報 告 者 ： 陳寶珍 督 導 參與人員： 屠治宇 副院長 呂云傑 醫 師 林美吟 藥 師 吳美淑 副護理長 實證醫學 病例討論報告 報 告 者 ：　陳寶珍 督　導 參與人員：　屠治宇 副院長 　　　　　　　　 　呂云傑 醫　師 林美吟 藥　師 　　　　 吳美淑 副護理長

臨床場景(clinical scenario) 感控室發現最近有一個問題，即同一病房中爆發3例疥瘡(Scabies)感染，因醫療人員需長期接觸病人，為預防感染擴大，故感控室考慮是否讓護理站工作人員使用治療疥瘡之藥物，不知道如何處理才最適當? 2018/12/5

Foreground question 爆發疥瘡(Scabies)感染，醫療人員接觸者是否須要使用治療疥瘡藥物來預防？ 2018/12/5

P I C O Patient 疥瘡感染接觸者 Intervention 使用疥瘡藥物預防治療 Comparison 不使用抗疥瘡藥物預防治療 Outcome 感染控制成效 2018/12/5

Searching strategies 先從已經過評讀的database開始找起(system,synopses,synthesis) 最後再找尚未經過嚴格評讀的study 2018/12/5

Searching for the best evidence Key words Scabies Contact Outbreak Nosocomial Infection control Prevention Cross infection Drug Benzyl benzoate 、Melathion 、crotamiton、gama benzene hexachloride、lindane、permethrin、ivermectin 2018/12/5

Database selection Best evidence (Prefiltered) databases UpToDate ACP journal club Cochrane database of systematic reviews PubMed Clinical Queries Primary (Unfiltered) databases PubMed 遠距圖書系統 思博網(EPS)中文電子期刊服務 2018/12/5

UpToDate 關鍵字:Scabies prevention 搜尋結果 2018/12/5

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ACP Journal Club 關鍵字:Scabies 搜尋結果: 1 articles 2018/12/5

Cochrane Library 關鍵字: Scabies+infection control 搜尋結果: 4 articles 2018/12/5

PubMed Clinical Queries 關鍵字:Scabies+Prevention 搜尋結果: 4 articles 2018/12/5

Best evidence (Prefiltered) databases Total 10 articles Exclusion 6 articles Inclusion 4 articles UpToDate Sexually transmitted diseases treatment guidelines 2002. Centers for Disease Control and Prevention. CDC MMWR Recomm Rep. 2002 May 10;51(RR-6):1-78 European guideline for the management of scabies Int J STD AIDS; 2001; Oct; 12;supp 3; 58-61 Interventions for treating scabies(review) cochrane database of systematic review 2018/12/5

Management of Sex Partners and Household Contacts Sexually transmitted diseases treatment guidelines 2002. Centers for Disease Control and Prevention. Management of Sex Partners and Household Contacts Both sexual and close personal or household contacts within the preceding month should be examined and treated. Management of Outbreaks in Communities, Nursing Homes, and Other Institutional Settings Scabies epidemics often occur in nursing homes, hospitals, residential facilities, and communities. Control of an epidemic can only be achieved by treatment of the entire population at risk. Ivermectin can be considered in this setting, especially if treatment with topical scabicides fails. 2018/12/5 CDC MMWR Recomm Rep. 2002 May 10;51(RR-6):1-78

European guideline for the management of scabies Indication for therapy Characteristic clinical finding High-risk contact persons with protracted or frequent skin contact (e.q. via hands) should be treated whether or not they have symptoms. Low-risk contacts Persons with indirect contract (e.q. via bedding) only require treatment in case of crusted scabies. Recommended regimens Permethrin 5% (once for 8-12 hours) Lindane 1% (once for 8-12 hours) Benzyl benzoate 25% (thrice, for 24 hours each day) Sulphur (6-33%) Other: Crotamiton 10%, allethrin, malathion 0.5% 2018/12/5 Int J STD AIDS; 2001; Oct; 12;supp 3; 58-61

Primary (Unfiltered) databases 檢索策略和檢索功能 PubMed 控制字彙(MeSH) 自然語言 中文期刊篇目索引影像系統 思博網(EPS)中文電子期刊服務 2018/12/5

PubMed Searching strategies ("Scabies / drug therapy"[Mesh] OR "Scabies / epidemiology"[Mesh] OR "Scabies / nursing"[Mesh] OR "Scabies / prevention and control"[Mesh] OR "Scabies / therapy"[Mesh] OR "Scabies / transmission"[Mesh]) AND ("Cross Infection / drug therapy"[Mesh] OR "Cross Infection / epidemiology"[Mesh] OR "Cross Infection / nursing"[Mesh] OR "Cross Infection / prevention and control"[Mesh] OR "Cross Infection / therapy"[Mesh] OR "Cross Infection / transmission"[Mesh]) AND "prevention and control "[Subheading] 2018/12/5

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When should you treat scabies empirically? long stretches without symptoms play role in treatment No controlled trials address whether empiric treatment of asymptomatic contacts or family members of those with scabies decreases its spread One case-control study, performed at a large tertiary-care teaching hospitalHealth care workers with more skin-to-skin contact with the patients (nurses, nursing students, and physical therapists) were 4.5 times more likely to develop scabies compared with those in less physical contact (physicians, medical students, and occupational therapists). Among the symptomatic health care workers, 17% of their household contacts developed scabies, too. 2018/12/5 VOL 56, NO 7 / JULY 2007 THE JOURNAL OF FAMILY PRACTICE

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●關鍵字:Scabies ●搜尋結果:5 articles 2018/12/5

關鍵字:Scabies 搜尋結果:4articles 2018/12/5

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Critical appraisal of Evidence No controlled trials address whether empiric treatment of asymptomatic contacts . Epidemiology Prevalence rate range from 11% to 21% (Vorou et al., 2007: Chambliss et al., 2000) Nurse,nursing students, and physical therapists are more 4.5 time more likely to develop scabies compared with those in less physical contact (physicians, medical students, and occupational therapists) (Page et al., 2007) Care report 29 indivdual including 4 inpatients and 25 personnel (Huseh et al., 1992) 27 cases occurred among 14 health care personnel and 13 patients ( Spanish, 2000) 17 cases were reported 11 healthcare workers and 6 patients (Larrosa et al., 2003) 2018/12/5

Critical appraisal of Evidence Expert opinion or consensus CDC Control of an epidemic can only be achieved by treatment of the entire population at risk UpToDate usual recommendations are that all members of the family and close contacts be treated at the same time to avoid an endless chain of cross contamination and reinfestation Hierarchy of evidence Case-control study Case report Expert opinion 2018/12/5

謹慎的文獻評讀 2018/12/5

Applicability 爆發疥瘡(Scabies)感染，醫療人員接觸者是否須要使用治療疥瘡藥物來預防？ Because scabies is transmitted by close or skin-to-skin contact, usual recommendations are that all members of the family and close contacts be treated at the same time to avoid an endless chain of cross contamination and reinfestation. Scabies epidemics often occur in nursing homes, hospitals, residential facilities, and communities Control of an epidemic can only be achieved by treatment of the entire population at risk. Contact should be treated simultaneously, regardless of symptoms, and provided with written instructions No controlled trials address whether empiric treatment of asymptomatic contacts or family members of those with scabies decreases itsspread. However,it is known that an initial infestation with scabies will not lead to pruritus fof up to 4 to 6 weeks. Asymptomatic contacts can be infected with scabies,and can transmit this infection to others before symptoms even occur. 2018/12/5

Thank you for your attention!!