24 hours with an agent active against the particular isolate.

▸ Conjunctivitis. Restrict the worker from direct patient care until the discharge resolves.

▸ Herpetic whitlow. Restrict the worker from direct patient care until the lesions have crusted.

▸ Streptococcal group A pharyngitis. Restrict the worker from direct patient care until he or she has been treated for 24 hours.

▸ Zoster. Restrict the worker from patient care until lesions have crusted if they can't be covered. If the lesions can be covered, the worker may have contact with patients, excluding newborns and immunocompromised patients.

By contrast, workers with measles should be excluded from the ambulatory facility until 7 days after the onset of the measles rash, workers with rubella should be excluded from the facility until 5 days from the onset of rash, and workers with mumps should be excluded from the facility until 5 days after the onset of parotitis.

“All health care workers should read the AAP statement both to protect themselves as well as the patient,” Dr. Klein said. “Since time away from work for common communicable diseases is often ambiguous, reviewing the statement is most valuable.”

Be sure to maintain vaccination records for all employees. Although immunizations are not mandatory, the AAP statement suggests the following five for health care workers in pediatric settings:

▸ Hepatitis B. The AAP recommends this vaccine for all employees who may come in contact with blood. All employees who may be at risk for bloodborne pathogens must be offered this vaccine to comply with the Occupational Safety and Health Administration, so be sure to keep a record on file if an employee refuses the vaccine.

▸ MMR. The AAP recommends two doses for all adults born after 1956.

▸ Varicella. The AAP recommends immunizing all staff members who have not been vaccinated or whose vaccination status is unknown.

▸ Influenza. The Centers for Disease Control and Prevention (CDC) recommends yearly flu vaccination for all health care workers.

▸ Adolescent-Adult Tdap. The CDC recommends this tetanus, diphtheria, and acellular pertussis vaccine for all health care workers who have direct contact with patients; remember that there should be at least a 2-year gap between administering Tdap and the most recent dose of tetanus-diphtheria vaccine.

Dr. Klein serves on the scientific advisory committees for the Merck & Co. vaccine division and Innovia Medical LLC.

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Encourage a 'no hand jewelry' policy during patient care, although it maybe difficult to implement. DR. KLEIN

Infection Control Begins With Shots, Clean Hands