Hospital Infection Control

Ambulatory care

How does ambulatory care currently impact infection control?

Ambulatory care is defined as medical or surgical care that is rendered for consultative, diagnostic, or therapeutic purposes in facilities where the patient does not remain overnight. Ambulatory care is provided in a variety of settings, including physician's offices, hospital-based clinics, public health clinics, ambulatory surgery centers, dental offices, and the home. This review will focus primarily on infection control and prevention in physician's offices and ambulatory surgery centers (ASCs). Other specialized ambulatory care settings, such as long-term care facilities, imaging centers, endoscopy suites, and hemodialysis centers are discussed separately.

In the past, the risk for infection in ambulatory care settings was considered to be low because: 1) outpatients had only minor illnesses or injuries (e.g., less host susceptibility); 2) the duration of office visits was brief (e.g., less opportunity for pathogen transmission); 3) the majority of procedures were minimally invasive. For these reasons, infection control and prevention activities were not previously considered a priority for most ambulatory care healthcare facilities.

Recent trends in healthcare delivery have challenged this traditional perception of risk, however. From 1990 to 2007, the number of licensed hospitals in the United States decreased from 6,649 to 5,708 (- 14%), the rate of hospital discharges decreased from 123.5 to 114.4 per 1,000 population (- 7%), and the average inpatient length of stay contracted from 6.4 to 4.8 days (- 25%).

Concurrently, utilization of ambulatory care services has dramatically increased. In fact, most outpatient encounters with the healthcare system now occur in ambulatory care settings. In 2007, there were approximately 1.2 billion ambulatory care visits. 994.3 million (83%) of these visits were to office-based physicians, which represents a 49% increase since 1991.

Overall, the average person visited a physician's office 3.4 times in 2007. From 1991 - 2008, the number of Medicare-certified ASCs increased from 1,460 to 5,174, and Medicare payments to these facilities increased from $375 million to $3.1 billion. According to the Ambulatory Surgery Center Association, outpatient procedures now account for more than three-quarters of all operations performed in the United States.

The outpatient population has also become more vulnerable and medically complex in recent years. Patients are now more likely to be immunocompromised, chronically debilitated, or technology dependent. More than one million cancer patient receive outpatient chemotherapy, radiation, or both. At least 500,000 persons per year receive outpatient infusion therapy via a central venous catheter for reasons such as nutritional support, home intravenous antimicrobial therapy, and chemotherapy. Some evidence also suggests that operations of higher complexity are now being performed in ASCs, often involving patients with greater co-morbidities.

Although outpatient services have greatly expanded, there has not been a proportionate expansion in infection control oversight. Most outpatient settings still lack the infrastructure and resources needed to support critical infection control and prevention activities, as evidenced by ongoing outbreaks and patient notification events in physician's offices and other ambulatory care facilities.

What elements of ambulatory care are necessary for infection prevention and control?

The Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) recommend a two-tier system of precautions for preventing the transmission of infection among healthcare personnel (HCP) and patients: 1) Standard Precautions; 2) Transmission-Based Precautions.

Standard Precautions are regarded as the foundation for infection prevention and control in all healthcare settings, including ambulatory care. Standard Precautions apply to all patients, regardless of diagnosis or presumed infection status, and are based on the principle that blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes harbor potentially transmissible infectious agents. The original components of Standard Precautions, introduced in 1996, included:

  1. Hand hygiene

  2. Personal protective equipment (PPE)

  3. Patient placement

  4. Reprocessing of patient equipment and instruments / devices

  5. Care of the environment

  6. Appropriate handling and transport of used / soiled textiles and laundry

  7. Basic safe injection practices

  8. Worker safety

Additional standards were introduced by CDC and HICPAC in 2007. In contrast to the original elements of Standard Precautions, which were developed for the protection of HCP, these new elements focused on protection of patients:

  1. Respiratory Hygiene / Cough Etiquette is a new standard that that implements containment measures at the point of initial patient contact (e.g., reception or triage areas of physician's offices) for patients with undiagnosed, potentially transmissible respiratory infections (as suggested by symptoms of cough, congestion, or rhinorrhea). This strategy evolved in response to observations made during the 2002 - 2003 epidemic of Severe Acute Respiratory Syndrome (SARS), during which failure to institute simple infection control measures with patients, visitors, and HCP resulted in secondary transmission of SARS-coronavirus.

  2. Surgical masks are now recommended by HCP placing catheters or injecting material into the spinal canal or epidural space. This standard evolved in response to a 2004 CDC investigation into eight cases of post-myelography meningitis in which droplet transmission of oropharyngeal flora from the operator was the most likely explanation. Ambulatory settings potentially impacted by this new standard include outpatient imaging centers and ASCs performing myelography, oncology clinics administering intrathecal chemotherapy, and pain remediation clinics administering epidural anesthetic or anti-inflammatory medications.

  3. Safe injection practices were better defined and re-iterated in response to ongoing outbreaks of hepatitis B and C viruses in a variety of ambulatory care settings, including a private medical office, a pain remediation clinic, an endoscopy clinic, and a hematology / oncology clinic.

Transmission-Based Precautions are intended to supplement Standard Precautions in selected patients with documented or suspected infection or colonization with highly transmissible or epidemiologically important organisms. The three categories of Transmission-Based Precautions are contact, droplet, and airborne.

Adapting Transmission-Based Precautions to ambulatory care settings can be challenging; for example, most outpatient facilities do not have an airborne infection isolation room. At a minimum, outpatient facilities should develop systems for rapidly triaging patients with commonly encountered clinical syndromes involving diagnostic uncertainty such as diarrhea, febrile cough illness, and febrile rash illness.

Patients identified as having a potentially transmissible infection should be placed in a single patient room as quickly as possible, provided with a surgical mask and education regarding cough etiquette (for respiratory illness), and transferred to a higher level of care when appropriate. See Controversies section for more details.

In addition to Standard and Transmission-Based Precautions, other key elements which contribute to successful infection control and prevention programs in ambulatory care include:

  1. Administrative measures

  2. Education of HCP and patients

  3. Surveillance and reporting of healthcare-associated infections (HAIs) and outbreaks

  4. Occupational health and safety programs

  5. Surgical antisepsis

  6. Judicious antibiotic use

The relative contribution of each of these elements depends on the services provided by the healthcare facility and the patient population served. For example, an ASC would be expected to have more detailed policies regarding surgical antisepsis and sterilization of reusable surgical instruments than a public health clinic; however, both facilities would be expected to have policies and procedures addressing reusable medical devices such as blood pressure cuffs, thermometers, and glucose monitoring equipment.

What conclusions from clinical trials or meta-analyses regarding ambulatory care guide infection control practices and policies?

Relatively few studies have examined the efficacy or feasibility of infection control practices in physician's offices, ASCs , or other outpatient settings. Most of the published studies are quasi-experimental or observational in design; none are randomized clinical trials or meta-analyses. In the absence of data specific to ambulatory care, most of the recommendations for infection prevention and control in outpatient facilities have been extrapolated from other healthcare settings (e.g., hospitals). Key conclusions related to infection control in ambulatory care are also based on expert opinion and legislative / regulatory mandates.

General recommendations for infection prevention and control in ambulatory care include:

Administrative Measures and Occupational Health:

  1. Written policies and procedures for infection control should be developed and incorporated into the objectives of the organization's patient safety program.

  2. Physicians and administrators should be aware of regulatory requirements from government agencies (e.g., Occupational Health and Safety Agency) that relate to the operation of ambulatory facilities.

  3. Human and fiscal resources should be provided to meet the occupational health needs related to infection control, including immunization of HCP, post-exposure evaluation and prophylaxis, and management of HCP with communicable diseases (e.g., work place exclusion criteria).

Education and Surveillance:

  1. Ongoing educational programs for staff concerning infection prevention practices should be implemented, reinforced, documented, and regularly updated.

  2. A system of communicating with local and state health authorities should be developed and maintained in order to facilitate reporting of notifiable diseases and suspected outbreaks.

  3. Outpatient facilities should perform targeted surveillance of HAIs, as appropriate to the scope of interventions performed on site (e.g., ASCs should collect, manage, and analyze data related to surgical site infections).

Antisepsis, Sterile Technique, and Judicious Use of Antibiotics

  1. Antiseptic technique should be maintained for immunization, venipuncture, suturing, incision or other invasive procedures, and for accessing or manipulating intravascular catheters.

  2. 70% alcohol should be used for skin antisepsis prior to immunization and routine venipuncture. 2% chlorhexidine in 70% isopropyl alcohol (preferred), or 2% aqueous chlorhexidine, or 10% povidone-iodone should be used for accessing / manipulating intravascular catheters, collecting blood cultures, and surgical skin antisepsis.

  3. Antimicrobial agents should be used appropriately to limit the emergence and spread of antimicrobial-resistant organisms.

Standard Precautions:

  1. Standard Precautions should be applied to every patient encounter.

  2. HCP should perform hand hygiene before and after patient contact, after exposure to blood or body fluids, before invasive procedures, and after removing gloves. Alcohol-based hand rinses (60 - 95% isopropyl or ethyl alcohol) are the preferred method of decontamination, except when hands are visibly soiled, in which case soap and water is preferred.

  3. Appropriate use of PPE (gloves, masks, gowns, etc.) should be used when the nature of the anticipated patient interaction suggests the possibility of contact with blood or body fluids.

  4. Beginning at the initial point of patient contact (e.g., reception and waiting areas), respiratory hygiene / cough etiquette should be used by patients and accompanying persons who have suspected respiratory infections. In addition to education and early identification, the key components of respiratory hygiene include: a) use of tissues to cover the mouth and nose during coughing and sneezing; b) disposal of used tissues in no-touch waste receptacles; c) use of surgical masks, when appropriate; d) hand hygiene after contact with respiratory secretions; and e) spatial separation (greater than or equal to three feet) of coughing patients from other persons in common waiting areas.

  5. Patients with potentially contagious diseases (especially children with uncontained gastrointestinal or respiratory secretions) should be rapidly triaged and placed in an exam room as soon as possible to minimize exposure to other patients.

  6. Proper protocols for the reprocessing of reusable medical equipment should be followed. Sterilization, high-level disinfection, and low-level disinfection should be performed for critical, semi-critical, and non-critical equipment, respectively.

  7. Environmental surfaces and objects should be cleaned frequently using a low-level disinfectant or detergent. Soiled textiles and linens should be handles with minimum agitation to prevention contamination of air, surfaces, and persons.

  8. Ambulatory care facilities should design and implement comprehensive sharps injury prevention programs that include use of engineering controls.

  9. Safe injection practices should be followed at all times. Syringes, needles, and cannulae should be regarded as sterile, single-use items. Single dose vials of parenteral medications should be used whenever possible, and medications from single dose vials should never be administered to multiple patients. Bags or containers of intravenous solutions should never be used as a common source supply for multiple patients.

Transmission-Based Precautions:

  1. Patients with known or suspected airborne or droplet infections should be scheduled at a time that minimizes exposure to other patients (e.g., at the end of the day). These patients should be triaged as quickly as possible and be placed directly in an exam room. In addition, patients should be placed in surgical masks and instructed to use respiratory hygiene / cough etiquette. HCP treating these patients should use appropriate PPE (surgical masks versus N95 respirator).

  2. Patients who have known infection or colonization with multi-drug resistant organisms should be triaged as quickly as possible and placed in a private exam room. Gloves should be used for all contact with the patient or immediate environment. Gowns should minimally be considered when heavy contamination of the environment is likely due to uncontained diarrhea, large draining wounds or abscesses, or uncontrolled respiratory secretions (e.g., in children).

What are the consequences of ignoring recommended infection prevention and control practices in ambulatory care?

Failure to adhere to recommended infection prevention and control practices in ambulatory care facilities can lead to transmission of infections among patients, visitors, employees, and healthcare personnel. These infections may result in serious morbidity and mortality, hospitalization, increased use of antibiotics, emergence of multi-drug resistant organisms, and increased cost of care.

Despite these consequences, data for most of the major healthcare associated infections is lacking in ambulatory care settings.

  1. Surgical Site Infection (SSI): The risk of SSI associated with procedures performed in ambulatory surgery centers is largely undefined, due to the absence of an adequate surveillance infrastructure. Adherence to infection control practices in ASCs is a major concern, as suggested by an infection control assessment done in 2008 that demonstrated at least one lapse in basic infection control practices in nearly 68% of the inspected ASCs. Several authors have suggested that rates of SSI are lower for procedures conducted in ASCs than in hospitals. However, there are relatively few studies specific to ASCs, and the reported SSI rates in these studies have varied widely from 0.022 - 16.0 infections per 100 procedures. Because most of these studies have relied on surveys of patients and / or physicians, the infection rates may be under-estimated as a result of sampling bias, recall bias, and poor compliance with voluntary reporting.

  2. Central Line Associated Bloodstream Infections (CLA-BSI): This section pertains to endemic CLA-BSI (e.g., those emanating from the insertion site, catheter hub, or both). Epidemic CLA-BSI (e.g., those associated with common source exposure to contaminated infusates) are discussed below. Data for outpatient CLA-BSIs are more robust than for SSIs but are still limited compared to inpatient data. Estimates for rates of endemic CLA-BSI in this population range from 0.0 - 2.0 infections per 1,000 catheter days. Similar to other settings, the risk of infection is influenced by the type of intravascular device (e.g., peripherally inserted central catheter versus surgically tunneled catheter versus implantable central port). In general, rates are lower than those observed in hospitals. For example, the rate of CLA-BSI for peripheral inserted central catheters when used for outpatient antibiotic therapy is estimated at 0.4 per 1,000 catheter days compared to 2.0 per 1,000 catheter days when used to treat inpatients.

Although numerous outbreaks and patient notifications events have been linked to physician's offices and other outpatient settings, there are surprising few studies which have systematically evaluated this risk. One review identified 53 reports of infectious disease transmission associated with outpatient settings from 1961 - 1990. Overall, 29 episodes were associated with common source transmission, 14 episodes with person-to-person transmission, and 10 episodes with airborne or droplet transmission of respiratory pathogens.

Examples of outbreaks in ambulatory care settings caused by noncompliance with standard infection control practices include:

  1. Transmission of hepatitis B virus (HBV) and hepatitis C virus (HCV) continues to occur in a variety on non-hospital based settings. Between 1998 and 2008, there were 33 outbreaks of viral hepatitis in outpatient facilities resulting in 448 persons contracting HBV or HCV. In virtually all cases, these recent outbreaks were due to lapses in safe injection practices. In past decades, person-to-person transmission of HBV due to non-adherence with personal protective equipment (e.g., gloves) was well described, particularly in dental clinics.

  2. Cutaneous abscesses due to pyogenic bacteria and non-tuberculosis mycobacteria have been associated with inoculation of contaminated vaccine from multi-dose vials in pediatric offices.

  3. Septic arthritis due to a variety of gram-positive and negative bacteria has been reported in orthopedic and primary care clinics following intra-articular injection of steroids from contaminated multi-dose vials.

  4. Bacterial infections of the central nervous system have occurred following epidural injection of contaminated anti-inflammatory, anesthetic, or radio-contrast solutions in outpatient pain clinics and ASCs.

  5. Exogenous (e.g., epidemic) bacteremia due to gram negative organisms has been described following administration of contaminated infusates (saline flushes, heparin flushes, etc.) through central venous catheters in adult and pediatric oncology clinics.

  6. Epidemic keratoconjunctivitis due to adenovirus has been reported in ophthalmology clinics as a result of inadequately disinfected ophthalmic equipment and / or inadequate hand hygiene.

  7. Pseudo-outbreaks, and less commonly, true pulmonary infections have occurred among outpatients undergoing bronchoscopy with improperly reprocessed flexible bronchoscopes.

In addition to the risk of healthcare associated infections during medical evaluation and treatment, community-acquired infections may also be transmitted in ambulatory care settings. Physician's offices and hospital outpatient departments are often the first point of contact for patients with infectious diseases, and the burden of infectious diseases in such settings is high. Approximately 20% of all patient visits to these sites are for infectious diseases, and acute upper respiratory infection is consistently one of the most commonly diagnosed conditions.

Airborne transmission of Mycobacterium tuberculosis has been reported in a variety of settings, including primary care, public health, HIV and dental clinics. A large proportion of measles cases in the United States during the 1980s were acquired in outpatient settings, most notably pediatric offices. Transmission of rubella has been documented in an outpatient obstetric setting. Secondary transmission of SARS-coronavirus occurred in physician's offices and outpatient emergency departments during the 2002 - 2003 epidemic. The emergence of other novel respiratory pathogens such as avian H5N1 influenza and pandemic H1N1 influenza in recent years has further emphasized the need for early institution of containment measures at the point of initial patient contact.

Summary of current controversies.

Although intended for all healthcare settings, Transmission-Based Precautions may be difficult or even impossible to implement in some outpatient settings. Moreover, the effectiveness of these interventions in ambulatory care is largely unestablished, especially with regards to contact precautions. Consistent and appropriate use of Standard Precautions may be sufficient in these settings, but data is limited and the optimal strategy is unknown.

Overview of important clinical trials, meta-analyses, case control studies, case series, and individual case reports related to infection control and ambulatory care.

As previously noted, there are no clinical trials or meta-analyses related to infection control in ambulatory care settings. The limited studies published tend to be descriptive epidemiology studies or surveys related to lapses in infection control practices, outbreak investigations, and environmental contamination (see Table I, Table II, Table III, Table IV, and Table V).

Table I.

Lapses in Infection Control in Ambulatory Care Settings
    Guy AY (2010) There were 23 patient notification events in 14 states during 1999 - 2009. The estimated total number of patients notified was 129,157 and the median number of patients notified per event was 1,851. 78% of these notifications were assoicated with delivery of healthcare in non-hopsital settings, primarily physician's offices and subspecialty clinics. All were the result of breaches in basic infection control practices, and the majority related to concerns regarding possible transmission of bloodborne pathogens.
    Shaefer MK (2010) 68% of ambulatory surgery centers had 1 or more lapses in infection control practices. Lapses by category: 19% in hand hygiene or personal protective equipment use, 28% in safe injection practices, 46% in handling blood glucose monitoring equipment, 28% in other equipment reprocessing, 18% in environmental cleaning.
    Zhou Z (2008) Only 58% of cystic fibrosis clinics had written policies addressing the use of contact precautions among outpatients with Burhholderia cepacia, methicillin resistant Staphylococcus aureus (MRSA), or other multi-drug resistant organisms.

Table II.

Hand Hygiene in Ambulatory Care
Bittle MJ (2009) Physician compliance with hand hygiene in outpatient departments at a major tertiary care hospital was 88%.
Robertson G (2008) In an outpatient otolaryngology practice, physician compliance with hand hygiene increased from 43% to 76% following an education intervention and increased provision of alcohol based hand rub.
Turnberg W (2009) Self-reported compliance with hand hygiene was 43% among nurses and 33% among medical practitioners at 5 primary and emergency care clinics.
Cohen HA (2002) Among 13 dermatologists in 2 outpatient clinics, hand carriage of methicillin resistant Staphylococcus aureus (MSSA) and MRSA was 69% and 8%, respectively. The average compliance with hand hygiene opportunities was 30%.
Aizman A (2003) Physicians in an ophthalmology clinic complied with hand hygiene between patient encounters 74% of the time.
Lohr JA (1991) Observed compliance with hand hygiene in a pediatric ambulatory care settings was approximately 50%.

Table III.

Selected Reviews of Infection Control in Ambulatory Care
Goodman RA (1991) Review detailing 53 reports of infectious disease transmission in outpatient health care settings from 1961 - 1990. Transmission involved medical clinics and emergency departments in 23 reports, ophthalmologist's offices in 11, dental clinics in 13, and alternative care settings in 6.
Herwaldt LA (1998) Narrative review focusing on transmission of Mycobacterium tubercuosis, hepatitis B Virus, HIV, Adenovirus, and Measles.
Nafzinger DA (1997) Narrative review of healthcare associated infections in ambulatory care, including detailed summaries of studies related to surgical site infections and central-line associated bloodstream infections.

Table IV.

Selected Studies Describing Recent Bacterial Outbreaks in Ambulatory Care
Watson JT (2005) Outbreak of catheter-associated Klebsiella oxytoca and Enterobacter cloacae bloodstream infection in an oncology chemotherapy center due to injection of contaminated isotonic sodium chloride flushes.
Cohen AL (2008) Outbreak of Serratia marcescens bloodstream infection and central nervous system infections after interventional pain management procedures in which contaminated contrast solution was injected into multiple patients.
Wiersma P (2010) Outbreak of bloodstream infections caused by 16 different, predominantly gram negative, organisms in bone marrow transplant outpatients; although no environmental source of contamination was identified, there were numerous breaches in safe injection practices.
Civen R (2006) Outbreak of Serratia marcescens meningitis and epidural abscesses following injection of contaminated betamethasone compounded at a community pharmacy.
Radcliffe R (2011) Outbreak of MSSA infections (meningitis, epidural abscess, bacteremia) associated with syringe reuse and multi-dose medication vials.
Kirschke DL (2003) Outbreak of MSSA soft tissue and joint infections after soft tissue or intra-articular injection of contaminated lidocaine from a multi-dose vial.
Archer WR (2010) Outbreak of MSSA following intra-articular injection of corticosteroids. MSSA was not cultured from tested multi-dose vials but numerous lapses in safe injection practices were noted.

Table V.

Environmental Contamination by Potential Pathogens in Ambulatory Care Settings
Pappas, DE (2010) 20% - 40% of toys and objects in the sick waiting room of a pediatric office were contaminated with respiratory viral RNA.
Charnock, C (2005) 100% of magazines in the waiting rooms of general practices surgeries were contaminated with low levels of predominantly non-pathogenic bacteria.
Merriman, E (2002) 100% of soft and 91% of hard toys in the waiting rooms of general practitioners showed some degree of bacterial contamination. Soft toys were more likely than hard toys to show moderate to high level contamination and more likely to have coliform contamination.
McKay, I (2000) 10% of toys in the waiting rooms of general practitioners were contaminated with potential pathogens. Bacteria were culture more frequently from soft toys than hard toys.
Cohen, A (1997) 100% of stethoscopes and 90% of otoscope handles in community pediatric clinics were contaminated by micro-organisms. MRSA was found on 7.3% of stethoscopes and 9.5% of otoscope handles. Cleaning with alcohol reduced bacterial colony counts by 96%.
Bifero, AE (2006) MRSA was isolated from 2 of 9 adjustment tables in a chiropractic office.
Johnston CP (2006) 19% of environmental surface cultures from an HIV clinic were positive for MRSA. Two healthcare workers in the clinic, neither who was colonized with MRSA, developed MRSA skin and soft tissue infections. Occupational exposure was suspected as the mode of transmission.
Smith Tl (1998) Among a cohort of 7 oncology outpatients colonized with vancomycin resistant enterocci (VRE), contamination of the treatment room occurred in 29% of patient encounters.
Grabsch EA (2006) Among a cohort of hemodialysis patients colonized with VRE who attended mock outpatient consultation sessions, environmental contamination occurred in 36% of encounters.

Controversies in detail.

Transmission-Based Precautions are generally intended to apply to all healthcare settings, including physician's offices and other outpatient facilities. However, the role of these precautions in preventing the spread of infectious agents in ambulatory care settings has not been conclusively established.

The need for Transmission-Based Precautions in ambulatory care settings is suggested by the following observations:

  1. The reception and waiting areas of ambulatory care facilities present unique opportunities for transmission of infectious agents among patients and accompanying persons. Patients often remain in crowded common areas for long periods of time, and the number of air exchanges in office buildings is often low or air is simply re-circulated. These conditions may facilitate the spread of respiratory pathogens via droplet or airborne routes if a potentially contagious individual is not appropriately isolated.

  2. Outbreaks of measles and tuberculosis have been traced to outpatient facilities. During the SARS outbreak in 2002 - 2003, secondary transmission of SARS-coronavirus occurred in physician's offices and outpatient departments. Transmission of influenza is suspected of occurring in physician's offices, especially during periods of increased disease prevalence, such as were seen during the 2009 pandemic of H1N1 influenza. Transmission of varicella, pertussis, and viral respiratory and gastrointestinal illnesses also likely occurs in ambulatory care settings; there are no published reports confirming this occurrence, although this may reflect the difficulty in distinguishing between healthcare associated and community exposure.

  3. Acquisition of epidemiologically important organisms is no longer limited to hospital-based settings, as evidenced by the emergence of community-acquired MRSA, VRE, and Clostridum difficile among outpatients with no known predisposing risk factors.

  4. Contamination of environmental surfaces by MRSA and VRE has been documented in ambulatory care settings. MRSA has also been recovered from the stethoscopes of office-based physicians. Potentially pathogenic bacteria have been recovered from toys and inanimate objects in pediatric waiting rooms. Bacterial contamination of magazines in waiting rooms has also been described, although the single study on this subject found primarily non-pathogenic organisms. There is concern that environmental contamination could serve as a potential ecological reservoir for the transmission of multi-drug resistant organisms (MDROs). Appropriate use of Transmission-Based Precautions, if implemented early during the patient encounter, could decrease the size of this reservoir and mitigate the spread of infectious agents via indirect contact.

  5. Respiratory viral RNA has been isolated from toys and other inanimate objects in pediatric waiting rooms. Transmission of rhinovirus following contact with environmental surfaces has been demonstrated in experimental settings. Respiratory syncytial virus (RSV) can survive on inanimate objects (including stethoscopes), and secretions containing RSV remain infectious for varying lengths of time.

  6. Among patients attending cystic fibrosis (CF) clinics, evidence supports a role for hand carriage and environmental contamination in the transmission of some respiratory pathogens (e.g., Pseudomonas aeruginosa and Burkholderia species); although difficult to prove conclusively, some studies suggest that potential pathogens may also spread person-to-person between CF patients.

Counter arguments to the need for Transmission-Based Precautions include:

  1. Clinical trials evaluating the effectiveness of Transmission-Based Precautions have not been conducted in ambulatory care settings.

  2. A prospective cohort study demonstrated that young children seen for well care in a pediatric office with a common waiting area were no more likely to develop viral respiratory or gastrointestinal infections than control subjects who were not exposed to the waiting room. This study suggests that transmission of communicable viral illnesses in waiting rooms may occur less frequently than commonly perceived.

  3. Although contamination of the outpatient environment by MDROs has been described, there is little data to suggest that actual transmission of these organisms occurs in ambulatory care (excluding CF clinics and hemodialysis centers). There is a single case report in the English literature that describes two healthcare workers in an outpatient HIV clinic who developed MRSA soft-tissue infections with the same strain of MRSA cultured from environmental specimens; although suggestive of a role for fomites in the transmission of MRSA, causality cannot be established by this descriptive study. Infection due to VRE as a result of transmission in the outpatient setting has not been reported.

  4. Given the lack of evidence for transmission in most outpatient settings, the consistent use of standard precautions (e.g., hand hygiene, respiratory hygiene, and environmental cleaning) has been suggested as sufficient to prevent infection due to MDROs. Selective application of Transmission-Based Precautions may be reasonable in some situations. For example, contact precautions may be appropriate when caring for outpatient with large draining wounds, uncontained diarrhea, or cystic fibrosis.

  5. Implementation of Transmission-Based Precautions in ambulatory care settings is challenging. Most office environments lack airborne infection isolation rooms. Triage in office settings may be suboptimal, and a potentially contagious individual may go unrecognized. Many office-based practices lack a system for alerting clinicians to the need for contact precautions in patient with known colonization by MDROs. A private exam room must be immediately available at the time that a patient with a potentially communicable disease or epidemiologically important pathogen is registered or triaged. In busy office settings, this goal may be unrealistic, and the patient may instead by directed to a common waiting area.

What national and international guidelines exist for infection control and ambulatory care?

Isolation and infection prevention standards for hospitals have existed since 1970, and these hospital-based recommendations have been well-documented, regularly updated, and widely disseminated. In comparison, guidelines specific to ambulatory care have been slow to evolve. The need for such guidelines, however, has increasingly been realized given the expanding scope and complexity of outpatient medicine.

In 2007 and 2011, the HICPAC and the CDC published guidelines relevant to infection control and prevention in ambulatory care settings. These standards better define best practices and can be used by healthcare professionals to guide decisions about the development and implementation of infection control policies and procedures.

  1. The 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings updated and expanded the 1996 Guideline for Isolation Precautions in Hospitals by establishing general recommendations that could be applied to a wide spectrum of healthcare settings (including but not limited to ambulatory care); these recommendations are based on common principles of infection control which can be further modified to reflect setting-specific needs.

  2. The 2011 Guide to Infection Prevention in Outpatient Settings: Minimum Expectations for Safe Care was the first CDC publication to specifically address infection control and prevention in ambulatory care. Rather than providing new recommendations, however, this summary guide essentially distilled existing evidence from the 2007 Guideline for Isolation Precautions into a concise reference guide which was uniquely applicable to ambulatory care. A companion document, entitled Infection Prevention Checklist for Outpatient Settings: Minimum Expectations for Safe Care, was published simultaneously and provides a tool for facilities to use in proactively assessing their infection control practices.

A number of other evidence-based guidelines relevant to infection control in ambulatory care settings have been developed collaboratively by the HICPAC, CDC, and / or Advisory Committee on Immunization Practices (ACIP). Some of these guidelines are relevant to specialized outpatient settings while others provide general guidelines that are applicable to all healthcare personnel and / or all healthcare settings.

Specialized Settings:

  1. Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients (2001)

  2. Guidelines for Infection Control in Dental-Healthcare-Settings (2003)

  3. Basic Infection and Prevention Plan for Outpatient Oncology Settings (2011)


  1. Immunizations in Health-Care Workers (1997)

  2. Guideline for Infection Control in Healthcare Personnel (1998)

  3. Guideline for Preventing Surgical Site Infections (1999)

  4. Guideline for Hand Hygiene in Health-Care Settings (2002)

  5. Guidelines for Environmental Infection Control in Health-Care Facilities (2003)

  6. Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings (2005)

  7. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Post-Exposure Prophylaxis (2005)

  8. Influenza Vaccination in Health-Care Personnel (2006)

  9. Management of Multi-Drug Resistant Organisms in Healthcare Facilities (2006)

  10. Guidelines for Disinfection and Sterilization in Healthcare Facilities (2008)

Systematically developed international guidelines on the subject of infection control in ambulatory care have been published by the United Kingdom National Institute for Health and Clinical Excellence (NICE) as well as by the Public Health Agency of Canada (PHAC):

  1. Prevention of Healthcare -Associated Infections in Primary and Community Care (NICE, 2003)

  2. Infection Prevention and Control Practices for Long Term Care, Home, and Community Care including Health Care Offices and Ambulatory Clinics (PHAC, 2007)

What other consensus group statements exist, and what do key leaders advise?

Position statements specific to outpatient pediatric care:

  1. American Academy of Pediatrics. Infection Prevention and Control in Pediatric Ambulatory Settings (2007)

  2. Canadian Pediatric Society. Infection Control in Pediatric Office Settings (2008)

Selected publications from other national associations and / or societies:

  1. Society for Healthcare Epidemiology of America. Requirements for Infrastructure and Essential Activities for Infection Control in Out-of-Hospital Settings: A Consensus Panel Report (1999)

  2. Cystic Fibrosis Foundation: Infection Control Recommendations for Patients with Cystic Fibrosis: Microbiology, Important Pathogens, and Infection Control Practices to Prevent Patient-to-Patient Transmission (2003)

  3. Association for Professionals in Infection Control and Epidemiology. Infection Control in Ambulatory Care (2004)

  4. Infectious Disease Society of America. Guidelines for Prevention of Intravascular Catheter-related Infections (2011)

Selected publications from other major international organizations:

  1. College of Physicians and Surgeons of Ontario. Infection Control in Physician's Offices (2003)

  2. British Columbia Centre for Disease Control. Guideline for Infection Prevention and Control in Physician's Offices (2004)

  3. Royal Australian College of General Practitioners. Infection Standards for Office Based Practices, 4th edition (2006)


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