post exposure management and infection control

Theresa G. Mayfield, D.M.D.University of Louisville School of Dentistry

Department of Diagnostic Sciences, Prosthodontics and Restorative Dentistry

Post-exposure Management

and Infection Control

CaseMr. Wright presents for routine restorative care in the University of Louisville School of Dentistry dental clinic. Dr. Blue has just completed a composite restoration on #9. As Dr. Blue is moving the bracket table to get up from his chair, the back of his forearm is stuck with a 7901 bur. The bur was used to finish the facial subgingival margin and is laden with debris and blood.

Questions

• Has an occupational exposure occurred?

• What are the next steps?

• What strategies might be employed to minimize the risk of future injuries?

Has an occupational exposure occurred?

Occupational Exposure Incident

• Specific eye, mouth, other mucous membrane, non-intact skin or parenteral contact with blood/OPIM (including saliva in dental settings) resulting from performance duties

2007 Bloodborne Pathogen Incident Analysis

Type of incident How occurred # PercentNeedle Stick While giving local anesthesia 10 40.0

During clean-up 2 8.0Unknown 1 4.0

Suture Needle While suturing 1 4.0

Scalpel Blade During clean-up 1 4.0

Bur/Cavitron tip Stick During treatment While using 1 4.0

Reaching past bracket table 2 8.0 Walking past bracket table 1 4.0

Clean-up 1 4.0 During handling in sterilization 1 4.0

Instrument Stick During patient treatment 1 4.0During clean up 1 4.0During handling in sterilization 1 4.0

Bite While taking radiographs by child 1 4.0Total 25 100.0

What are the next steps?

PEP Steps

• Treat the exposure site

• Report and document

• Evaluate the exposure

• Evaluate the exposure source

• Disease-specific PEP management

Occupational Exposures

Occupational Exposures

Wound careWound careWound careWound care

• Clean wounds with soap and water• Flush mucous membranes with

water• No benefit to:

-applying of antiseptics or disinfectants

-squeezing (“milking”) puncture sites

• Avoid use of bleach and other agents caustic to skin

Notify one of the Notify one of the attending faculty of the attending faculty of the

incidentincident

Notify one of the Notify one of the attending faculty of the attending faculty of the

incidentincident

Both you and the attending Both you and the attending faculty let the patient know faculty let the patient know of the incident and educate of the incident and educate

the patient of the the patient of the importance for blood importance for blood testing and follow uptesting and follow up

Both you and the attending Both you and the attending faculty let the patient know faculty let the patient know of the incident and educate of the incident and educate

the patient of the the patient of the importance for blood importance for blood testing and follow uptesting and follow up

Go to the Clinical Affairs Go to the Clinical Affairs Office and get the proper Office and get the proper paperwork to fill out and take paperwork to fill out and take to the ACBto the ACB

Go to the Clinical Affairs Go to the Clinical Affairs Office and get the proper Office and get the proper paperwork to fill out and take paperwork to fill out and take to the ACBto the ACB

Postexposure Management:The Exposure Report

• Date and time of exposure• Procedure details…what, where, how, with

what device• Exposure details...route, body substance

involved, volume/duration of contact

• Exposure management details– The reports are numbered for accounting purposes and

to ensure all follow-up paperwork gets completed

• All reports are kept confidential

Go to the ACB for baseline Go to the ACB for baseline testing for exposed testing for exposed

individual and patientindividual and patient

Go to the ACB for baseline Go to the ACB for baseline testing for exposed testing for exposed

individual and patientindividual and patient

Exposure Incident Reporting

• We have a referral protocol in place – The ACB

• Refer for testing and follow-up counseling

PreventionProphylaxis

Occupational Exposure

Risk of Infection

Following a specific exposure, the risk of infection vary with factors such as:

• The pathogen involved• The type of exposure• The amount of blood involved in the

exposure• The amount of virus in the patient's blood at

the time of exposureDepartment of Health & Human Services. CDC. Brochure.Exposure to Blood - What Health-Care Workers Need to Know, 2003

CDC. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR 2005;54(No. RR-9):1--17.

• Approximately 0.3% following percutaneous exposure

• Approximately 0.09% following mucous membrane exposure

Risk of HIV Infection Following Occupational Exposure to HIV-Infected Blood


Evaluate the Exposure

• The exposure should be evaluated for potential to transmit HBV, HCV, or HIV based on the type of body substance involved, the route, and the severity of exposure.


• Factors to consider:– Type of exposure

• Percutaneous injury• Mucous membrane exposure• Nonintact skin exposure• Bites involving blood

– Type and amount of fluid tissue• Blood• Fluids containing blood• Potentially infectious fluid or tissue• Direct contact with concentrated virus


• Factors to consider:– Infectious status of the patient

• HBV• HCV• HIV

– Susceptibility of exposed HCP• Hepatitis B vaccine and response status• HBV,HCV,HIV status- baseline testing as soon as

possible

Evaluate the Exposure Source

• Test patient for:– HBsAg– HCV antibody– HIV antibody

• When source patient is not known evaluate the likelihood of high risk exposure

Average Risk of Transmissionafter Percutaneous Exposure to

Blood

HIVHepatitis CHepatitis B (only HBeAg+) HBeAg-

0.31.830.06.0

Risk (%)Source

Initiating PEP

• PEP should be started as soon as possible, preferably within hours, rather than days, following exposure

• When uncertain as to which drugs to choose, start the basic regimen rather than delay

• PEP should be administered for 4 weeks, if tolerated

CDC. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR 2005;54(No. RR-9):1--17. http://www.aidsetc.org

Initiating PEP

• Reevaluate exposed HCP within 72 hours of exposure, especially as additional information about the exposure or source patient becomes available

• If the source is found to be negative, PEP should be discontinued

• Rapid HIV testing of the source patient can facilitate decisions regarding PEP when the source patient’s HIV status is unknown


Selecting the PEP regimen

• Selection of number (2 or ≥3) of drugs is based on assessment of risk for HIV infection

• Selection of which agents to use is based largely on potential toxicity of PEP drugs and on likelihood of efficacy (especially in the case of resistant virus)– few data on efficacy of individual antiretroviral

agents in PEP CDC. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR 2005;54(No. RR-9):1--17. http://www.aidsetc.org

How Many Drugs to Use?

• Two-drug PEP regimens improve tolerability and therefore chances of completing full 4 weeks

• Three- (or more) drug PEP regimens provide potentially greater antiviral activity

• Guidelines recommend more drugs for higher risk exposures


Which Drugs to Use?

• Consultation with an expert is recommended

• Regimens should be chosen to minimize potential drug toxicities and maximize the likelihood of adherence

• Consideration should be given to the history of the source person, including history of and response to antiretroviral therapy and disease stage


Basic and Expanded HIV Postexposure

Prophylaxis Regimens

• Basic Regimens:




• Alternate Basic Regimens:




• Preferred Expanded Regimen:– Basic Regimen + the following:




• Alternate expanded regimen:– Basic Regimen + one of the following:


Basic and Expanded HIV Postexposure Prophylaxis Regimens

Antiretroviral agents generally NOT recommended for PEP:

• Nevirapine• Delavirdine• Abacavir• Zalcitabine• Didanosine + stavudine

Antiretroviral agents to be used for PEP only with expert consultation:

• Enfuvirtide CDC. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR 2005;54(No. RR-9):1--17. http://www.aidsetc.org

Selection of Drugs for PEP: Consultation is Part of the Guideline

“Because of the complexity of selecting HIV PEP regimens, when possible, these recommendations should be implemented in consultation with persons having expertise in antiretroviral therapy and HIV transmission”


Healthcare personnel with documentedand possible occupationally acquired

AIDS/HIV Infection (2002)Occupation Documented Possible

Nurse 24 35

Laboratory worker, clinical 16 17

Physician, nonsurgical 6 12

Laboratory technician, nonclinical 3 -

Housekeeper/maintenance worker 2 13

Technician, surgical 2 2

Embalmer/morgue technician 1 2

Health aide/attendant 1 15

Respiratory therapist 1 2

Technician, dialysis 1 3

Dental worker, including dentist - 6

Emergency medical technician/paramedic - 12

Physician, surgical - 6

Other technician/therapist - 9

Other healthcare occupation - 5

Total 57 139

What strategies might be employed to minimize the risk of future

injuries?

Guidelines for Infection Guidelines for Infection Control in Dental Health-Care Control in Dental Health-Care

Settings—2003Settings—2003

CDC. CDC. MMWRMMWR 2003;52(No. RR-17) 2003;52(No. RR-17)

http://www.cdc.gov/oralhealth/http://www.cdc.gov/oralhealth/

infectioncontrol/guidelines/index.htminfectioncontrol/guidelines/index.htm

Infection Control Program GoalsInfection Control Program Goals

Provide a safe working Provide a safe working environmentenvironment

• Reduce health care-associated Reduce health care-associated infections infections

• Reduce occupational Reduce occupational exposuresexposures

Why Is Infection Control Important Why Is Infection Control Important in Dentistry?in Dentistry?

Both patients and dental health care personnel Both patients and dental health care personnel (DHCP) can be exposed to pathogens(DHCP) can be exposed to pathogens

Contact with blood, oral and respiratory secretions, Contact with blood, oral and respiratory secretions, and contaminated equipment occursand contaminated equipment occurs

Proper procedures can prevent transmission of Proper procedures can prevent transmission of infections among patients and DHCPinfections among patients and DHCP

Standard PrecautionsStandard Precautions

Apply to Apply to allall patients patients

Integrate and expand Universal Precautions Integrate and expand Universal Precautions to include organisms spread by blood and to include organisms spread by blood and also also

• Body fluids, secretions, and excretions except Body fluids, secretions, and excretions except sweat, whether or not they contain bloodsweat, whether or not they contain blood

• Non-intact (broken) skinNon-intact (broken) skin

• Mucous membranesMucous membranes

Elements of Standard PrecautionsElements of Standard Precautions

HandwashingHandwashing

Use of gloves, masks, eye protection, and Use of gloves, masks, eye protection, and gownsgowns

Patient care equipmentPatient care equipment

Environmental surfacesEnvironmental surfaces

Injury preventionInjury prevention

Personnel Health Elements of an Personnel Health Elements of an Infection Control ProgramInfection Control Program

Education and trainingEducation and training

ImmunizationsImmunizations

Exposure prevention and postexposure managementExposure prevention and postexposure management

Medical condition management and work-related Medical condition management and work-related illnesses and restrictionsillnesses and restrictions

Health record maintenanceHealth record maintenance

Preventing Transmission of Preventing Transmission of Bloodborne PathogensBloodborne Pathogens

Are transmissible in health care settingsAre transmissible in health care settings

Can produce chronic infectionCan produce chronic infection

Are often carried by persons unaware of their Are often carried by persons unaware of their infectioninfection

Bloodborne viruses such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV)

Average Risk of Bloodborne Virus Average Risk of Bloodborne Virus Transmission after NeedlestickTransmission after Needlestick

SourceSource RiskRisk

HBVHBVHBsAgHBsAg++ and HBeAg and HBeAg++ 22.0%-31.0% clinical hepatitis; 37%-62% 22.0%-31.0% clinical hepatitis; 37%-62%

serological evidence of HBV infectionserological evidence of HBV infection

HBsAgHBsAg++ and HBeAg and HBeAg-- 1.0%-6.0% clinical hepatitis; 23%-37% 1.0%-6.0% clinical hepatitis; 23%-37% serological evidence of HBV infectionserological evidence of HBV infection

HCVHCV 1.8% (0%-7% range)1.8% (0%-7% range)

HIVHIV 0.3% (0.2%-0.5% range)0.3% (0.2%-0.5% range)

Concentration of HBV in Body FluidsConcentration of HBV in Body Fluids

HighHigh ModerateModerate Low/Not DetectableLow/Not Detectable

BloodBlood SemenSemen UrineUrine

SerumSerum Vaginal FluidVaginal Fluid FecesFeces

Wound exudatesWound exudates SalivaSaliva SweatSweat

TearsTears

Breast MilkBreast Milk

Estimated Incidence of HBV Infections Among Estimated Incidence of HBV Infections Among HCP and General Population, HCP and General Population,

United States, 1985-1999United States, 1985-1999

0

50

100

150

200

250

300

350

1985 1987 1989 1991 1993 1995 1997 1999

Year

Inci

den

ce p

er 1

00,0

00

Health Care Personnel

General U.S. Population

Source: Cleveland et al., JADA 1996;127:1385-90. Personal communication ADA, Chakwan Siew, PhD, 2005.

Per

cen

tHBV Infection Among U.S. DentistsHBV Infection Among U.S. Dentists

Year

0

2

4

6

8

10

12

14

16

1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003

Hepatitis B VaccineHepatitis B Vaccine

Vaccinate all DHCP who are at risk of Vaccinate all DHCP who are at risk of exposure to bloodexposure to blood

Provide access to qualified health care Provide access to qualified health care professionals for administration and professionals for administration and follow-up testingfollow-up testing

Test for anti-HBs 1 to 2 months after Test for anti-HBs 1 to 2 months after 3rd dose3rd dose

Transmission of HBV from Infected Transmission of HBV from Infected DHCP to PatientsDHCP to Patients

Nine clusters of transmission from dentists and oral Nine clusters of transmission from dentists and oral surgeons to patients, 1970–1987surgeons to patients, 1970–1987

Eight dentists tested for HBeAg were positiveEight dentists tested for HBeAg were positive

Lack of documented transmissions since 1987 may Lack of documented transmissions since 1987 may reflect increased use of gloves and vaccinereflect increased use of gloves and vaccine

One case of patient-to-patient transmission, 2003One case of patient-to-patient transmission, 2003

Occupational Risk of HCV Occupational Risk of HCV Transmission among HCPTransmission among HCP

Inefficiently transmitted by occupational Inefficiently transmitted by occupational exposuresexposures

Three reports of transmission from blood Three reports of transmission from blood splash to the eye splash to the eye

Report of simultaneous transmission of HIV Report of simultaneous transmission of HIV and HCV after non-intact skin exposureand HCV after non-intact skin exposure

HCV Infection in HCV Infection in Dental Health Care SettingsDental Health Care Settings

Prevalence of HCV infection among Prevalence of HCV infection among dentists similar to that of general population dentists similar to that of general population (~ 1%-2%) (~ 1%-2%)

No reports of HCV transmission from No reports of HCV transmission from infected DHCP to patients or from patient infected DHCP to patients or from patient to patient to patient

Risk of HCV transmission appears very lowRisk of HCV transmission appears very low

Transmission of HIV from Infected Transmission of HIV from Infected Dentists to PatientsDentists to Patients

Only one documented case of HIV Only one documented case of HIV transmission from an infected dentist to transmission from an infected dentist to patientspatients

No transmissions documented in the No transmissions documented in the investigation of 63 HIV-infected HCP investigation of 63 HIV-infected HCP (including 33 dentists or dental students)(including 33 dentists or dental students)

Health Care Workers with Documented and Possible Occupationally Acquired HIV/AIDS

CDC Database as of December 2002

* 3 dentists, 1 oral surgeon, 2 dental assistants

Documented Possible

Dental Worker 0 6 *

Nurse 24 35

Lab Tech, clinical 16 17

Physician, nonsurgical 6 12

Lab Tech, nonclinical 3 –

Other 8 69

Total 57 139

Risk Factors for HIV Transmission after Risk Factors for HIV Transmission after Percutaneous Exposure to HIV-Infected Blood Percutaneous Exposure to HIV-Infected Blood

CDC Case-Control StudyCDC Case-Control Study

Deep injuryDeep injury

Visible blood on deviceVisible blood on device

Needle placed in artery or veinNeedle placed in artery or vein

Terminal illness in source patientTerminal illness in source patient

Source: Cardo, et al., Source: Cardo, et al., N England J Medicine N England J Medicine 1997;337:1485-90.1997;337:1485-90.

Characteristics of Percutaneous Characteristics of Percutaneous Injuries Among DHCPInjuries Among DHCP

Reported frequency among general dentists has Reported frequency among general dentists has declineddeclined

Caused by burs, syringe needles, other sharps Caused by burs, syringe needles, other sharps

Occur outside the patient’s mouthOccur outside the patient’s mouth

Involve small amounts of bloodInvolve small amounts of blood

Among oral surgeons, occur more frequently Among oral surgeons, occur more frequently during fracture reductions and procedures during fracture reductions and procedures involving wireinvolving wire

Exposure Prevention StrategiesExposure Prevention Strategies

Engineering controlsEngineering controls Work practice controlsWork practice controls Administrative controlsAdministrative controls

Engineering ControlsEngineering Controls

Isolate or remove the hazard Isolate or remove the hazard

Examples:Examples:

• Sharps containerSharps container

• Medical devices with injury protection Medical devices with injury protection features (e.g., self-sheathing needles)features (e.g., self-sheathing needles)

Work Practice ControlsWork Practice Controls

Change the manner of performing tasksChange the manner of performing tasks

Examples include:Examples include:

• Using instruments instead of fingers to Using instruments instead of fingers to retract or palpate tissueretract or palpate tissue

• One-handed needle recappingOne-handed needle recapping

Administrative ControlsAdministrative Controls

Policies, procedures, and enforcement Policies, procedures, and enforcement measuresmeasures

Placement in the hierarchy varies by the Placement in the hierarchy varies by the problem being addressedproblem being addressed

• Placed before engineering controls for Placed before engineering controls for airborne precautions (e.g., TB) airborne precautions (e.g., TB)

Post-exposure Management Post-exposure Management ProgramProgram

Clear policies and proceduresClear policies and procedures

Education of dental health care personnel Education of dental health care personnel (DHCP) (DHCP)

Rapid access toRapid access to

• Clinical careClinical care

• Post-exposure prophylaxis (PEP)Post-exposure prophylaxis (PEP)

• Testing of source patients/HCPTesting of source patients/HCP

Wound managementWound management Exposure reportingExposure reporting Assessment of infection riskAssessment of infection risk

• Type and severity of exposureType and severity of exposure

• Bloodborne status of source personBloodborne status of source person

• Susceptibility of exposed personSusceptibility of exposed person

Post-exposure ManagementPost-exposure Management

Hand HygieneHand Hygiene

Why Is Hand Hygiene Important?Why Is Hand Hygiene Important?

Hands are the most common mode of Hands are the most common mode of

pathogen transmissionpathogen transmission

Reduce spread of antimicrobial resistanceReduce spread of antimicrobial resistance

Prevent health care-associated infectionsPrevent health care-associated infections

Hands Need to be Cleaned WhenHands Need to be Cleaned When

Visibly dirtyVisibly dirty

After touching contaminated After touching contaminated objects with bare handsobjects with bare hands

Before and after patient Before and after patient treatment (before glove treatment (before glove placement and after glove placement and after glove removal)removal)

Personal Protective Personal Protective EquipmentEquipment

Personal Personal Protective Protective EquipmentEquipment

A major component of Standard PrecautionsA major component of Standard Precautions

Protects the skin and mucous membranes Protects the skin and mucous membranes from exposure to infectious materials in spray from exposure to infectious materials in spray or spatter or spatter

Should be removed when leaving treatment Should be removed when leaving treatment areasareas

Masks, Protective Eyewear, Face ShieldsMasks, Protective Eyewear, Face Shields

Wear a surgical mask and either eye protection with Wear a surgical mask and either eye protection with solid side shields or a face shield to protect mucous solid side shields or a face shield to protect mucous membranes of the eyes, nose, and mouthmembranes of the eyes, nose, and mouth

Change masks between patientsChange masks between patients

Clean reusable face protection between patients; if Clean reusable face protection between patients; if visibly soiled, clean and disinfectvisibly soiled, clean and disinfect

Protective ClothingProtective Clothing

Wear gowns, lab coats, or Wear gowns, lab coats, or uniforms that cover skin and uniforms that cover skin and personal clothing likely to become personal clothing likely to become soiled with blood, saliva, or soiled with blood, saliva, or infectious materialinfectious material

Change if visibly soiledChange if visibly soiled

Remove all barriers before leaving Remove all barriers before leaving the work areathe work area

GlovesGloves

Minimize the risk of health care personnel Minimize the risk of health care personnel acquiring infections from patientsacquiring infections from patients

Prevent microbial flora from being transmitted Prevent microbial flora from being transmitted from health care personnel to patientsfrom health care personnel to patients

Reduce contamination of the hands of health Reduce contamination of the hands of health care personnel by microbial flora that can be care personnel by microbial flora that can be transmitted from one patient to anothertransmitted from one patient to another

Are not a substitute for handwashing!Are not a substitute for handwashing!

Recommendations for GlovingRecommendations for Gloving

Wear gloves when contact with Wear gloves when contact with blood, saliva, and mucous blood, saliva, and mucous membranes is possiblemembranes is possible

Remove gloves after patient care Remove gloves after patient care

Wear a new pair of gloves for Wear a new pair of gloves for each patienteach patient

Sterilization and Disinfection Sterilization and Disinfection of Patient Care Itemsof Patient Care Items

Critical InstrumentsCritical Instruments

Penetrate mucous membranes or contact bone, Penetrate mucous membranes or contact bone, the bloodstream, or other normally sterile the bloodstream, or other normally sterile tissues (of the mouth)tissues (of the mouth)

Heat sterilize between uses or use sterile single-Heat sterilize between uses or use sterile single-use, disposable devicesuse, disposable devices

Examples include surgical instruments, scalpel Examples include surgical instruments, scalpel blades, periodontal scalers, and surgical dental blades, periodontal scalers, and surgical dental bursburs

Semi-critical InstrumentsSemi-critical Instruments

Contact mucous membranes but do not Contact mucous membranes but do not penetrate soft tissue penetrate soft tissue

Heat sterilize or high-level disinfect Heat sterilize or high-level disinfect

Examples: Dental mouth mirrors, Examples: Dental mouth mirrors, amalgam condensers, and dental amalgam condensers, and dental handpieceshandpieces

Noncritical Instruments Noncritical Instruments and Devicesand Devices

Contact intact skinContact intact skin

Clean and disinfect using a low to intermediate Clean and disinfect using a low to intermediate level disinfectantlevel disinfectant

Examples: X-ray heads, facebows, pulse Examples: X-ray heads, facebows, pulse oximeter, blood pressure cuffoximeter, blood pressure cuff

Automated Cleaning Automated Cleaning

Ultrasonic cleanerUltrasonic cleaner

Instrument washerInstrument washer

Washer-disinfectorWasher-disinfector

Manual CleaningManual Cleaning

Soak until ready to cleanSoak until ready to clean

Wear heavy-duty utility Wear heavy-duty utility gloves, mask, eyewear, gloves, mask, eyewear, and protective clothingand protective clothing

Preparation and PackagingPreparation and Packaging

Critical and semi-critical items that will be Critical and semi-critical items that will be stored should be wrapped or placed in stored should be wrapped or placed in containers before heat sterilizationcontainers before heat sterilization

Hinged instruments opened and unlockedHinged instruments opened and unlocked

Place a chemical indicator inside the packPlace a chemical indicator inside the pack

Wear heavy-duty, puncture-resistant utility Wear heavy-duty, puncture-resistant utility glovesgloves

Heat-Based SterilizationHeat-Based Sterilization

Steam under pressure (autoclaving)Steam under pressure (autoclaving)

• Gravity displacementGravity displacement

• Pre-vacuum Pre-vacuum

Dry heatDry heat

Unsaturated chemical vaporUnsaturated chemical vapor

Liquid Chemical Liquid Chemical Sterilant/DisinfectantsSterilant/Disinfectants

Only for heat-sensitive critical Only for heat-sensitive critical and semi-critical devicesand semi-critical devices

Powerful, toxic chemicals Powerful, toxic chemicals raise safety concernsraise safety concerns

Heat tolerant or disposable Heat tolerant or disposable alternatives are availablealternatives are available

Storage of Sterile and Storage of Sterile and Clean Items and SuppliesClean Items and Supplies

Use date- or event-related shelf-life practicesUse date- or event-related shelf-life practices

Examine wrapped items carefully prior to useExamine wrapped items carefully prior to use

When packaging of sterile items is damaged, When packaging of sterile items is damaged, re-clean, re-wrap, and re-sterilizere-clean, re-wrap, and re-sterilize

Store clean items in dry, closed, or covered Store clean items in dry, closed, or covered containmentcontainment

Environmental Infection Environmental Infection ControlControl

Environmental SurfacesEnvironmental Surfaces

May become contaminated May become contaminated

Not directly involved in infectious disease Not directly involved in infectious disease transmissiontransmission

Do not require as stringent decontamination Do not require as stringent decontamination proceduresprocedures

Categories of Environmental SurfacesCategories of Environmental Surfaces

Clinical contact surfacesClinical contact surfaces

• High potential for direct contamination from High potential for direct contamination from spray or spatter or by contact with DHCP’s spray or spatter or by contact with DHCP’s gloved handgloved hand

Housekeeping surfacesHousekeeping surfaces

• Do not come into contact with patients or Do not come into contact with patients or devicesdevices

• Limited risk of disease transmissionLimited risk of disease transmission

Clinical Contact SurfacesClinical Contact Surfaces

General Cleaning RecommendationsGeneral Cleaning Recommendations

Use barrier precautions (e.g., heavy-duty utility gloves, Use barrier precautions (e.g., heavy-duty utility gloves, masks, protective eyewear) when cleaning and masks, protective eyewear) when cleaning and disinfecting environmental surfacesdisinfecting environmental surfaces

Physical removal of microorganisms by cleaning is as Physical removal of microorganisms by cleaning is as important as the disinfection processimportant as the disinfection process

Follow manufacturer’s instructions for proper use of Follow manufacturer’s instructions for proper use of EPA-registered hospital disinfectantsEPA-registered hospital disinfectants

Do not use sterilant/high-level disinfectants on Do not use sterilant/high-level disinfectants on environmental surfacesenvironmental surfaces

Cleaning Clinical Contact SurfacesCleaning Clinical Contact Surfaces

Risk of transmitting infections greater Risk of transmitting infections greater than for housekeeping surfacesthan for housekeeping surfaces

Surface barriers can be used and Surface barriers can be used and changed between patientschanged between patients

OROR

Clean then disinfect using an EPA-Clean then disinfect using an EPA-registered low- (HIV/HBV claim) to registered low- (HIV/HBV claim) to intermediate-level (tuberculocidal intermediate-level (tuberculocidal claim) hospital disinfectantclaim) hospital disinfectant

Cleaning Housekeeping SurfacesCleaning Housekeeping Surfaces

Routinely clean with soap and water or an EPA-Routinely clean with soap and water or an EPA-registered detergent/hospital disinfectant routinelyregistered detergent/hospital disinfectant routinely

Clean mops and cloths and allow to dry thoroughly Clean mops and cloths and allow to dry thoroughly before re-usingbefore re-using

Prepare fresh cleaning and disinfecting solutions Prepare fresh cleaning and disinfecting solutions daily and per manufacturer recommendationsdaily and per manufacturer recommendations

Medical WasteMedical Waste

Medical Waste: Medical Waste: Not considered infectious, Not considered infectious, thus can be discarded in regular trashthus can be discarded in regular trash

Regulated Medical Waste: Regulated Medical Waste: Poses a Poses a potential risk of infection during handling potential risk of infection during handling and disposaland disposal

Regulated Medical Waste ManagementRegulated Medical Waste Management

Properly labeled containment to Properly labeled containment to prevent injuries and leakage prevent injuries and leakage

Medical wastes are “treated” in Medical wastes are “treated” in accordance with state and local EPA accordance with state and local EPA regulations regulations

Processes for regulated waste include Processes for regulated waste include autoclaving and incinerationautoclaving and incineration

Special ConsiderationsSpecial Considerations Dental handpieces and other Dental handpieces and other

devices attached to air and devices attached to air and waterlineswaterlines

Dental radiologyDental radiology

Aseptic technique for Aseptic technique for parenteral medicationsparenteral medications

Single-use (disposable) Single-use (disposable) DevicesDevices

Preprocedural mouth rinsesPreprocedural mouth rinses

Oral surgical proceduresOral surgical procedures

Handling biopsy specimensHandling biopsy specimens

Handling extracted teethHandling extracted teeth

Laser/electrosurgery Laser/electrosurgery plumes or surgical smokeplumes or surgical smoke

Dental laboratoryDental laboratory

Mycobacterium Mycobacterium tuberculosistuberculosis

Creutzfeldt-Jacob Disease Creutzfeldt-Jacob Disease (CJD) and other prion-(CJD) and other prion-related diseasesrelated diseases

Infection Control Protocols

• Apply to faculty, staff, and students

• Annual Updates• Online clinic manual

CDC Guidelines – MMWR October 25 2002/51(RR16);1-44

Contact Information

Theresa G. Mayfield D.M.D.

Associate Professor

University of Louisville School of Dentistry

[email protected]

mailto:[email protected]

post exposure management and infection control

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