Is droplet isolation necessary for patients with active shingles?

Infection Control for Active Shingles

Standard contact precautions are sufficient for patients with active shingles (herpes zoster), and droplet isolation is not required unless the patient is immunocompromised or has disseminated disease. 1

Transmission Risk Assessment

The varicella-zoster virus (VZV) that causes shingles presents different transmission risks depending on the patient's presentation:

• Localized shingles: Contact precautions are adequate when lesions are limited to one or a few adjacent dermatomes and can be completely covered 1
• Disseminated shingles: Defined as lesions in >3 dermatomes, requires both airborne and contact precautions 1
• Immunocompromised patients: Should be placed under airborne and contact precautions until disseminated infection is ruled out 1

Specific Isolation Procedures

For Localized Shingles (Most Common Scenario):

• Ensure all lesions are completely covered with clean, dry bandages or clothing 1
• Implement contact precautions:
  • Place patient in a single room or maintain >3 ft spatial separation from others
  • Use appropriate PPE including gloves and gown
  • Limit patient transport and movement
  • Use dedicated or disposable patient-care equipment 2

For Disseminated Shingles or Immunocompromised Patients:

• Implement both airborne and contact precautions
• Place patient in an airborne isolation room (AIR) with negative pressure
• If AIR is unavailable, place patient in a private room with door closed
• Healthcare workers should wear appropriate PPE including N95 respirators or masks 2

Staff Considerations

• Only staff with documented immunity to VZV should care for patients with shingles 1
• 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

Treatment Impact on Transmission

• Antiviral medications (acyclovir, valacyclovir, famciclovir) decrease viral shedding and reduce the duration of lesions 1
• Starting antiviral treatment as soon as possible, ideally within 72 hours of rash onset, is crucial for managing herpes zoster and may reduce transmission risk 2, 3

Duration of Precautions

• Maintain precautions until all lesions are dry and crusted 1
• For immunocompromised patients, continue precautions throughout the course of the illness and reassess regularly 1

Common Pitfalls to Avoid

1. Misclassifying the extent of disease: Failing to recognize disseminated disease that requires airborne precautions
2. Inadequate covering of lesions: Lesions must be completely covered to prevent contact transmission
3. Relying on verbal history of immunity: Healthcare workers' immunity status should be verified with documentation before allowing contact with cases 1
4. Premature discontinuation of precautions: Precautions should continue until all lesions are fully crusted, not just when they begin to dry

By following these evidence-based guidelines, healthcare facilities can effectively prevent the transmission of VZV from patients with active shingles while providing appropriate care.