FOCUS ON INFECTION PREVENTION Scabies: Strategies for Management and Control Sharon Bradley RN, CIC INTRODUCTION Senior Infection Prevention Analyst Scabies is a highly contagious skin infestation caused by the parasite Sarcoptes scabiei mite.1,2 The risk of scabies is increased for individuals who are immunocompromised or ABSTRACT elderly in settings where close body and skin contact is common, such as in healthcare Scabies is a highly contagious parasitic facilities or institutions.3,4 Scabies manifests in two ways: classic (typical) and crusted infestation of the skin and a clinically (atypical).3 Classic scabies is characterized by a raised rash and intense itching. In classic significant cause of morbidity, especially scabies cases, the person may be infested with 15 mites or fewer.3 Crusted scabies is a among people who are debilitated, hyper-infestation that is often unrecognized and difficult to eradicate; in this form of immunocompromised, institutional- the disease, thick crusted areas of skin contain thousands of mites.4 Mite infestation ized, or elderly. The Pennsylvania and accompanying scratching of the skin can cause lesions resulting in secondary infec- Patient Safety Authority identified tion or even death from sepsis.5,6 Scabies outbreaks can result from delayed or incorrect hundreds of scabies reports in the diagnosis or improper treatment of scabies infestation.1 Pennsylvania Patient Safety Reporting System database, including informa- SCABIES IN PENNSYLVANIA HEALTHCARE FACILITIES tion gaps in scabies-control practices. Pennsylvania Patient Safety Authority analysts queried the Pennsylvania Patient Safety Implementation of an outbreak control Reporting System (PA-PSRS) database for scabies events reported from nursing homes plan is necessary to accurately identify, from April 2014 (when nursing homes began reporting scabies) through November treat, and isolate individual scabies 2015 and from Pennsylvania hospitals and ambulatory surgical facilities (ASFs) cases and to prevent and control from June 2004 (when the acute-care facilities first began reporting events) through outbreaks and disruption of facility November 2015. Pennsylvania nursing homes are also required by PA Code § 211.1. operations. The key element to avoiding to report cases of scabies to the appropriate Division of Nursing Care Facilities field scabies outbreaks and treatment fail- office.7 The PA-PSRS scabies criteria mirrors the 2014 revised McGeer criteria for long- ures is a working knowledge of current term care.8 For more information see “Surveillance Criteria to Identify Scabies Cases.” scabies clinical indicators, surveillance, The database was searched for indication of outbreaks, which were defined as three or transmission, diagnosis, treatment, more cases within a four-week period.9 and control measures. Successful con- trol of a scabies outbreak requires a Pennsylvania nursing homes reported 484 cases of scabies and 37 outbreaks. One facility-specific outbreak control plan, hundred ten scabies events were reported from hospital inpatient, emergency, and out- including techniques for early case patient settings, as well as from ASFs, with one outbreak occurring in a psychiatric unit identification and treatment, robust (Table 1). Event report narratives from hospital and ASF settings identified problems infection and environmental controls, associated with inadequate communication to receiving units or facilities, including and protocols for communication and delays in diagnosis, treatment, and instituting precautions; cancelled surgeries; and education. (Pa Patient Saf Advis 2016 unrecognized contacts resulting in exposures. Jun;13[2]:66-73.) The following are de-identified examples of scabies event narratives reported to the Authority from hospitals and ASFs:* The patient was transferred from another facility with an active scabies infection and was targeted for standard isolation room. The handoff from the emergency department was given with no verbal or written documentation of scabies infection. Contact precau- tions were delayed and four staff members were exposed. A technician went into the patient’s room to draw blood, and the nurse told her to be careful because the patient had scabies. There was no contact-precautions sign posted to indicate this. Scan this code The physician performed scabies scraping on a patient with positive results but did not with your mobile communicate this to the nursing staff, and the patient was not on contact precautions device’s QR for four hours. reader to access the Authority's toolkit on this * The details of the PA-PSRS event narratives in this article have been modified to preserve topic. confidentiality. Page 66 Pennsylvania Patient Safety Advisory Vol. 13, No. 2—June 2016 ©2016 Pennsylvania Patient Safety Authority transmission, symptoms, diagnosis and SURVEILLANCE CRITERIA TO IDENTIFY SCABIES CASES control (Figure). Both criteria 1 and 2 must be present. TRANSMISSION Criteria 1. The following: Scabies is predominantly spread by direct ——  A maculopapular and/or itching rash skin-to-skin contact during patient care Criteria 2. At least one of the following: activities such as physical assessment or assisting with activities of daily living. ——  Physician diagnosis Mites cannot jump or fly, but they can ——  Laboratory confirmation by means of scraping or biopsy crawl about 2.5 cm per minute under the ——  Epidemiologic link to a case of scabies with laboratory confirmation skin.9,10 Scabies can also be spread by indi- Note: Rule out rashes due to skin irritation, allergic reactions, eczema, psoriasis, and rect contact with fomites such as clothing, other noninfectious skin conditions. Consider an epidemiologic linkage to a case if linens, and upholstered furniture used there is evidence of a common source of exposure. by people with crusted scabies.1 Topical lotions or medications can serve as a res- Source: Stone ND, Ashraf MS, Calder J, et al. Society for Healthcare Epidemiology Long-Term Care Special Interest Group. Surveillance definitions of infections in long-term care facilities: ervoir for mites as they can survive up to revisiting the McGeer criteria. Infect Control Hosp Epidemiol 2012 Oct;33(10):965-77. Also seven days in oil-based solutions.11 available: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538836/ Once a fertilized female mite transfers to the host’s skin by direct contact, she penetrates and tunnels under the surface A patient was transported from emer- Surgery was cancelled after admis- layer of the skin and repeatedly deposits gency [department] to imaging with sion and sedation because it was two to three eggs a day in her burrow dur- a large, red, scaly appearing rash. determined by physician that the ing her two-month lifespan.1,12 The female [Staff was] not wearing personal patient had scabies. mite is harbored in a small vesicle at the protective equipment. The techni- end of the burrow.1 The egg larvae hatch in 3 to 4 days, surface, burrow, and feed cian was not informed of the rash or SCABIES CLINICAL INDICATORS possible contagious scabies infesta- on skin cells until they mature over 7 to A working knowledge of scabies clini- 10 days, after which the fertilization and tion until returning the patient to cal indicators is critical to avoid scabies burrowing cycles repeat.1,2 Scratching the emergency [department]. There was treatment failures and outbreaks. The itchy skin can result in harboring mites no isolation band on the patient and Authority has developed a graphic under the fingernails, which then can not marked in computer or chart. displaying the key elements of scabies spread the infestation to other parts of the body, new hosts, or fomites. Table 1. Hospital and Nursing Home Scabies Cases SETTING TIME FRAME NUMBER OF CASES OUTBREAKS Hospital inpatient medical, surgical, June 2004 through 70 1 psychiatric unit outbreak specialty, and psychiatric units, November 2015 for 3 total cases imaging, and laboratories* Hospital outpatient, emergency June 2004 through 33 None reported department, and ultrasound* November 2015 Ambulatory surgical facility* June 2004 through 7 None reported November 2015 Nursing homes† April 2014 through 484 37 outbreaks ‡ November 2015 * Hospital and ambulatory surgical facility case reports found in PA-PSRS. † Nursing homes began reporting scabies cases through PA-PSRS in April 2014. ‡ Five of the 37 nursing home outbreaks totaled 272 cases. Vol. 13, No. 2—June 2016 Pennsylvania Patient Safety Advisory Page 67 ©2016 Pennsylvania Patient Safety Authority FOCUS ON INFECTION PREVENTION Scabies Transmission, Symptoms, Diagnosis, and Control Scabies mite Burrow TRANSMISSION Scabies are transferred from an infested host to a new host by skin- to-skin contact and in severe cases from infested clothing, bedding, or Rash the environment. Burrowing Female Mite SYMPTOMS Symptoms of raised rash and intense itching are caused by an allergic reaction to the mites, burrow, eggs, and fecal pellets under the skin. Eggs Fecal Pellets DIAGNOSIS Scabies mites, eggs, burrows, and fecal pellets can be identified microscopically from skin scrapings, needle removal of the mite, or by the adhesive tape test. Scabies Control- Multidisciplinary Team CONTROL AND PREVENTION  Active surveillance  Early diagnosis and treatment  Infection control precautions Scabies outbreaks can be controlled by early  Environmental and laundry diagnosis, early concurrent treatment with scabicide and environmental and textile cleaning, contact prophylaxis, education, and communication as part of a written scabies outbreak control plan. MS16370 Page 68 Pennsylvania Patient Safety Advisory Vol. 13, No. 2—June 2016 ©2016 Pennsylvania Patient Safety Authority Transmission can continue until the mites Surveillance and Outbreak methods for scabies, Leung and Miller and eggs are killed by treatment, environ- Criteria describe the key steps to perform an mental disinfection, or after three to four A high suspicion of scabies is warranted accurate skin scraping or burrow ink test.16 days off the skin.1 Persons with severe or in persons with persistent, undiagnosed Katsumata and Katsumata described a crusted scabies can shed thousands of live rashes and itching, new complaints of simple method to detect scabies by trans- mites into the environment.1,3 rash and itching every four to six weeks, ferring mites from the patient’s skin on thick crusted skin surfaces, or if there is the sticky side of transparent adhesive Symptoms evidence of a common source of expo- tape to a slide, enabling microscopic A person infested with typical scabies sure to an active case.4 Surveillance and visualization of mites moving around usually presents with severe itching inten- case findings are critical to determine in the space between the slide and the sified at night, a generalized raised or the location and scope of an outbreak, tape. Detecting mites by this method is blistered rash on the skin folds of fingers, the possible outbreak source person, its most effective when the tape is applied buttocks, genitalia, breasts, wrists, elbows, ongoing transmission, and the end of the to the thin skin of the toes and fingers.17 and axilla, or lesions associated with outbreak; reporting and communicating For more information, see “Key Steps to burrows. According to the Centers for with outside sources, such as the local Identify Scabies.” Disease Control and Prevention (CDC), health department, also is critical. Scabies can be misdiagnosed as psoriasis, the rash in bedbound patients may be The New Jersey Department of Health eczema, contact dermatitis, impetigo, more noticeable on patients’ backs, but- has defined a scabies outbreak in a long- insect bites, or non-specific dermatitis.15 tocks, and legs.3 An allergic reaction term care or residential facility as “one The severity of the infestation may prog- to the mites, their saliva, eggs, or fecal or more laboratory confirmed cases of ress extensively before being noticed, material results in the rash and itching.5 scabies (via positive skin scraping), or at because of the long incubation period in Scabies mites are microscopic, but the least two clinically suspected cases (clini- first-time cases or misdiagnosis and subse- burrows may be visible with a handheld cally diagnosed and treated individuals) quent delay in treatment, which provides magnifying glass as centimeter-long, tiny, in residents, healthcare providers, visitors a significant opportunity to transmit grayish-white or red raised wavy lines or volunteers within a four-week period the scabies mite to others. CDC recom- under the skin.12 of time.”9 The Pennsylvania code of mends consulting with a dermatologist The first time a person is infested with communicable and non-communicable experienced in confirming the diagnosis scabies, he or she may have no symptoms diseases defines an outbreak as an of scabies, and in cases of crusted scabies, during the four- to six-week incubation unusual increase in the number of cases ensuring that a staff member is trained to period but can still spread mites during of a disease, infection or condition, perform a microscopic skin scraping for this time.13 Individuals with previous whether reportable or not as a single case, scabies mites and material.4 scabies infestations are more sensitive above the number of cases that a person and become symptomatic in one to four required to report would expect to see in Treatment days. Delayed diagnosis or treatment and a particular geographic area or among a Synchronous treatment is appropriate for scratching, which opens a portal of entry subset of persons (defined by a specific the infested person, for those with close for pathogens, may result in secondary demographic or other features.14 personal contact with an infested person skin infections such as bacterial skin in the previous four weeks, or in the case infections, impetigo, cellulitis, or post- Diagnosis of crusted scabies, for those who have had streptococcal glomerulonephritis.5,6 Scabies can be diagnosed by the clinical contact with the linens or environment Crusted scabies can manifest as hyperker- manifestation; an ink test to identify a of the infested person.13 Prescription atotic nails and thick crusts or scales on burrow; the examination of skin scrap- scabicides are used to kill scabies mites the skin harboring thousands of scabies ings for mites, their eggs, or fecal matter and their eggs.13 Carefully select a scabi- mites and eggs.6 These thick, sometimes using a microscope (dermatoscopy); or by cide: some products may not be safe for fissured crusts generally involve the hands an adhesive tape test to visualize mites.15-17 children or pregnant women, may cause and feet but can be found elsewhere on A negative skin scraping might not rule skin irritation, or may be neurotoxic. the body.6 The presence of itching may be out active scabies because the small num- The advantages, disadvantages, and con- variable in persons with crusted scabies or ber of mites in a classic scabies case may tradictions for specific medications and altered immune response.10 make the burrows hard to visualize.3 In treatment regimens are detailed on the a 2011 systematic review of diagnostic CDC scabies website.18 Vol. 13, No. 2—June 2016 Pennsylvania Patient Safety Advisory Page 69 ©2016 Pennsylvania Patient Safety Authority FOCUS ON INFECTION PREVENTION the scabicide under fingernails and toe- KEY DIAGNOSTIC STEPS TO IDENTIFY SCABIES nails.10,18,19 Avoid skin-to-skin contact for at least eight hours after treatment.20 Burrow Ink TEST1 Persistent itching may be present for ——  Identify the burrow using a handheld magnifying glass in an area not excoriated several weeks after treatment as the dead by scratching. mites, eggs, eggshells, and fecal pellets ——  Gently rub ink from a felt tip or fountain pen over a suspected burrow. emerge from the burrows.9,13 If weekly ——  Gently wipe off the excess ink with an alcohol swab. skin assessments find persistent itching or ——  Visualize the burrow where the ink has been absorbed into the burrow tunnel. new burrows more than two to four weeks after the last treatment, repeat treatment Skin Scraping (Dermatoscopy)2 may be necessary.9,20 Suspect treatment ——  Identify the burrow using a handheld magnifying glass or the burrow ink test in failure when persistent, intensified or new an area not excoriated by scratching. lesions appear within two to four week of ——  Prepare the skin site and the slide with a drop of mineral oil. treatment. For more information, see “Key ——  Gently scrape the skin off the burrow with a blunt scalpel blade or the edge of Factors is Scabies Treatment Failures.” the glass slide. OR SCABIES OUTBREAK CONTROL ——  Use the tip of a sterile needle and a drop of mineral oil to remove the scabies PLAN mite from the end of its burrow. An outbreak control plan is essential to ——  Place a cover slip over the slide and repeat for about 4 to 6 scrapings for each prevent the morbidity, potential mortality, patient. and significant operational burden associ- ——  Transfer the slide to the laboratory or have a trained person examine the slide ated with a scabies outbreak. Outbreaks under a microscope. often result in the following: Adhesive tape TEST3 —— Unplanned use of scarce facility ——  Cut a section of strong transparent adhesive tape the same size as a glass slide. resources to manage infected patient ——  Press the strip of adhesive tape onto a suspected scabies lesion on the patient’s —— Staff sick leave and overtime skin. —— Additional healthcare supplies and ——  Wait several seconds, then pull tape off the skin. cleaning expenses ——  Transfer the adhesive side of the tape directly onto a glass slide. —— Lost revenue from temporary clo- ——  Use a microscope to visualize mites between the slide and the tape. sures of affected units —— Irrational panic among staff Notes 1. Leung V, Miller M. Detection of scabies: a systematic review of diagnostic methods. Can J A written outbreak control plan is best Infect Dis Med Microbiol 2011;22(4):143-6. coordinated with a multidisciplinary 2. Cahill CK, Rosenberg J, Schweon SJ, et al. Scabies surveillance, prevention, and control. team. A robust plan includes developing Ann Long Term Care 2009 Apr 22;17(4):31-5. and implementing measures for early 3. Katsumata K, Katsumata K. Simple method of detecting sarcoptes scabiei var hominis detection and treatment of new scabies mites among bedridden elderly patients suffering from severe scabies infestation using an cases, using contact prophylaxis, employ- adhesive-tape. Intern Med 2006;45(14):857-9. ing infection and environmental controls, ensuring good communication, and pro- viding education.20 It is essential to review and confirm the effectiveness of outbreak- Synchronous treatment with both an Softening and removing scaly crusts control activities after an outbreak has oral antiparasitic and a topical scabicide from the skin and from under the nails resolved.9 The Authority’s accompanying has been effective for cases of crusted enhances penetration of the scabicide. Scabies Outbreak Control Checklist scabies or failed treatment, and oral This can be accomplished by loosening tool (http://patientsafetyauthority.org/ alone for cases of intolerance to topical the hardened skin with application of a EducationalTools/PatientSafetyTools/ solutions.1,13,18 Crusted scabies requires at keratolytic agent, brushing off the crusts, Pages/home.aspx) provides a structure least two treatments, about a week apart.4 and trimming the nails and massaging to identify gaps in readiness plans, Page 70 Pennsylvania Patient Safety Advisory Vol. 13, No. 2—June 2016 ©2016 Pennsylvania Patient Safety Authority Infection and Environmental KEY FACTORS IN SCABIES TREATMENT FAILURES Controls The following actions provide infection ——  Incorrect diagnosis.1 and environmental control: ——  Failure to follow the topical scabicide directions for first and second applications.1 —— Institute contact precautions for ——  Insufficient penetration of scabicide into crusted lesions or under nails.1 patient care, housekeeping, and ——  Re-infestation due to continued exposure to other, active scabies cases.1 laundry activities until 24 hours ——  Failure to remove mites from linens and the environment.1 after treatment is started for indi- ——  Failure of immunosuppressed patients to respond to treatment.2 viduals with scabies, and clean the environment.1,4,9 Notes —— Provide clear descriptions about how 1. Management of scabies in long-term care facilities, schools and other institutions. [internet]. to implement contact precautions Trenton (NJ): New Jersey Department of Health; 2014 Jul [accessed 2014 Jan 18]. [21 p]. for scabies; consider practicing job- Available from Internet: http://www.state.nj.us/health/cd/documents/faq/scabies_guidance.pdf specific steps in a clinical scenario or 2. Cahill CK, Rosenberg J, Schweon SJ, et al. Scabies surveillance, prevention, and control. simulation exercise. Ann Long Term Care 2009 Apr 22;17(4):31-5. —— Consider enhanced precautions for persons with crusted scabies, including separating from classic investigate scabies cases, and control out- —— Train a clinician to perform skin scabies cases, cohorting staff, and breaks. Control measures are considered scrapings in the event of a persistent continuing contact precautions effective and the outbreak resolved when outbreak and ensure access to testing until successful treatment has been no new cases are identified within two six- supplies.4 verified.4 week incubation periods or twelve weeks. —— Treat all infested persons and their —— Synchronize environmental cleaning This allows for weekly assessment and rec- asymptomatic contacts at the same with treatment or prophylaxis.9 ognition of asymptomatic secondary cases time to avoid reinfestation.20 —— Limit visitors or require use of PPE.20 while still in the incubation period.1,9 —— Furlough healthcare workers with —— Remove or kill scabies mites by col- symptoms of scabies until 24 hours lecting fabrics used in at least the Early Detection and Treatment after treatment. Continue the use of last 3 days in a plastic bag, then wash The following actions provide early detec- personal protective equipment (PPE) and dry on the hot cycle (122 degrees tion and treatment: for a few days to be sure they are no Fahrenheit), dry clean, or remove —— Institute heightened surveillance dur- longer infested.9,21 from use or body contact for at least ing admission assessments for rapid —— Provide prophylactic treatment for 72 hours.3 detection of symptoms and second- everyone who has had skin-to-skin —— Disinfect shared equipment such as ary infections.3,4,9 contact with individuals with scabies wheel and shower chairs and blood —— Confirm cases and outbreak or exposure to the environment of pressure cuffs.9 definitions, and discuss control individuals with crusted scabies.4,20 —— Thoroughly vacuum room, furniture, strategies with local or state health —— Consider facility-wide mass prophy- and carpet daily to remove contami- departments.4,6 laxis for residents, staff, volunteers, nated skin cells shed from crusted —— Institute a line listing to track and and others, based on several factors: scabies cases. Change vacuum bag identify the index case, trends, time- * The amount of time diagnosis, daily.3,9 lines, and locations for patient, staff, treatment, and isolation was and volunteer or family cases.20 delayed Communication and Education —— Use a line patient and staff listing * The number of symptomatic or To provide communication and educa- to track outbreak parameters; one suspected cases tion, take the following steps: is available at: http://patientsafe- * The mobility of patients and staff —— Communicate job-specific informa- tyauthority.org/EducationalTools/ * Whether there are any cases of tion explaining scabies transmission, PatientSafetyTools/Pages/home.aspx. the highly transmissible crusted symptoms, surveillance, diagnosis, scabies1,20 and treatment. Reinforce required Vol. 13, No. 2—June 2016 Pennsylvania Patient Safety Advisory Page 71 ©2016 Pennsylvania Patient Safety Authority FOCUS ON INFECTION PREVENTION activities using educational modali- ASFs because the HAI event taxonomy failures through PA-PSRS event reports. ties such as simulation exercises or in PA-PSRS does not include scabies Much of the morbidity, mortality, and posters and handouts of scabies fact infestations. In Pennsylvania, hospitals are operational disruption associated with sheets.20 obligated to report infections only to the scabies outbreaks is preventable. The —— Train and hold healthcare workers CDC National Healthcare Safety Network most important risk-reduction strategies accountable for identifying, report- (NHSN), which does not collect reports are timely and accurate identification, ing, and documenting suspicious on scabies infestations. Additionally, treatment, and isolation of scabies cases; skin conditions.1 scabies outbreak definitions vary from environmental control; and development —— Establish a multidisciplinary process state to state. Finally, the nursing home of a facility-specific outbreak control and accountable personnel to iden- reporting system captures criteria but not plan. For this reason, it is important to tify and notify contacts, institute narrative information. raise awareness and identify the gaps in a visitor restrictions, and coordinate In terms of limitations in healthcare set- healthcare facility’s ability to respond to local and state health department tings, in a setting such as nursing homes, scabies before an outbreak ensues. The and media contacts as necessary.9,20 it can be challenging to access a micro- Authority’s Scabies Outbreak Control scope or obtain a dermatology consult for Checklist can be a useful tool to identify —— Establish a relationship with a con- timely diagnosis. gaps in facility practices and to target sultant dermatologist to provide resources and accountability for imple- information and dermatologic con- mentation of appropriate risk reduction sultation to individuals with scabies CONCLUSION strategies. or their contacts.1,9 Pennsylvania hospitals, ASFs, and nursing homes have reported scabies cases, out- Acknowledgment Limitations breaks, and delays in diagnosis, treatment, Edward Finley, BS, Senior Data Analyst, Limitations of this study are that scabies Pennsylvania Patient Safety Authority, provided and isolation, as well as communication data analysis expertise. may be under-reported in hospitals and NOTES 1. Cahill CK, Rosenberg J, Schweon SJ, et al. 6. McCarthy JS, Kemp DJ, Walton SF, nursing home residents. J Gerontol A Biol Scabies surveillance, prevention, and Currie BJ. Scabies: more than just Sci Med Sci 2001 Jul;56(7):M424-7 control. Ann Long Term Care 2009 Apr an irritation. Postgrad Med J 2004 11. Arias KM. Association for Professionals 22;17(4):31-5. Jul;80(945):382-7. Also available: http:// in Infection Control and Epidemiology. 2. Scabies—epidemiology and risk factors. dx.doi.org/10.1136/pgmj.2003.014563 Quick reference to outbreak investigation [internet]. Atlanta (GA): Centers for Dis- 7. Title 28, Pennsylvania Code, § 211 - Pro- and control in healthcare facilities. Gaith- ease Control and Prevention (CDC); 2010 gram standards for long-term care nursing ersburg (MD): Aspen Publishers; 2000. Nov 2 [accessed 2016 Jan 18]. Available: facilities. http://www.pacode.com/ Organisms and disease associated with http://www.cdc.gov/parasites/scabies/ secure/data/028/chapter211/chap211toc. outbreaks. p. 144-6. epi.html html. 12. Scabies—biology. [internet]. Atlanta (GA): 3. Scabies—general information FAQs. [inter- 8. Stone ND, Ashraf MS, Calder J, et al. Centers for Disease Control and Preven- net]. Atlanta (GA): Centers for Disease Society for Healthcare Epidemiology tion (CDC); 2010 Nov [cited 2016 Jan 18]. Control and Prevention (CDC); 2010 Long-Term Care Special Interest Group. http://www.cdc.gov/parasites/scabies/ Nov [cited 2016 Jan 18]. Available: http:// Surveillance definitions of infections biology.html www.cdc.gov/parasites/scabies/gen_info/ in long-term care facilities: revisiting 13. Scabies—treatment. [internet]. Atlanta index.html the McGeer criteria. Infect Control Hosp (GA): Centers for Disease Control and 4. Scabies—crusted scabies cases (single or Epidemiol 2012 Oct;33(10):965-77. Also Prevention (CDC); 2015 Sep [cited 2016 multiple). [internet]. Atlanta (GA): Cen- available: http://www.ncbi.nlm.nih.gov/ Jan 18]. http://www.cdc.gov/parasites/ ters for Disease Control and Prevention pmc/articles/PMC3538836/ scabies/treatment.html (CDC); 2010 Nov 2 [cited 2016 Jan 18]. 9. Management of scabies in long-term care 14. Title 28, Pennsylvania Code, § 27 - Com- Available: http://www.cdc.gov/parasites/ facilities, schools and other institutions. municable and non-communicable scabies/health_professionals/crusted.html [internet]. Trenton (NJ): New Jersey diseases. http://www.pacode.com/secure/ 5. Scabies—disease. [internet]. Atlanta (GA): Department of Health; 2014 Jul [cited data/028/chapter27/chap27toc.html Centers for Disease Control and Preven- 2014 Jan 18]. [21 p]. http://www.state. 15. Scabies—diagnosis. Atlanta (GA): Cen- tion (CDC); 2010 Nov 2 [cited 2016 Jan nj.us/health/cd/documents/faq/ ters for Disease Control and Prevention 18]. Available: http://www.cdc.gov/ scabies_guidance.pdf (CDC); 2010 Nov [cited 2016 Jan 18]. parasites/scabies/disease.html 10. Wilson MM, Philpott CD, Breer WA. http://www.cdc.gov/parasites/scabies/ Atypical presentation of scabies among diagnosis.html Page 72 Pennsylvania Patient Safety Advisory Vol. 13, No. 2—June 2016 ©2016 Pennsylvania Patient Safety Authority 16. Leung V, Miller M. Detection of sca- 18. Scabies—medications. Atlanta (GA): Cen- Control and Prevention (CDC); 2010 bies: A systematic review of diagnostic ters for Disease Control and Prevention Nov 2 [accessed 2016 Jan 18]. Available: methods. Can J Infect Dis Med Microbiol (CDC); 2015 Sep 15 [cited 2016 Jan 18]. http://www.cdc.gov/parasites/scabies/ 2011;22(4):143-6. http://www.cdc.gov/parasites/scabies/ prevent.html 17. Katsumata K, Katsumata K. Simple health_professionals/meds.html 21. Scabies—workplace frequently asked ques- method of detecting sarcoptes scabiei var 19. Paasch U, Haustein UF. Management of tions (FAQs). [internet]. Atlanta (GA): hominis mites among bedridden elderly endemic outbreaks of scabies with alle- Centers for Disease Control and Preven- patients suffering from severe scabies thrin, permethrin, and ivermectin. Int J tion (CDC); 2013 Jul 19 [cited 2016 Jan infestation using an adhesive-tape. Intern Dermatol 2000 Jun;39(6):463-70. 18]. http://www.cdc.gov/parasites/ Med 2006;45(14):857-9. 20. Scabies—prevention and control. [inter- scabies/gen_info/faq_workplace.html net]. Atlanta (GA): Centers for Disease Vol. 13, No. 2—June 2016 Pennsylvania Patient Safety Advisory Page 73 ©2016 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 13, No. 2—June 2016. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. 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