What contact precautions should be in place for a patient in long-term care with suspected herpes zoster (shingles)?

Contact Precautions for Suspected Shingles in Long-Term Care

Patients with suspected herpes zoster (shingles) in long-term care settings should be placed under both airborne and contact precautions until all lesions are dry and crusted. 1

Isolation Requirements

• Airborne and Contact Precautions:

  • Implement both airborne and contact precautions immediately upon suspicion of shingles 1
  • Maintain these precautions until all lesions are completely dry and crusted 1
  • Place patient in a negative air-flow room if available 1
  • If negative air-flow rooms are unavailable, isolate patient in a closed room 1

• Room Placement:

  • Single-occupancy room preferred
  • Door should remain closed to minimize airborne transmission 1
  • Restrict non-immune individuals from entering the room 1

Healthcare Personnel Considerations

• Staff Assignment:

  • Only staff with documented immunity to varicella-zoster virus (VZV) should care for patients with suspected shingles 1, 2
  • Evidence of immunity includes:
    • Documented receipt of 2 doses of varicella vaccine
    • Laboratory evidence of immunity
    • Laboratory confirmation of previous disease
    • Healthcare provider verification of history of varicella or herpes zoster 1

• Non-immune Staff Exposure Management:

  • Exclude non-immune exposed staff from duty from day 8 after first exposure through day 21 after last exposure 1
  • If varicella develops in staff, exclude until all lesions are dry and crusted 1
  • Consider post-exposure vaccination within 3-5 days for exposed non-immune staff 1

Protective Equipment and Precautions

• Required Personal Protective Equipment:

  • Gown and gloves for all patient contact (contact precautions) 1
  • N95 respirator or equivalent for entering room (airborne precautions) 1
  • Eye protection if splash risk exists

• Hand Hygiene:

  • Perform hand hygiene before and after all patient contact
  • Use alcohol-based hand sanitizer or soap and water
  • Hand hygiene required even when gloves are worn

Special Considerations

• Immunocompromised Patients:

  • Maintain stricter isolation for immunocompromised patients with localized herpes zoster until disseminated infection is ruled out 1
  • Patients with disseminated zoster (lesions in >3 dermatomes) require more rigorous isolation measures 1

• Vulnerable Populations:

  • Take extra precautions to protect:
    • Pregnant women without immunity to varicella
    • Premature infants
    • Immunocompromised individuals 1, 2

• Transmission Risk Management:

  • Cover all lesions completely with clean, dry bandages until fully crusted 1
  • Restrict patient movement outside the room unless medically necessary
  • If transport is required, ensure lesions are covered and patient wears a surgical mask

Treatment Considerations

• Antiviral Therapy:
  • Initiate antiviral treatment as soon as possible, ideally within 72 hours of rash onset 1, 3
  • Antiviral medications decrease viral shedding and reduce the duration of lesions 1
  • Early treatment may reduce risk of transmission and complications

Common Pitfalls to Avoid

• Delayed Implementation of Precautions:

  • Do not wait for laboratory confirmation before implementing precautions
  • Implement precautions based on clinical suspicion alone

• Inadequate Staff Immunity Screening:

  • Verify immunity status of all healthcare workers before allowing contact with suspected cases
  • Do not rely solely on verbal history of chickenpox without verification 2

• Premature Discontinuation of Precautions:

  • Do not discontinue precautions until all lesions are completely dry and crusted
  • Some lesions may take longer to crust, requiring extended precautions

• Nosocomial Transmission Risk:

  • Remember that VZV can be transmitted through the airborne route even without direct contact 1, 4
  • A recent case report documented hospital-acquired chickenpox from a healthcare worker who contracted it from a patient with herpes zoster 4

By following these comprehensive precautions, long-term care facilities can effectively minimize the risk of varicella-zoster virus transmission from patients with suspected shingles to other residents and staff.