EBM临床情境讨论汇总课件

1、EBM臨床情境討論A01組, 義大醫院第1页，共27页。Clinical scenario感控室發現最近有一個問題，即同一病房中爆發3疥瘡(Scabies)感染，因醫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站工作人員使用治疥瘡之藥物 , 知道如何處才最適當?第2页，共27页。Search strategy第3页，共27页。Background knowledgeIt is transmitted from person to person via direct skin contact. At standard room conditions infectious mites

2、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

3、, excoriation, and impetigo Patients may be asymptomatic for the first 2-4 weeks of infestation 第4页，共27页。Problem 1, PICOPatient and/or problem: No symptomatic staff who contact scabies patient Intervention : Mediation for treat scabiesComparison intervention : No interventionOutcomes : Prevent scabi

4、es outbreak 第5页，共27页。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

5、paper is cited第6页，共27页。1.Chambliss NL. Treating asymptomatic bodily contacts of patients with scabies. Arch Fam Med. 2000 May;9(5):473-4. 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 C

6、itationsLevel: 2cLevel: 2c第7页，共27页。Evidence appraisalControl 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 visi

7、tors 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 第8页，共27页。Evidence appraisalPatients who are fir

8、st 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

9、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.第9页，共27页。Scabies treatments treatment agentUS FDA

10、 approved for scabies treatmentcommentsPermethrinYesFirst-line therapyLindaneYesNeurotoxic; second-line therapyCrotamitonYesNot very effective; weak antipruriticMalathionApproved for head lice treatmentNot uesd in the US Allethrin sprayNoUsed in Europe6-10% precipitated sulfurNoWell tolerated in chi

11、ldren under 2 months of age and pregnant womenBenzyl benzoateNoUsed in EuropelvermectinApproved for strongyloidiasis and onchocerciasis treatmentOral, effective dose 200g/kgAm J Clin Dermatol 2004;5(1)第10页，共27页。Conclusion當同一病房中爆發3疥瘡(Scabies)感染時，因照護的醫人員是最長期接觸此病人者，為預防感染，故建議可讓護站工作人員使用治疥瘡之藥物 ,以防疫情再度擴大。

12、第11页，共27页。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。第12页，共27页。Problem 2, PICOPatient and/or problem: No symptomatic staff who contact scabies patientIntervention : LindanceComparison intervention : Permethrin or IvermectinOutc

13、omes : Cure rate 第13页，共27页。Search strategyTerms: scabies and lidaneLevel :IcLevel :Ic第14页，共27页。Evidence appraisalEvidence 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

14、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 scabie

15、s. Cochrane Database of Systematic Reviews 2004, Issue 1第15页，共27页。Walker GJA, Johnstone PW. Interventions for treating scabies. Cochrane Database of Systematic Reviews 2004, Issue 1第16页，共27页。Drug comparsionEvidence regarding the effectivess of permethrin vs lindane is conflicting. This systematic re

16、view 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 cont

17、rolling persistent itch (Level A) Walker GJA, Johnstone PW. Interventions for treating scabies. Cochrane Database of Systematic Reviews 2004, Issue 1第17页，共27页。Evidence appraisal An RCT comparing the use of lindane with oral ivermectin found similar cure rates at 15 days with both treatments (Level A

18、) 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, Issu

19、e 1第18页，共27页。Comparison of the efficacy of topical 1% lindane vs 5% permethrin in scabies: a randomized, double-blind study 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 sig

20、nificantly 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第19页，共27页。Cost effectivenessIn The UK, permethrin is at least 10 times more

21、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第20页，共2

22、7页。Cost effectivenessWalker GJA, Johnstone PW. Interventions for treating scabies. Cochrane Database of Systematic Reviews 2004, Issue 1第21页，共27页。國內藥物Benzyl benzoateCrotamitonLindaneMalathionMesulfen (scaphen)Sulfur第22页，共27页。Gamma-benzene hexachlorideDelice(Lindane)1%, 10ml/pk Benzyl Benzoate(B.B lotion)25%,100ml/bot Mesulphen(Scalphen) 330mg/g,15g/tube本院治療疥瘡之藥物品項第23页，共27页。Cost comparisonDrugApplication schedule單價Cost per course(adult)Benzyl benzoate 25% (B.B lotion)one pplication 自費價205 (100ml/bot)205元 (100ml)Mes