Transcript Walker GJA, Johnstone PW. Interventions for treating

EBM臨床情境討論
A01組, 義大醫院
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 , 不知道如何處才
最適當?
Search strategy
Background knowledge
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It is transmitted from person to person via direct skin contact.
At standard room conditions infectious mites can survive for up to
36 hours off the host.
Pruritic response to infestation of human mite Sarcoptes scabiei.
Severely itchy lesions typically present as small papules with
noticeable curvy or straight burrows commonly located in skin
folds.
Secondary signs may include general rash, urticaria, eczema,
excoriation, and impetigo
Patients may be asymptomatic for the first 2-4 weeks of
infestation
Problem 1, PICO
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Patient and/or problem:
No symptomatic staff who contact
scabies patient
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Intervention :
Mediation for treat scabies
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Comparison intervention :
No intervention
Outcomes :
Prevent scabies outbreak
Search strategy
Search
terms: scabies and asymptomatic
result: 17 papers found
Discard irrelevant papers
Finally, 1 paper is cited
terms: scabies and outbreak → 221 papers
limits: published in the last 10 years, English
result: 45 papers found
Discard irrelevant papers
Finally, 1 paper is cited
Citations
1.Chambliss NL.
Treating asymptomatic bodily contacts of patients
with scabies. Arch Fam Med. 2000 May;9(5):473-4.
Level: 2c
2.Scheinfeld N. Controlling scabies in institutional
settings: a review of medications, treatment models,
and implementation. Am J Clin Dermatol.
2004;5(1):31-7
Level: 2c
Evidence appraisal
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Control of an epidemic can only be achieved by
treatment of the entire population at risk.
Ivermectin, the only oral treatment, is not approved
for scabies in the US. In an outbreak of scabies in a
nursing home, residents, staff, and frequent visitors
should all be treated even if they are not symptomatic.
Ivermectin is useful in treating patients with
Norwegian or crusted scabies, or who are debilitated.
Ivermectin has no serious reported adverse effects.
Scheinfeld N. Am J Clin Dermatol. 2004
Evidence appraisal
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Patients who are first exposed to scabies often do not develop
symptoms for several weeks.
A well documented case report detailed the spread of scabies in a
day care center, in which 21% of the staff and children were
eventually infected. More than 570 family members of the
children also became symptomatic.
The standard treatment for scabies is 5% permethrin cream
applied from the neck down and left.
Alternatives include 1% lindane, which should be avoided in
children and pregnant women. In adults, ivermectin is effective as
a single oral dose.
Arch Fam Med. 2000 May.
Scabies treatments
Am J Clin Dermatol 2004;5(1)
treatment agent
US FDA approved for
scabies treatment
comments
Permethrin
Yes
First-line therapy
Lindane
Yes
Neurotoxic; second-line
therapy
Crotamiton
Yes
Not very effective; weak
antipruritic
Malathion
Approved for head lice
treatment
Not uesd in the US
Allethrin spray
No
Used in Europe
6-10% precipitated No
sulfur
Well tolerated in children
under 2 months of age and
pregnant women
Benzyl benzoate
No
Used in Europe
lvermectin
Approved for
strongyloidiasis and
onchocerciasis treatment
Oral, effective dose
200μg/kg
Conclusion
當同一病房中爆發3例疥瘡(Scabies)感染時，
因照護的醫療人員是最長期接觸此病人者，為
預防感染，故建議可讓護理站工作人員使用治
療疥瘡之藥物 ,以防疫情再度擴大。
Plain language explanation
疥瘡為高傳染性的疾病，醫護人員為第一線照
護者，屬於被傳染的高危險群，雖然各位沒
有症狀，但是我們仍然建議各位醫護人員使
用治療疥瘡藥物，以預防疥瘡藉由醫護人員
之傳播而造成疥瘡的爆發。
Problem 2, PICO
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Patient and/or problem:
No symptomatic staff who contact
scabies patient
Intervention :
Lindance
Comparison intervention :
Permethrin or Ivermectin
Outcomes :
Cure rate
Search strategy
Terms: scabies and lidane
Level :Ic
Level :Ic
Evidence appraisal
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Evidence regarding the effectivess of permethrin
vs lindane is conflicting. This systematic review
found four RCTs comparing these agents. Two
small trials found clinical cure at 28 days was
greater with permethrin, but the other two RCTs,
including the largest of the four trials, failed to
show any significant difference in clinical
outcome. Permethrin, however, to be more
effective in controlling persistent itch (Level A)
Walker GJA, Johnstone PW. Interventions for treating scabies.
Cochrane Database of Systematic Reviews 2004, Issue 1
Walker GJA, Johnstone PW. Interventions for
treating scabies. Cochrane Database of
Systematic Reviews 2004, Issue 1
Drug comparsion
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Evidence regarding the effectivess of permethrin vs
lindane is conflicting. This systematic review found
four RCTs comparing these agents. Two small trials
found clinical cure at 28 days was greater with
permethrin, but the other two RCTs, including the
largest of the four trials, failed to show any significant
difference in clinical outcome. Permethrin, however,
to be more effective in controlling persistent itch
(Level A)
Walker GJA, Johnstone PW. Interventions for treating scabies.
Cochrane Database of Systematic Reviews 2004, Issue 1
Evidence appraisal
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An RCT comparing the use of lindane with
oral ivermectin found similar cure rates at 15
days with both treatments (Level A)
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A subsequent RCT found that although the
effects of topical lindane and oral ivermectin
were similar at 2 weeks, ivermectin produced
significanlty greater cure rates at 4 weeks
(Level A)
Walker GJA, Johnstone PW. Interventions for treating scabies.
Cochrane Database of Systematic Reviews 2004, Issue 1
Comparison of the efficacy of topical 1% lindane vs 5%
permethrin in scabies: a randomized, double-blind study
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Permethrin provided an improvement rate
of 84.6% after two weeks, whereas lindane
was effective only in 48.9% of patients.
CONCLUSION: Permethrin (5%) cream was
found to be significantly more effective in
the treatment of scabies in comparison with
lindane in this study, and it seems that it
could be an alternative treatment.
The Cochrane Central Register of Controlled Trials (CENTRAL) 2008 Issue 2
Cost effectiveness
In The UK, permethrin is at least 10 times more
expensive per treatment (£5.52 per 30 g of
cream),than benzyl benzoate (£0.62 per
100ml),and about twice as expensive as
crotamiton (£2.99 per 100ml) and malathion
(£2.35 per 100ml)
Walker GJA, Johnstone PW. Interventions for treating scabies.
Cochrane Database of Systematic Reviews 2004, Issue 1
Cost effectiveness
Walker GJA, Johnstone PW. Interventions for treating scabies.
Cochrane Database of Systematic Reviews 2004, Issue 1
國內藥物
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Benzyl benzoate
Crotamiton
Lindane
Malathion
Mesulfen (scaphen)
Sulfur
本院治療疥瘡之藥物品項
Gamma-benzene hexachloride
Delice(Lindane)
1%, 10ml/pk
Benzyl Benzoate
(B.B lotion)
25%,100ml/bot
Mesulphen
(Scalphen)
330mg/g,15g/tube
Cost comparison
Drug
Application schedule
單價
Cost per
course(adult)
Benzyl benzoate
25% (B.B lotion)
one pplication
自費價205
(100ml/bot)
205元 (100ml)
Mesulphen
(scalphen)
up to three
applications,on
consecutive days
健保價40.5元
(15gm)
243元 (90gm)
Delice(Lindane)
1%
one pplication
自費價35元
(10ml/pk)
350元 (100ml)
中央健保局 and 義大醫院藥品基本檔
Conclusion
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Patients with documented scabies should be
isolated and placed in a single ward to
optimize staff infection control precautions.
it may be asymptomatic for the first 2-4 weeks of
infestation, so if have outbreak of scabies , the staff
who contract scabies patient need give prevent
medication.
在給予預防性藥物的選擇上，國內並無文獻所提之首
選藥物permethrine ，而院內之替代藥物有B.B lotion、
scalphen以及Lindane。
療程花費上相較於其他治療藥物， B.B lotion的費
用較低。
Plain language explanation
雖然Permethrin或Ivermectin效果優於
Lindane，但本院並無Permethrin或
Ivermectin可供選擇，所以我們決定建議各
位醫護人員使用Lindane。
謝謝大家 !!
Lake District