Scabies, Fleas, or Bedbugs? Investigation of Skin Rashes in an Inpatient Eating Disorders Treatment Facility Unit

Background We investigated a cluster of skin rashes on an inpatient adult and pediatric eating disorders treatment facility (EDTF) unit where group activities occur and include therapy dogs. Methods An epidemiological investigation was launched after scabies was diagnosed in patient A (occupying room X). An interprofessional team was engaged and included EDTF leaders, dermatology, environmental services, and infection prevention. Patient A was treated for scabies and persons with epidemiologic links were informed of possible exposure. Within two weeks, patient B (occupying room X) was evaluated by dermatology for a rash deemed inconsistent with scabies, but bed bug bites could not be excluded. Pest control professionals assessed room X for bed bugs, none were found. Four weeks later, a bed bug was visualized in room X (occupied by patient B). Pest control professionals confirmed presence of bed bugs and treated the room with high temperature heat. The investigation was expanded to persons with epidemiological links to patient B. Results 92 employees were informed of scabies exposure, no post exposure prophylaxis administered as none reported skin-to-skin contact. 55 patients had a concurrent inpatient stay with patient A. Of these, 9 had possible skin-to-skin contact and received prophylaxis. 25 were discharged and informed of possible exposure, none sought prophylaxis. Therapy dogs were examined, no fleas identified. Heat treatment cost was approximately $1000.00. There were no bedbugs identified outside room X and no additional patients with bed bug-related rashes. Investigative data supports source of bed bugs was outside the facility. Policies are under revision to restrict personal items, such as bedding, brought to EDTF. Conclusions This investigation illustrates challenges with identifying etiology of arthropod-related skin rashes in a special population and the need to reevaluate hypotheses as data unfolds over time. An interprofessional team supported timely implementation of control measures.