Outbreaks in the Nursing Home: Responding Responsibly

When scabies, bedbugs, and other infestations impact the nursing homes, pharmacists can help staff and patients cope.

Outbreaks and infestations can create panic in nursing home environments. Infestation by human-colonizing insects or mites creates health care expenses, increases labor costs, and reduces productivity. Almost without exception, an outbreak of a contagious disease or an infestation with a nuisance organism means that daily routines are disrupted as staff implement numerous labor-intense procedures to right things. Pretty soon, staff and residents alike begin scratching as psychogenic itching or acarophobia starts.

Due to the drugs they dispense and information they provide, pharmacists make for critical teammates during outbreaks. If vermin are reported in your community—eg, bedbugs, scabies, ticks, lice—all health care clinicians should maintain a “high index of suspicion” about possible outbreaks or infestations. Often, they spread to nursing homes and their vulnerable elders with remarkable speed.¹

A Bug by Any Other Name…

Let’s simply call these infestations “vermin,” and acknowledge that they are the enemy. Eliminating vermin means waging war, and knowing the enemy is a prudent step in any war. Whether staff reports seeing wingless, reddish-brown, flattened ovals (bedbugs; Cimex lectularius) crawling on sheets, or residents have intense nocturnal itching, with or without a connect-the-dots-appearing rash (scabies; Sarcoptes scabiei), pharmacists need to know how to identify and eradicate each culprit. The Centers for Disease Control and Prevention’s (CDC’s) Web site provides excellent information to help identify/recognize invaders.^2,3

Any clinician who states with certainty that he or she can “eyeball” a rash on a nursing home resident and identify it puts the nursing home at risk—it’s simply not possible.^2,3 Elders, especially immunocompromised elders, may not present typical symptoms when bitten by or exposed to vermin. Elders’ symptoms may mimic a variety of conditions, and a good individual and collective history is needed (Table).

For example, bedbugs can be asymptomatic or cause itchy, bloody welts. Bedbug-eaten skin can look like pruritic papules, wheals, vesicles, or bullae, as can a scabies outbreak and a number of other skin infestations.^3-7 In addition, cognitively impaired residents may ignore itching or overreact, creating gaping wounds with their fingernails.

Know the Vermin

Clinicians sometimes don’t know where to start in terms of identifying the outbreak or infestation. The CDC’s Web site is a first step, but a concurrent step is to call local officials. Most vermin can be confirmed in the facility’s laboratory or by state or local public health officials. If staff can collect a sample or samples, positive identification leads to definitive diagnosis and can help direct efforts efficiently.

With any outbreak, all residents and staff should be checked for signs and symptoms, especially those who occupy adjacent rooms, socialize together, or provide care to affected residents. Infestations often arrive with new admissions, especially when infested patients are transferred from an infested home or between institutions. During periods of epidemic outbreaks, some facilities may choose to or be forced to suspend admissions and transfers.^1-4

Teamwork among health care providers is rarely more important than during an outbreak. With definitive eradication as the goal, pharmacy needs to collaborate with environmental services or housekeeping, nursing, and the infection control officer closely. Most facilities use integrated pest management (IPM), an effective and environmentally sensitive approach to vermin eradication. The facility’s infection control officer is the best source of information about the specific IPM used.

IPM combines commonsense practices like hygiene and pesticide application, and considers vermin’s life cycles and their interaction with people and the environment. Elements of a comprehensive IPM program include monitoring for infestation. The exact monitoring method will vary with the suspected or confirmed infestation, but usually involves having gloved staff use flashlights and magnifying glasses to visually inspect residents. In the case of bedbugs, specially trained dogs are often used to sniff out nests.

IPM also specifies when and how to remove clutter or dispose of infested furniture or belongings that are beyond salvage. It describes effective eradication methods (eg, combs for lice, vacuuming and medication for lice and scabies, heat treatment for bedbugs). It will describe appropriate chemical pesticides and their judicious use.^4,8-10

Will This Ever End?

It’s normal to feel frustrated, taxed, and a little pruritic when vermin invade—and it can feel like the infestation goes on forever. The health care brigade must target treatment to specific symptoms and vermin eradication—a general shotgun approach wastes resources and time. Some interventions include symptomatic antihistamine use and topical corticosteroids. If infection develops, appropriate topical or oral antibiotics based on infection type will be necessary.^3,5,11

Depending on the outbreak or infestation, mass prophylaxis, treatment, or intervention may or may not be necessary. The health care team can provide background about the specific outbreak in the area; provide guidance on how to deal with the problem; and will always remind staff that treatment can cause adverse events, so unless it is needed, it should not be used.

Treatment frequently fails, especially when bedbugs invade, and usually reflects the infesting agent’s tenacity and pesticide resistance. Vermin can infest areas chronically and can occasionally lead to significant morbidity. Although the phrase “7-year itch” was first used to describe a persistent, undiagnosed scabies infestation,¹² it could apply to bedbugs or lice. Once residents develop chronic unrelieved itching and scratching, secondary bacterial infections and later cellulitis, lymphangitis, and acute glomerulonephritis are possible, as is anemia.^7,13,14

Vermin infestations cause emotional suffering in addition to physical symptoms. Extreme anxiety, insomnia, paranoia, and stress are common. Many symptoms worsen at night because the vermin are nocturnal or the affected individual has nothing else to distract from the pruritis, ^15,16 causing residents and staff to lose sleep as they worry that they may have “cooties.” Others may be overly vigilant if they think they have been exposed. Staff, nursing home residents, and their guests and families may need emotional support and ongoing reassurance after the vermin has been eradicated.

The Pharmacist’s Role

Pharmacists with an interest in infection control can help the infection control officer, medical director, and facility administrator develop appropriate policies in conjunction with the IPM plan, based on local health department guidance and national guidelines.

In elders, pharmacists should consider any order for medication for an itchy rash not necessarily a red flag, but a subtle clue that bedbugs, scabies, lice, or other vermin may be a problem. This is especially true if other high-risk facilities—schools, daycare facilities, jails, etc—are experiencing outbreaks.^1,7

Pharmacists should always expect the next outbreak. Consider bedbugs,1 first identified 2500 years ago and epidemic ever since—except when they have been pandemic. They become pandemic at approximately 30-year intervals, partially coinciding with military activities and major social upheavals.^1,17,18 Bedbugs are now considered pandemic in several areas of the country.

If crotamiton, ivermectin, or permethrin are employed, they should be used aggressively, especially if residents have atypical, crusted rashes. Use caution when prescribing lindane; the FDA issued an advisory emphasizing that it is a second-line treatment, because the risk of adverse reaction is great in children and adults weighing less than 110 lb. In addition, pharmacists should remind staff to trim residents’ nails and treat the underside of the nail as well as possible.^12,19,20

End Note

Vermin aren’t just offensive, extremely annoying, or unpleasant. They also cause damage and disease that is costly in terms of quality of life and resource utilization. Pharmacists who understand the etiology and pathophysiology of vermin infestation and know the pharmacodynamic and pharmacokinetic profiles of OTC and prescription treatments are well positioned to help. PT

Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy and a freelance writer from Virginia.

References

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2. Reinhardt K, Harder A, Holland S, Hooper J, Leake-Lyall C. Who knows the bed bug? knowledge of adult bed bug appearance increases with people’s age in three counties of Great Britain. J Med Entomol. 2008;45:956-958.

3. Zhu YI, Stiller MJ. Arthropods and skin diseases. Int J Dermatol. 2002;41:533-549.

4. US Centers for Disease Control and Prevention (CDC) and the US Environmental Protection Agency (EPA). Joint statement on bedbug control in the United States. www.cdc.gov/nceh/ehs/publications/bed_bugs_cdc-epa_statement.htm. Accessed September 26, 2011.

5. Liebold K, Schliemann-Willers S, Wollina U. Disseminated bullous eruption with systemic reaction caused by Cimex lectularius. J Eur Acad Dermatol Venereol. 2003;17:461-463.

6. Parish LC, Witkowski JA. The bedbugs never left. Skinmed. 2004;3:69-70.

7. Sansom JE, Reynolds NJ, Peachey RD. Delayed reaction to bed bug bites. Arch Dermatol. 1992;128:272-273.

8. Hurst S, Humphreys M. Bedbugs: not back by popular demand. Dimens Crit Care Nurs. 2011;30:94-96.

9. Pfiester M, Koehler PG, Pereira RM. Ability of bed bug-detecting canines to locate live bed bugs and viable bed bug eggs. J Econ Entomol. 2008;101:1389-1396.

10. Berg R. Bed bugs: the pesticide dilemma. J Environ Health. 2010;72:32-35.

11. Cestari TF, Martignago BF. Scabies, pediculosis, bedbugs, and stinkbugs: uncommon presentations. Clin Dermatol. 2005;23:545-554.

12. Arlian LG, Estes SA, Vyszenski-Moher DL. Prevalence of Sarcoptes scabiei in the homes and nursing homes of scabietic patients. J Am Acad Dermatol. 1988;19:806-811.

13. Silverman AL, Qu LH, Blow J, Zitron IM, Gordon SC, Walker ED. Assessment of hepatitis B virus DNA and hepatitis C virus RNA in the common bedbug (Cimex lectularius L.) and kissing bug (Rodnius prolixus). Am J Gastroenterol. 2001;96:2194-2198.

14. Pritchard MJ, Hwang SW. Cases: Severe anemia from bedbugs. CMAJ. 2009;181:287-288.

15. Elston DM, Stockwell S. What's eating you? bedbugs. Cutis. 2000;65:262-264.

16. Anderson AL, Leffler K. Bedbug infestations in the news: a picture of an emerging public health problem in the United States.J Environ Health. 2008;70:24-27, 52-53.

17. Orkin M, Maibach HI. Current concepts in parasitology: this scabies pandemic. N Engl J Med. 1978;298:496-498.

18. Orkin M. Resurgence of scabies. JAMA.1971;217:593-597.Lapeere H, Vander Stichele RH, Naeyaert JM. Evidence in the treatment of head lice: drowning in a swamp of reviews. Clin Infect Dis. 2003;37:1580-1582.

19. Jaramillo-Ayerbe F, Berrio-Munoz J. Ivermectin for crusted Norwegian scabies induced by use of topical steroids. Arch Dermatol. 1998;134:143-145.

20. Manuel J. Invasion of the bedbugs. Environ Health Perspect. 2010;118:A429.