An outbreak of scabies in a residential home

A nosocomial scabies outbreak originating from immunocompromised transplant patients in Turkey: Upholstery as a possible cause

BACKGROUND

Inpatients with crusted scabies represent an important source of nosocomial transmission with consequent outbreaks among patients and healthcare workers. This study aimed to report the course of an institutional scabies outbreak, which progressed with infestation of immunosuppressed transplant patients, health care workers, and caregivers.

METHODS

Patients diagnosed with scabies in a nosocomial outbreak in a 200-bed, tertiary hospital were included. Following a diagnosis of scabies in the index patient, strict contact isolation measures were implemented. During the outbreak, a root cause analysis (RCA) was carried out by an infection prevention and control team.

RESULTS

Forty-two individuals were affected (7 patients, 25 health care workers, and 10 family members of the patients) during the outbreak consisting of three attacks. Index case was a multiple myeloma patient who received hematopoietic stem cell transplantation and presented with crusted scabies. A RCA suggested that upholstery could serve as a means of reservoir. All upholstery of the sofa and armchairs in patient rooms as well as in lounge areas were replaced by wipeable leather material. After the 19-week course of the outbreak, no additional cases of scabies have been observed until now.

CONCLUSION

A high index of suspicion should be maintained, particularly in immunocompromised patients, in order to achieve rapid diagnosis of scabies and to implement institutional infection control measures. It should also be borne in mind that the transmission may occur through direct contact as well as fomites, such as upholstery.

Do we know how scabies outbreaks in residential and nursing care homes for the elderly should be managed? A systematic review of interventions using a novel approach to assess evidence quality

Currently no national guidelines exist for the management of scabies outbreaks in residential or nursing care homes for the elderly in the United Kingdom. In this setting, diagnosis and treatment of scabies outbreaks is often delayed and optimal drug treatment, environmental control measures and even outcome measures are unclear. We undertook a systematic review to establish the efficacy of outbreak management interventions and determine evidence-based recommendations. Four electronic databases were searched for relevant studies, which were assessed using a quality assessment tool drawing on STROBE guidelines to describe the quality of observational data. Nineteen outbreak reports were identified, describing both drug treatment and environmental management measures. The quality of data was poor; none reported all outcome measures and only four described symptom relief measures. We were unable to make definitive evidence-based recommendations. We draw on the results to propose a framework for data collection in future observational studies of scabies outbreaks. While high-quality randomised controlled trials are needed to determine optimal drug treatment, evidence on environmental measures will need augmentation through other literature studies. The quality assessment tool designed is a useful resource for reporting of outcome measures including patient-reported measures in future outbreaks.

Retrospective analysis of institutional scabies outbreaks from 1984 to 2013: lessons learned and moving forward

Scabies outbreaks can be disruptive in institutional settings, and are associated with considerable but under-researched morbidity, especially in vulnerable populations. In this paper, we describe key findings from a retrospective review of scabies outbreaks reported in the literature over the past 30 years. We undertook this review to gain insights into the impact of institutional outbreaks, the burden in terms of attack rates, economic costs, treatment trends, the types of index cases and outbreak progression. We found 84 reports over 30 years, with outbreaks most frequently reported in aged care facilities (n = 40) and hospitals (n = 33). On average, scabies outbreaks persisted for 3 months, and the median attack rate was 38%. While 1% lindane was once the most commonly employed acaricide, 5% permethrin and oral ivermectin are increasingly used. Crusted scabies represented the index case for 83% of outbreaks, and scabies was misdiagnosed in 43% outbreaks. The frequency of reported scabies outbreaks has not declined consistently over time suggesting the disease is still highly problematic. We contend that more research and practice emphasis must be paid to improve diagnostic methods, surveillance and control, health staff education and management of crusted scabies to prevent the development of scabies outbreaks in institutional settings.

Control of large institutional scabies outbreaks

BACKGROUND

Scabies outbreaks in community facilities may reach large dimensions and take a protracted course. Highly contagious crusted scabies is a major cause of nosocomial outbreaks.

PATIENTS AND METHODS

On the occasion of an extensive scabies outbreak in a north Bavarian sheltered workshop and its associated residential homes with over 500 exposed individuals, a multifaceted control strategy was developed and pursued. Knowledge from a comprehensive review of the literature was utilized.

RESULTS

Our successful scabies elimination concept includes: 1) Careful organization (formation of an outbreak management team, registration and information of all exposed individuals, prospective time management, financial calculation); 2) simultaneous clinical examination of all individuals at risk; 3) synchronous topical treatment of all exposed individuals with permethrin 5 % cream on day 0, repeated treatment of proven and doubtful cases on days 1 and 14; systemic treatment of selected cases with oral ivermectin; 4) decontamination and quarantine measures; 5) follow-up investigations and repeated treatment if indicated.

CONCLUSIONS

Management of large institutional scabies outbreaks requires a high degree of motivation, communication skills and perseverance.

Factors related to missed diagnosis of incidental scabies infestations in patients admitted through the emergency department to inpatient services

OBJECTIVES

Scabies is highly contagious and requires prompt diagnosis and implementation of infection control measures to prevent transmission and outbreaks. This study investigated the clinical and administrative correlates associated with missed diagnosis of scabies in an emergency department (ED).

METHODS

This was a retrospective study of patients with incidental scabies infestations who were admitted to a university hospital via the ED during a 4-year period.

RESULTS

A total of 135 inpatients were identified as having scabies; among them, 111 patients (82%) had visited the ED. Scabies were diagnosed during the ED stay in 39 of 111 patients (35%), while the diagnosis was missed in the ED in 72 patients (65%). Although no geographic clusters suggestive of nosocomial scabies transmission were registered, 160 medical workers and one hospitalized patient received prophylactic treatment due to direct skin-to-skin contact with inpatient scabies cases during the study period. Overcrowding (odds ratio [OR] = 8.4; 95% confidence interval [CI] = 1.9 to 38.0) and time constraints (OR = 8.2; 95% CI = 1.9 to 34.7) in the ED were associated with a missed diagnosis of scabies during ED stay. Patients with lower illness severity scores were at higher risk for failure to diagnose and to treat scabies prior to hospital admission (OR = 5.7; 95% CI = 1.6 to 20.9).

CONCLUSIONS

Missed diagnoses of scabies during ED stay may result in nosocomial spread and increase the unnecessary use of prophylactic treatments. ED overcrowding, time constraints, and less severe illness compromise ED recognition of scabies. Health care workers should be especially alert for signs of scabies infestations under these conditions.

Nosocomial scabies

Scabies is a parasitic dermatosis with a worldwide distribution. This infestation affects millions of people annually and may cause large nosocomial outbreaks with considerable morbidity among patients and healthcare workers. Immunocompromised or elderly institutionalized patients admitted with unrecognized crusted scabies are the main source of nosocomial transmission. Factors that facilitate the development of hospital-acquired scabies and nosocomial epidemics are: poor knowledge of scabies epidemiology, unfamiliarity of healthcare workers with atypical presentations, long incubation period, diagnostic delay and incomplete monitoring. Within hospitals, containment of an outbreak relies on the strict implementation of appropriate infection control measures and treatment administration to contacts. It is associated with a considerable working and economic burden.

An outbreak of scabies in a long-term care facility: the role of misdiagnosis and the costs associated with control

In August 2003, an outbreak of scabies was detected in a Canadian long-term care facility. The outbreak was likely associated with 2 index cases, 1 involving classic scabies and the other involving Norwegian scabies. The scabies control costs totaled CDN $200,000, and the facility received negative publicity for a short period after the outbreak.

Atypical presentation of scabies among nursing home residents

BACKGROUND

Scabies epidemics are not uncommon in nursing homes. Effective treatment is enhanced by prompt clinical diagnosis and early intervention. The clinical presentation of scabies may vary in older, immunocompromised or cognitively impaired persons.

METHODS

We performed a retrospective study of all residents diagnosed with scabies in a multilevel long-term care geriatric facility. The duration of the outbreak was from May to September 2000.

RESULTS

Fifteen residents contracted scabies during the outbreak. All affected residents had predominantly truncal lesions. Twelve residents had diffuse erythematous, papulosquamous lesions. Pruritus occurred in only 5 residents. Three residents with severe dementia and notably impaired functional status failed to respond to Permethrin cream (5%). All 3 residents responded to treatment with oral Ivermectin.

CONCLUSION

Older nursing home residents with scabies may present with atypical skin lesions. Residents with cognitive impairment and restricted mobility may be treatment resistant. The diagnosis of scabies should be considered in any nursing home resident with an unexplained generalized rash. Residents with dementia and severe functional impairment that fail to respond to Permethrin cream (5%) may benefit from treatment with oral Ivermectin.

An outbreak of scabies in a teaching hospital: lessons learned

OBJECTIVE

To investigate an outbreak of scabies in an inner-city teaching hospital, identify pathways of transmission, institute effective control measures to end the outbreak, and prevent future occurrences.

DESIGN

Outbreak investigation, case-control study, and chart review.

SETTING

Large tertiary acute-care hospital.

RESULTS

A patient with unrecognized Norwegian (crusted) scabies was admitted to the acquired immunodeficiency syndrome (AIDS) service of a 940-bed acute-care hospital. Over 4 months, 773 healthcare workers (HCWs) and 204 patients were exposed to scabies. Of the exposed HCWs, 147 (19%) worked on the AIDS service. Risk factors for being infested with scabies among HCWs included working on the AIDS service (odds ratio [OR], 5.3; 95% confidence interval [CI95], 2.17-13.15) and being a nurse, physical therapist, or HCW with extensive physical contact with infected patients (OR, 4.5; CI95, 1.26-17.45). Aggressive infection control precautions beyond Centers for Disease Control and Prevention barrier and isolation recommendations were instituted, including the following: (1) early identification of infected patients; (2) prophylactic treatment with topical applications for all exposed HCWs; (3) use of two treatments 1 week apart for all cases of Norwegian scabies; (4) maintaining isolation for 8 days and barrier precautions for 24 hours after completing second treatment for a diagnosis of Norwegian scabies; and (5) oral ivermectin for treatment of patients who failed conventional therapy.

CONCLUSIONS

HCWs with the most patient contact are at highest risk of acquiring scabies. Because HCWs who used traditionally accepted barriers while caring for patients with Norwegian scabies continued to develop scabies, we found additional measures were required in the acute-care hospital. HCWs with skin exposure to patients with scabies should receive prophylactic treatment. We recommend (1) using heightened barrier precautions for care of patients with scabies and (2) extending the isolation period for 8 days or 24 hours after the second treatment with a scabicide for those patients with Norwegian scabies. Oral ivermectin was well tolerated for treating patients and HCWs who failed conventional treatment. Finally, we developed a surveillance system that provides a "barometric measure" of the infection rate in the community. If scabies increases in the community, a tiered triage system is activated to protect against transmission among HCWs or hospital patients.

Crusted (Norwegian) scabies in a patient with dystrophic epidermolysis bullosa

A 13-year-old girl with severe non-mutilating recessive dystrophic epidermolysis bullosa (EB) was admitted to hospital because of a Staphyloccus aureussepsos, deterioration of her general condition and worsening of her skin disease, which itched severely. In addition to the blisters and erosions normally seen, she was covered from head to toe with scales and hyperkeratotic crusts. Despite intensive topical therapy, her skin condition did not improve significantly until scabies was detected and treated 1 week after admission. Because of the huge number of mites found and the crusted appearance, a diagnosis of crusted (Norwegian) scabies was made. She was successfully treated with two doses of ivermectin orally and one application of lindane ointment. Permethrin cream was not tolerated. In this patient crusted scabies may have developed because of: (i) a modified host response due to malnourishment; (ii) inability to scratch because of the absence of fingernails; and (iii) abnormal scratching behaviour because of the vulnerability of EB skin, or a combination of these factors. Limited isolation measures were taken on admission and full measures were taken immediately after the diagnosis of crusted scabies was made. Prophylactic treatment of ward personnel was not undertaken. Fortunately, there was not an outbreak of scabies in the hospital.

Crusted ("Norwegian") scabies in a specialist HIV unit: successful use of ivermectin and failure to prevent nosocomial transmission

A nosocomial outbreak of scabies in a specialist inpatient HIV unit resulted from a patient admitted with crusted scabies. Treatment of his infestation with topical scabicides alone failed and he remained infectious for several weeks. His infestation was then eradicated with combined topical treatment and oral ivermectin. In total, 14 (88%) out of 19 ward staff became symptomatic, and 4 (21%) had evidence of scabies on potassium hydroxide examination of skin scrapings. The ward infection control policy was changed to distinguish patients with crusted scabies from those with ordinary scabies. A second patient with crusted scabies was treated with combined oral and topical therapy early in his admission and nursed with more stringent isolation procedures. No nosocomial transmission occurred and his infestation responded rapidly to treatment. Patients with crusted scabies require strict barrier nursing if nosocomial transmission is to be avoided. Ivermectin combined with topical scabicides may be a more efficacious treatment than topical scabicides alone in such patients.

Scabies in the extended care facility. Revisited

Infestations with Sarcoptes scabiei var hominis remain a problem in nursing home patients. While the traditional signs of scabies include burrows and red papules found on the fingerwebs, chest, waist, or genitalia, the elderly or infirm patient may have only a nonspecific pruritic eruption. Epidemics in skilled care facilities may be controlled and the scabies mite even eradicated from the institutions with appropriate diagnosis and adequate treatment of both patients and personnel and their contacts.

Scabies in nursing homes: an eradication program with permethrin 5% cream

Permethrin 5% cream was used to treat scabies in three large nursing homes under a compassionate-plea protocol for chronic, therapy-resistant infestations. All residents, staff, and frequent visitors were treated whether or not symptomatic. Family members of these groups were treated either when symptomatic or directly exposed to scabies. Nine hundred ninety-five persons were treated, 202 of whom were diagnosed with scabies. Approximately 35% (111 of 313) of nursing home residents were diagnosed with scabies. These were patients in whom multiple treatments with other scabicides were unsuccessful. At the completion of the study, 195 patients were examined for efficacy of treatment. Of these, 91 (46.7%) had clearing of lesions with one medication application, 77 (39.5%) with two treatments, and 23 (11.8%) with three or more treatments. The overall cure rate was 98%. Adverse experiences occurred in 2.4% of cases and were mild (i.e., pruritus and rash).

Crusted scabies in a patient with the acquired immunodeficiency syndrome

A case of crusted (Norwegian) scabies in a patient with the acquired immunodeficiency syndrome (AIDS) is described and seven previous reports of this association are reviewed. Injury to epidermal Langerhans' cells by the human immunodeficiency virus or cytotoxic cells may explain the appearance of this unusual form of scabies in patients with AIDS.

Staphylococcus aureus colonization of burrows in erythrodermic Norwegian scabies. A case study of iatrogenic contagion

Scanning electron microscopy demonstrated extensive bacterial colonization of scabies burrows honeycombing the stratum corneum of an elderly woman with erythroderma. Cultures of scybala revealed hemolytic Staphylococcus aureus, possibly responsible for the erythroderma. Epidemiologic data revealed a trail of scabies through two nursing homes and one hospital during the 2-year period that physicians believed she had a drug-induced erythroderma.