Did you think that it might be scabies? Identification of a case of Norwegian scabies on an acute care medical-surgical unit

Abstract

BACKGROUND: Norwegian Scabies is a variant form of normal scabies caused by the parasitic mite, Sarcoptes scabei. The mite load and contagiousness of Norwegian (or crusted) scabies is extremely high. Typical scabies is difficult to transmit from patient to healthcare worker unless there is prolonged, unprotected skin-to-skin contact between the infested person and the healthcare worker. Persons with atypical or crusted scabies harbor hundreds to millions of mites in layers of crusted skin lesions. Additionally any exposure to contaminated bedding or upholstered furniture in close proximity to a patient with crusted scabies may be a source of transmission. The diagnosis of Norwegian Scabies can be difficult. This was the case at our 117-bed northern California acute care hospital. The index patient was a 72-year-old female admitted on May 12, 2004, with a diagnosis of weakness, severe dermatitis, shortness of breath, hypothermia, and rule-out sepsis. On May 28, 2004, a punch biopsy revealed the conclusive diagnosis of Norwegian scabies. PROJECT: Upon notification of the diagnosis, a multidisciplinary team was formed including the infectious disease chief, infection control manager, dermatology, employee health, in-patient and outpatient pharmacy, environmental services, medical-surgical leadership, director of quality, hospital leadership, and the county public health communicable disease department. Clear and concise communication was a key component of our rapid response. Contact precautions were implemented immediately upon notification of the diagnosis. Data collection consisting of a line listing of names of staff members who had cared for the patient prior to contact precautions was initiated. We did not have a policy and procedure specific to a scabies outbreak, but we did have an outbreak policy as well as the California Department of Health Services Division of Communicable Disease Control “Management of Scabies Outbreaks in California Health Care Facilities” to follow. Using the two documents as guidelines, we developed an outbreak definition, surveillance data collection document, and decided on an effective treatment plan for patients and staff. RESULTS: A total of 368 staff and patients were prophylaxed with permethrin cream, and 252 discharged patients notified and offered prophylaxis. CONCLUSIONS: Bedside staff learned an important lesson related to thinking of non-intact skin and the possibility of scabies and our team approach proved to be very successful with a total of only 19 secondary cases.