-
-
KEY SUMMARY POINTS
Epidemiology:
-
Anthrax can be transmitted by inhalation, ingestion or inoculation.
(Inhalation is the most likely route during a bioterrorist attack)
-
The spore form of anthrax is highly resistant to physical and chemical agents;
spores can persist in the environment for years
-
Anthrax is not transmitted from person to person
Clinical:
-
Incubation period is 1-5 days (range up to 43 days)
-
Inhalation anthrax presents as acute hemorrhagic mediastinitis
-
Biphasic illness, with initial phase characterized by nonspecific flu-like
illness followed by acute phase characterized by acute respiratory distress
and toxemia (sepsis)
-
Chest x-ray findings: Mediastinal widening in a previously healthy patient
is pathognomonic for anthrax
-
Mortality rate for inhalation anthrax approaches 90%, even with treatment
Diagnosis:
-
Gram stain shows gram positive bacilli, occurring singly or in short chains,
often with squared off ends (safety-pin appearance). In advanced disease,
a gram stain of unspun blood may be positive.
-
Distinguishing characteristics on culture include: non-hemolytic, non-motile,
capsulated bacteria that are susceptible to gamma phage lysis
-
ELISA and PCR tests are available at national reference laboratories
-
Laboratory specimens should be handled in Biosafety Level 2 facilities
Treatment:
-
Prompt initiation of antibiotic therapy is essential
-
Antibiotic susceptibility testing is KEY to guiding treatment
-
Ciprofloxacin is the antibiotic of choice for penicillin-resistant anthrax
or for empiric therapy while awaiting susceptibility results
-
All patients should be treated with anthrax vaccine; antibiotic treatment
should be continued until 3 doses of vaccine have been administered (Days
0, 14 and 28). If vaccine is unavailable, antibiotic treatment should be
continued for 60 days.
Prophylaxis:
-
If vaccine is available, all exposed persons should be vaccinated with 3
doses of anthrax vaccine (Days 0, 14 and 28)
-
Start antibiotic prophylaxis immediately after exposure with
ciprofloxacin or doxycycline. (If strain is penicillin susceptible, therapy
can be modified to penicillin or amoxicillin.)
-
Antibiotic prophylaxis should be continued until 3 doses of vaccine have
been administered; if vaccine is unavailable, antibiotics should be continued
for 60 days
Patient Isolation:
-
Universal precautions. Patients do not require isolation rooms.
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ALL SUSPECT CASES OF ANTHRAX MUST BE REPORTED
IMMEDIATELY TO
THE BUREAU OF COMMUNICABLE DISEASE:
| During Business Hours: |
212-788-9830 |
| After Hours (Nights, Weekends and Holidays): |
212-POISONS |
|
-
Introduction/Epidemiology
Anthrax is a disease caused by Bacillus anthracis which can infect
most warm-blooded animals, including man. Transmission to humans usually
occurs through contact with infected animals or contaminated animal products.
Humans become infected by inoculation, inhalation, or ingestion of the bacterium.
In humans, naturally-occurring anthrax primarily involves the skin or rarely,
the lungs or the gastrointestinal tract. The bacillus produces a resistant
spore which could be dispersed as a small particle aerosol. In the event
of a biologic terrorist attack, aerosolization is the most likely mode of
transmission, and inhalational anthrax would be the predominant form of disease
affecting persons exposed to the aerosol.
The spore form of B. anthracis is highly resistant to physical and
chemical agents. The organism has been shown to persist for years in factories
contaminated during the processing of infected animal products. Soil, animal
feed, and to a lesser extent, ground water are the major reservoirs for anthrax.
Although human anthrax is infrequent and sporadic in the United States and
most other industrialized countries, human cases (primarily cutaneous) continue
to be reported from Africa, Asia, Europe, and the Americas. Although
anthrax-contaminated soil exists in many foci throughout the United States,
the number of cases reported annually in has declined throughout the last
five decades; five human cases (all cutaneous anthrax) were reported between
1981-1996. There have been no reports of anthrax in New York City in over
50 years.
A suspected case of anthrax in a patient without a clear exposure
history (e.g., a traveler returning from an area with known animal cases
or a person with exposure to imported animal hides) may be the first clue
of a bioterrorist attack. Therefore, even a single, suspect case should prompt
immediate notification of the Bureau of Communicable Disease (Business hours:
212-788-9830; After hours: 212-764-7667)
Person to person transmission of anthrax is extremely rare.
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Significance as a Potential Bioterrorist Agent
Anthrax has been weaponized by many countries during the last 50 years, including
the United States (during the 1950's) and Iraq during the Gulf War.
-
Anthrax is easy to cultivate and spores are readily produced.
-
Anthrax spores are highly resistant to heat and disinfection.
-
If aerosolized spores are inhaled, a severe hemorrhagic mediastinitis can
occur with mortality rates approaching 90% even with appropriate treatment.
-
Currently, anthrax vaccine is in limited supply in the United States and
not available to the general public.
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Clinical Manifestations
During an act of bioterrorism, release of an aerosol will be the most
likely route of transmission. Given this, most exposed individuals will present
with symptoms of inhalation anthrax with only a few, if any, having the cutaneous
form of the disease. Gastrointestinal anthrax would be much less likely.
Inhalation Anthrax presents as acute hemorrhagic
mediastinitis after inhalation of airborne particles contaminated with B.
anthracis spores. Inhalation anthrax does not present as an acute
pneumonia.
-
Incubation period - illness usually occurs within 1-5 days
of exposure (may be as long as 43 days)
Symptoms - Typically biphasic illness
Initial Phase is characterized by flu-like symptoms:
-
mild, nonspecific respiratory illness
malaise, fatigue, myalgia
low-grade fever
nonproductive cough
mild chest discomfort (occasionally)
rhonchi may be heard, exam otherwise normal
Acute Phase develops after 2-5 days, it may be briefly preceded by
1-2 days of improvement. Characteristic findings include:
-
acute severe respiratory distress
dyspnea, cyanosis, stridor and profuse diaphoresis
subcutaneous edema of chest and neck
markedly elevated temperature, pulse, respiratory rate
moist crepitant rales
| x-ray findings: |
mediastinal widening in an otherwise healthy
persons is a pathognomonic sign; pleural effusion may be present, evidence
of pneumonia is often lacking |
Shock develops rapidly, sometimes accompanied by evidence of hemorrhagic
meningitis, and patients usually die within 24 hours of onset of the acute
phase. In prior outbreaks, mortality rates approached 90% despite appropriate
antibiotic therapy.
The differential diagnosis of acute mediastinitis includes: esophageal
perforation; trauma; contiguous spread from a head, neck or thoracic infection;
and post-surgical infections after cardiothoracic procedures. Anthrax
should be strongly considered in any previously healthy patient with acute
mediastinitis.
The diagnosis of inhalation anthrax requires a very high index of suspicion,
most often based on epidemiologic evidence of a potential exposure. In the
initial stages after a bioterrorist attack, a recognized source of exposure
would likely be absent -- clinical suspicion is of utmost importance.
Cutaneous Anthrax: presents as a "malignant pustule
or malignant carbuncle" resulting from introduction of the anthrax bacillus
beneath the skin by inoculation or contamination of a pre-existent break
in the skin.
-
Incubation period - ranges from 1-7 days but is commonly
2-5 days
Symptoms - an evolving skin lesion, usually located on the
exposed parts of the body (face, neck, arms), with a varying degree of associated
edema. The skin lesion typically progresses as follows:
-
Small, painless, pruritic papule >>> small ring of vesicles
that coalesce into a single large vesicle >>> vesicle ruptures
to form depressed ulcer >>> 1-3 cm eschar develops in center
(7-10 days from onset of lesion) >>> eschar falls off (after
1-2 weeks) leaving a permanent scar.
Systemic symptoms including fever, headache, myalgias, and regional
lymphangitis/lymphadenopathy have been described. Lesions on the face and
neck may be associated with significant edema and impingement of the trachea
from neck swelling can occur. "Malignant edema" describes a syndrome with
marked edema, induration and multiple bullae at the site of inoculation
associated with generalized toxemia. Septicemia is rare. Untreated cutaneous
anthrax has a case fatality rate up to 20%, but fatalities are rare (<
1%) with effective antibiotic treatment.
Gastrointestinal Anthrax: occurs after the ingestion
of contaminated food, particularly raw or undercooked meat from infected
animals. There has never been a case of gastrointestinal anthrax reported
in the United States.
-
Incubation period - ranges from 2-7 days
Symptoms - Two clinical presentations, intestinal
and oropharyngeal, have been described. The symptoms of intestinal
anthrax are initially nonspecific and include nausea, vomiting, anorexia
and fever. As the disease progresses, abdominal pain, hematemesis and bloody
diarrhea develop, occasionally accompanied by ascites. The patient may present
with the findings of an acute surgical abdomen. Oropharyngeal anthrax is
associated with cervical edema and necrosis. A lesion, resembling a cutaneous
anthrax lesion, may be seen in the oral cavity on the posterior wall, the
hard palate or the tonsils. Patients typically complain of fever, dysphagia
and lymphadenopathy. Toxemia, shock and cyanosis characterize the terminal
stages of both forms of the disease. The case fatality rate for gastrointestinal
anthrax ranges from 25 to 60%.
Meningitis: Meningitis occurs in less than 5% of
cases, and may be a complication of any form of anthrax (inhalational,
gastrointestinal or cutaneous). Rarely does it occur without a primary focus.
It is usually hemorrhagic.
-
Incubation period - concurrent with or one to several days
after the onset of cutaneous, inhalation or gastrointestinal anthrax.
Symptoms - abrupt onset of meningeal symptoms including nausea,
vomiting, myalgia, chills and dizziness. Laboratory findings are notable
for a hemorrhagic meningitis. Encephalomyelitis and cortical hemorrhages
have been reported; death occurs in 1-6 days.
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Laboratory Diagnosis
Laboratory work with clinical specimens must
be done under Biosafety Level 2
conditions. If infection with Bacillus anthracis is suspected, please
immediately call
the New York City Bureau of Communicable Disease at 212-788-9830 to arrange
for
submission of specimens to an appropriate reference laboratory for
confirmatory
testing. After hours call the Poison Control Center at 212-POISONS
(212-764-7667). |
-
Culture is the definitive test for anthrax.
Bacillus anthracis can be isolated from blood, pleural fluid, CSF,
ascitic fluid, vesicular fluid or lesion exudate. Sputum cultures are rarely
positive. When culturing a lesion, collect either vesicular fluid or exudate
from the ulcer. If there is no visible exudate, lift the edge of the eschar
with a pair of forceps and collect the fluid near the edge.
Blood cultures may be positive for bacterial growth in 12-48 hours using
standard technology; however, the ability of most clinical microbiology
laboratories to definitively identify B. anthracis may be limited.
-
Microscopy
-
Gram stain
-
Gram stain should be performed on vesicular fluid or exudate from ulcerative
lesions for suspected cutaneous anthrax, pleural fluid for suspected inhalation
anthrax, and CSF for suspected meningeal anthrax. In advanced disease,
a gram stain of unspun blood may be positive. The Gram stain shows gram
positive bacilli, usually occurring singly or in short chains, often with
squared-off ends (safety-pin appearance).
-
Direct Fluorescent Antibody (DFA) Test
-
Rapid diagnostic staining technique. This test has been used to examine exudate
from cutaneous lesions, CSF and tissue. Not generally helpful for inhalation
anthrax because respiratory/pleural fluid specimens are usually negative
in the early stages of disease when rapid diagnosis is most critical. This
test is currently available only at national reference laboratories.
-
Rapid diagnostic tests
-
An ELISA assay for protective antigen detection and PCR for detection of
nucleic acid can provide a preliminary diagnosis of anthrax within several
hours. Currently, these tests are only available at reference laboratories.
-
Evaluation of a Blood Culture that is Suspicious for Anthrax:
The following steps are needed to presumptively identify anthrax in the
microbiology laboratory:
-
Overnight incubation on a blood or nutrient agar isolation plate
-
Gram stain shows large gram positive rods with square or concave ends
-
Blood agar colonies are non-hemolytic, rough, gray-white, tenacious colonies
with comma- shaped protrusions
-
Subculture to blood agar plates to test for lysis with gamma phage and penicillin
susceptibility. (NOTE: Although naturally-occurring anthrax is
penicillin-sensitive, in the event of a bioterrorist event, an anthrax strain
resistant to penicillin may have been released.)
-
Test for lack of growth on phenylethyl alcohol blood agar, lack of gelatin
hydrolysis, and lack of salicin fermentation
-
The bacterial capsule can be demonstrated on nutrient agar containing 0.7%
sodium bicarbonate incubated overnight in a candle jar. Examine for capsule
with methylene blue or India ink.
To distinguish Bacillus anthracis from other Bacillus
species: Distinguishing features include that Bacillus anthracis
is non-hemolytic, non-motile, capsulated and susceptible to gamma phage lysis.
Summary: Bacillus anthracis is a gram positive bacillus that
is white or gray in color, nonhemolytic or weakly so, nonmotile, gamma phage
and usually penicillin susceptible, and able to produce the characteristic
capsule.
-
Serology - not helpful for rapidly establishing the diagnosis during
the acute illness.
-
Autopsy Findings - identifying thoracic hemorrhagic necrotizing
lymphadenitis and hemorrhagic necrotizing mediastinitis in a previously healthy
patient is essentially pathognomonic for inhalation anthrax. Hemorrhagic
meningitis would also be a distinct clue to the diagnosis of anthrax.
**NOTE: In the event of a bioterrorist event, the anthrax strain may be
penicillin resistant. There are currently no NCCLS standards for susceptibility
testing for B. anthracis. Microbiology laboratories must alert the
Bureau of Communicable Disease (212-788-9830, after hours 212-POISONS) as
soon as B. anthracis is identified so that susceptibility testing
at a national reference laboratory can be arranged. The results of susceptibility
testing are crucial in guiding both therapy and prophylaxis for potentially
infected persons.
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Handling Laboratory Specimens
Biosafety Level 2 practices, containment equipment and facilities are
recommended for procedures on clinical materials suspected as being positive
for anthrax. Laboratory staff handling specimens from persons who might
have anthrax must wear surgical gloves, protective gowns and shoe covers.
Laboratory tests should be performed in Biological Safety Level 2 cabinets
and blood cultures should be maintained in a closed system. Every effort
should be made to avoid splashing or creating an aerosol, and protective
eye wear and masks should be worn if work cannot be done in a Biological
Safety Level 2 cabinet. A full-face mask respirator with a HEPA (high efficiency
particulate air) filter is an acceptable alternative to masks and protective
eye wear, but use of this equipment is not mandatory.
Accidental spills of potentially contaminated material should be decontaminated
immediately by covering liberally with a disinfectant solution (5% hypochlorite
or 10% formalin), left to soak for 30 minutes, and wiped up with absorbent
material soaked in disinfectant. All biohazardous waste should be decontaminated
by autoclaving. Contaminated equipment or instruments may be decontaminated
with a hypochlorite solution, hydrogen peroxide, iodine, peracetic acid,
1% glutaraldehyde solution, formaldehyde, ethylene oxide, copper irradiation
or other O.S.H.A. approved solutions, or by autoclaving or boiling for 10
minutes.
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Treatment
The key to successful treatment is prompt administration of an antimicrobial
at the first suspicion of anthrax. During a biologic emergency, before
susceptibility is determined (which may take several days), assume penicillin
and tetracycline resistance and treat with ciprofloxacin at 400 mg IV every
12 hours. Penicillin is the antibiotic of choice for treating infections
with penicillin-sensitive anthrax.
Treatment for Non-Pregnant Adults:
Inhalation anthrax (this regimen also recommended for
gastrointestinal and meningeal anthrax)
-
For penicillin resistant anthrax, administer ciprofloxacin
at 400 mg IV every 8 to 12 hours (Alternative quinolone options include:
ofloxacin 400 mg IV every 12 hours or levofloxacin 500 mg IV every 24 hours).
If the isolate is tetracycline susceptible, doxycycline 200 mg
initially, followed by 100mg IV every 12 hours is equally efficacious.
-
For penicillin susceptible anthrax, administer Penicillin G
IV 80,000 units/kg body weight in the first hour followed by a maintenance
dose of 320,000 units/kg body weight/day. The average adult dose is 4 million
units every 4 hours; can also be administered as 2 million units every 2
hours. (Amoxicillin 500 mg IV every 8 hours is an alternative regimen,
with a dosing schedule that may be easier to administer in the event of a
large-scale outbreak.)
-
Supportive therapy is often required (e.g., volume expanders, vasopressor
agents and oxygen). A tracheotomy may be needed if cervical edema compromises
the airways.
Cutaneous anthrax
-
Mild disease
Penicillin susceptible anthrax - Potassium penicillin V orally at
30 mg/kg body weight/day in four equal portions every 6 hours, or amoxicillin
500 mg orally every 8 hours.
Penicillin resistant anthrax - ciprofloxacin 500 mg orally every 12
hours or (if tetracycline susceptible) doxycycline 100 mg orally every 12
hours.
-
Extensive lesions
Penicillin susceptible anthrax - Penicillin G IV 2-4 million units
every 4-6 hours or amoxicillin 500 mg IV every 8 hours.
Penicillin resistant anthrax - Ciprofloxacin 400 mg IV every 12 hours
or (if tetracycline susceptible) doxycycline 100 mg IV every 12 hours. When
the edema and systemic symptoms have improved, treatment may be completed
with the above oral regimens. In the absence of an aerosol exposure, therapy
should be continued for 7-10 days. The skin lesions will continue to evolve
despite the use of effective antibiotics but severe edema and systemic symptoms
will be prevented. Glucosteroids for the first 3-4 days of treatment may
reduce morbidity and mortality in severe cutaneous anthrax (malignant edema),
particularly in the setting of laryngeal edema.
Alternative Therapies
*** In the event of severe penicillin allergy, documented resistance
of Bacillus anthracis to penicillin, inability to administer the
frequent IV dosing required for penicillin, or the exhaustion of penicillin
supplies; Ciprofloxacin (400 mg IV every 12 hours), Ofloxacin (400
mg IV or orally every 8 to 12 hours), Levofloxacin (500 mg IV or orally
every 24 hours) or Doxycycline (100 mg IV every 12 hours) (if
proven susceptible) are the preferred alternatives.
In addition, the following drugs have been shown to have in vitro
activity against anthrax and could potentially be used as alternative agents
in the event of an emergency, if the preferred antimicrobials listed above
are unavailable or in short supply:
| erythromycin |
|
aminoglycosides |
|
vancomycin |
| imipenem |
|
cephalothin/cefazolin |
|
chloramphenicol |
| clindamycin |
|
tetracycline |
|
extended-spectrum penicillins |
*** In vitro testing suggests that B. anthracis is generally
resistant to sulfamethoxazole, trimethoprim, cefuroxime, cefotaxime, ceftriaxone,
ceftazadime, and aztreonam. Therefore, these antibiotics should not be used
for treatment or prophylaxis of anthrax infection.***
Therapy in pediatric patients and pregnant women
-
For penicillin-resistant anthrax, although ciprofloxacin is not generally
given to children less than 16 years of age due to concerns about the development
of arthropathy, the high mortality rate from anthrax infection weighs heavily
in favor of using ciprofloxacin in this clinical situation.
Ciprofloxacin should be given at 20-30 mg/kg/day orally or IV in
2 divided doses, not to exceed 1 gram/day.
-
For penicillin-susceptible anthrax, Penicillin G is the drug
of choice. The recommended intravenous dose for children with severe
cutaneous anthrax, inhalation anthrax, or gastrointestinal anthrax is 250,000
units/kg body weight/day administered every 4 hours. Amoxicillin
500 mg IV every 8 hours for children > 20 kg and 40 mg/kg/day IV in divided
doses every 8 hours for children < 20 kg, is an alternative antibiotic.
Oral formulations can be used for milder disease or when IV therapy is not
available.
-
If ciprofloxacin supplies are exhausted and the patient is penicillin allergic
or the anthrax strain is not susceptible to penicillin, doxycycline
would be the preferred alternative agent (5 mg/kg/day IV or orally divided
every 12 hours). Although doxycycline is not routinely administered to children
< 8 years of age because of the risk of discoloration of teeth, the high
mortality rate from systemic anthrax makes use of this agent the greater
priority.
-
Penicillin G is the drug of choice for pregnant women, if
the isolate is penicillin-susceptible. The dosing schedule is as outlined
for adults above. Ciprofloxacin, although not routinely prescribed
during pregnancy, is the preferred alternative drug for penicillin-resistant
strains, as tetracyclines can result in rare but serious liver toxicity during
pregnancy. If doxycycline is used because of exhaustion of quinolone supplies
or severe allergy to either penicillin or ciprofloxacin, liver function tests
should be performed.
Vaccination and Duration of Therapy
-
All patients treated for inhalational anthrax should also receive anthrax
vaccine due to the risk that delayed germination of mediastinal spores can
result in disease recurrence. Three doses of vaccine (Days 0, 14 and 28)
should be administered.
-
In the absence of available anthrax vaccine, antibiotic treatment for inhalation
anthrax should be continued for 60 days. (Patients should be switched to
oral medications, as soon as possible.) If anthrax vaccine is available for
post- exposure vaccination, antibiotic therapy can be discontinued after
three doses of vaccine (Days 0, 14, and 28) have been administered.
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Isolation of Patients
Inhalation, cutaneous and gastrointestinal anthrax have never been transmitted
directly from human-to-human. All staff should observe Standard
Precautions when caring for patients with suspected or confirmed anthrax.
In addition, the following is advised:
-
For cutaneous anthrax, cover the lesion with a sterile dressing. Contact
Wound and skin precautions should be observed for patients with skin lesions.
-
Gloves should be worn for touching potentially infective material; gowns
should be worn only if soiling is likely. Masks are not necessary, since
patients with inhalation anthrax do not produce small particle aerosols
containing sufficient spore counts (8,000 to 10,000 spores) to cause secondary
infections.
-
HANDS MUST BE WASHED AFTER TOUCHING THE PATIENT OR POTENTIALLY CONTAMINATED
ARTICLES AND BEFORE TAKING CARE OF ANOTHER PATIENT.
-
Patients do not require isolation rooms.
-
Articles contaminated with infective material including bandages should be
discarded and bagged and labeled before being sent for decontamination and
reprocessing.
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Disposal of Infectious Waste
Use of tracking forms, containment, storage, packaging, treatment and disposal
methods should be based upon the same rules as all other regulated medical
wastes.
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-
Autopsy and Handling of Corpses
All postmortem procedures should be performed using Universal
Precautions.
-
All persons performing or assisting in postmortem procedures must wear mandated
P.P.E. (personal protective equipment) as delineated by O.S.H.A. guidelines.
-
Instruments should be autoclaved or sterilized with a 10% bleach solution
or other solutions approved by O.S.H.A. Surfaces contaminated during postmortem
procedures should be decontaminated with an appropriate chemical germicide
such as iodine, 10% hypochlorite or 5% phenol (carbolic acid).
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Management of Exposed Persons
In the event of a bioterrorist release of Bacillus anthracis spores,
it may be difficult to define who has been exposed. Once the site of the
attack is determined, all persons at the site of the release or downwind
of the release (assuming an aerosol dispersal) would be considered potentially
exposed.
Since inhalation anthrax does not spread from person to person, household
and other contacts (such as healthcare workers caring for cases) of exposed
persons are not considered exposed and do not require prophylaxis (unless
they too were exposed to the aerosolized anthrax spores at the time of the
attack).
-
Inhalational exposures: Initiation of antibiotic therapy quickly after
exposure has been shown to markedly reduce the mortality of inhalation anthrax
in animal studies. The best available prophylactic regimen is the combination
of antibiotic therapy and vaccination. Antibiotic susceptibility information
on clinical isolates should guide prophylactic antibiotic choices.
While awaiting antibiotic susceptibility test results, or if susceptibility
results confirm penicillin resistance, begin therapy immediately
with oral ciprofloxacin (500 mg po bid), levofloxacin (500
mg po per day), ofloxacin (400 mg po per bid), or
doxycycline (100 mg po bid). If the isolate is penicillin
susceptible, potassium penicillin V (30 mg/kg/day in 4
divided doses) or amoxicillin (500 mg po every 8 hours) are the
preferred preventive treatment.
-
Recommendations for prophylactic treatment of children, while awaiting
antibiotic susceptibility results or if susceptibility results confirm
penicillin resistance, include: ciprofloxacin (20-30 mg per kg
of body mass per day divided every 12 hours) or doxycycline (5 mg per kg
of body mass per day divided every 12 hours). If the isolate is
penicillin-susceptible, all children should be treated with
a penicillin antibiotic (for children weighing at least 20 kg, amoxicillin
500 mg po every 8 hours; for children < 20 kg, amoxicillin 40 mg per kg
per day in divided doses every 8 hours).
-
Duration of antibiotic prophylaxis: Therapy should be continued for
at least 4 weeks, or until three doses of anthrax vaccine have been
administered (Days 0, 14 and 28). If vaccine is unavailable, antibiotic
prophylaxis should be continued for at least 60 days, and withdrawn under
medical supervision.
-
Exposures through cuts, abrasions or injections: Immediately wash
the infected part, and apply a disinfectant solution such as hypochlorite
solution. Promptly begin therapy as outlined under the treatment section
for "Cutaneous anthrax-mild disease"; continue therapy for 7-10 days. Anthrax
vaccine is not indicated.
-
Ingestional exposures: Treat as for exposure by cuts or abrasions.
-
All persons exposed to anthrax should be instructed to watch for
signs/symptoms of flu-like illness for at least 7 days. Should such symptoms
occur, patients must be immediately evaluated by a physician for the possible
institution of intravenous antibiotic therapy.
-
VACCINATION - An alum-absorbed, cell-free killed vaccine for anthrax
has been developed and used primarily by the military and laboratory
workers/veterinarians. The vaccine efficacy against cutaneous anthrax has
been documented for humans; evidence for protection against inhalation and
gastrointestinal anthrax is limited to animal studies.
For prophylaxis, the vaccine is given parenterally (0.5mL subcutaneously)
in three doses 2 weeks apart (Days 0, 14 and 28). Currently, there are limited
vaccine supplies in the United States, and distribution is restricted to
the military or persons at high-risk due to occupational exposures. (NOTE:
Data from animal studies suggest that two doses of anthrax vaccine given
two weeks apart may be sufficient, and in the setting of limited vaccine
supplies may be a practical alternative).
Adverse reactions to anthrax vaccine are not common. About 6% of patients
may develop a local reaction and 2-3% experience mild systemic symptoms.
(NOTE: The FDA has only licensed the vaccine for use in healthy adults
aged 18-65 years; the safety and efficacy of the vaccine for children and
pregnant women has not been studied).
For current information about the availability of human anthrax vaccine,
call the New York City Department of Health, Bureau of Communicable Disease
212-788-9830.
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Reporting to the Health Department
Human and animal anthrax are reportable diseases in New York City and
New York State. All suspect human cases should be reported
immediately by phone:
-
During business hours
-
-
Report suspect cases of human anthrax to:
1st: New York City Department of Health at
212-788-9830
2nd: New York State Department of Health at 518-473-4439.
-
Report cases of animal anthrax to:
1st: New York City Department of Health, Bureau of Veterinary
Public Health Services 212-676-2120
2nd: New York State Public Health Veterinarian at
518-474-4436
3rd: New York State Division of Animal Industry at
518-457-3502
-
After business hours
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References
Benenson AS, ed. Control of Communicable Diseases Manual. 16th ed.
Washington, DC: American Public Health Association; 1995:18-22.
Brachman PS. Anthrax. In: Hoeprich PD, Jordan MC, Ronald AR., eds.
Infectious Diseases: a treatise of infectious processes. 5th ed.
Philadelphia, PA: J.B. Lippincott Company; 1994:1003-1008.
Edward M. Anthrax. In: Feigin RD, Cherry JD, eds. Textbook of Pediatric
Infectious Diseases. 3rd ed. Philadelphia, PA; 1992:1053-1056.
Fleming DO, Richardson JH, Tulis JJ, Vesley D, eds. Laboratory Safety
Principles and Practices. 2nd ed. Washington, DC: American Society for
Microbiology;1995:324.
Friedlander AM. Anthrax. In: Sidell FR, Takafuji ET, Franz DR, eds.
Textbook of Military Medicine. Washington, D.C.: Office of the Surgeon
General at TMM Publications; 1997:467-478.
Inglesby TV, Henderson DA, Bartlett JG, et al. Anthrax: Civilian Medical
and Public Health Management following use of a Biological Weapon.
JAMA 1999: (in press).
LaForce FM. Anthrax. Clin Infect Dis. 1994;19:1009-1014.
Lew D. Bacillus Anthracis (Anthrax). In: Mandell G, Bennett J, Dolin
R, eds. Principles and Practice of Infectious Diseases.
4th ed. New York: Churchill Livingstone; 1995:1885-1889.
Meselson M, Guillemin J, Hugh-Jones M, et al. The Sverdlosk anthrax outbreak
of 1979. Science 1994;226:1202-1208.
Pile JC, Malone JD, Eitzen EM, Friedlander AM. Anthrax as a potential biological
warfare agent. Arch Intern Med. 1998;158:429-434.
Turnbull PCB, Kramer JM. Bacillus. In: Balows A, Haulser WJ, Herrman KL,
Shadomy HJ, eds. Manual of Clinical Microbiology 5th ed. Washington,
DC: American Society for Microbiology; 1991:298-299.
US Army Medical Research Institute of Infectious Diseases. Medical Management
of Biological Casualties. 3rd Edition. Fort Detrick, MD. 1998.
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Table 1: Inhalational Anthrax Treatment and Prophylaxis
|
Therapy |
Prophylaxis* |
|
Adult Doses |
Adult Doses |
| Susceptibility Results Unknown or Penicillin-
Resistant** |
Ciprofloxacin 400mg IV q 8- 12h
(Alternative quinolones include: ofloxacin 400mg IV q 8-12h or
levofloxacin (500mg IV q 24h)
Doxycycline 200mg IV x 1, then 100mg IV q 12h (if
tetracycline-susceptible) |
Ciprofloxacin 500mg po bid
(Alternative quinolones include: ofloxacin 400mg po q 8- 12h or
levofloxacin (500mg po q 24h
Doxycycline 100mg po bid (if tetracycline susceptible) |
| Penicillin Susceptible |
Penicillin G 80,000 units per kg in 1st hour followed
by 320,000 units/kg/day. (Average adult dose is 4 million units q 4hr
or 2 million units q 2h)
Amoxicillin 500mg IV q 8h |
Penicillin VK 30mg/kg/d in 4 divided doses
Amoxicillin 500mg po q 8h |
|
Pediatric Doses |
Pediatric Doses |
| Susceptibility results unknown or penicillin- resistant |
Ciprofloxacin 20-30mg/kg/day IV in 2 divided doses
(maximum daily dose not to exceed 1 gram/d)
Doxycycline (if ciprofloxacin not available) 4 mg/kg/d IV in 2 divided
doses |
Ciprofloxacin 20-30mg/kg per day po divided in
2 doses
Doxycycline 5mg/kg/per day in 2 divided doses |
| Penicillin-susceptibility |
Penicillin G 250,000 units/kg per day IV administered
every 4 hours
Amoxacillin 500mg IV q 8h if > 20kg
or
40mg/kg per day IV divided into 3 doses if < 20kg |
Penicillin VK 30 mg/kg per day po administered
in 4 divided doses
Amoxicillin 500mg po q 8h if > 20kg
or
40mg/kg per day po divided in 3 doses if < 20kg |
| * |
Antibiotic prophylaxis should be continued for
60 days if anthrax vaccine is not available (or if vaccine is available,
antibiotics should be continued until 3rd dose of vaccine has been
administered). |
|
| ** |
In pregnant women, penicillin-resistant anthrax
should be treated with ciprofloxacin. If doxycycline is used, liver function
tests should be monitored closely. |
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