Jim Martin, Commissioner

Kathleen E. Toomey, M.D., M.P.H., Division Director

Georgia Department of Human Resources • Division of Public Health

Two Peachtree Street NW • Suite 15-470 • Atlanta, Georgia 30303-3186 • Tel: (404) 657-2700 • Fax: (404) 657-2715

 

GDPH Guidelines for Anthrax (B. anthracis ) Diagnostic Testing

(revised 10/16/01) 

 

Asymptomatic Persons WITHOUT Known Exposure to Anthrax

(“Worried well”—includes low risk threats)

·        Provide reassurance about the low risk for infection without known exposure and education about anthrax as an agent in bioterrorism;

·        Recommend referral to private health care provider for further concerns and/or diagnostics as deemed appropriate.  Currently, no screening tests are available for the detection of anthrax infection in the absence of symptoms.  Nasal swabs may be useful as an epidemiologic tool when a confirmed case is identified but are not routinely used for diagnosis or screening. CDC currently does NOT recommend the use of nasal swab specimens as part of evaluating anthrax threats/implied threats or evaluating concerned citizens who think they may have been exposed to anthrax.

 

Asymptomatic Persons WITH Known Exposure to Anthrax or to Credible Anthrax Threats

·        Conduct individual risk assessment in coordination with public health officials and refer to private health care provider if post-exposure prophylaxis is necessary.  Currently, no screening tests are available for the detection of anthrax infection in the absence of symptoms.  Although data are limited, nasal swabs may be useful if performed early (within 0-24 hours) following known or credible inhalation exposure to B. anthracis.

·        In this situation, decontamination of patients and their clothing is NOT routinely recommended.

·        Patients should be educated regarding clinical symptoms of anthrax infection and advised to seek medical attention immediately if they develop fever or flu-like illness.

 

        Post-exposure Prophylaxis (PEP) Recommendations (per CDC Health Alert, 10/14/01)

 

 

Initial therapy

Duration

Adults (including pregnant woman 1,2 and immmunocompromised) 

Ciprofloxacin 500 mg po BID

                 Or

Doxycycline 100 mg po BID

60 days

Children 1,3

 

Ciprofloxacin 15-20 mg/kg po Q12 hrs 4

                  Or

Doxycycline 5:

   >8 yrs and >45 kg: 100 mg po BID

   >8 yrs and ≤ 45 kg: 2.2 mg/kg po BID

   ≤ 8 yrs: same as >8 yrs and ≤ 45 kg

60 days

           

1.       If susceptibility testing allows, therapy should be changed to oral amoxicillin for post-exposure prophylaxis to continue therapy out to 60 days.

2.       Although tetracyclines are not recommended during pregnancy, their use may be indicated for life-threatening illness.  Adverse affects on developing teeth and bones are dose related, therefore, doxycycline might be used for a short course of therapy (7-14 days) prior to the 6th month of gestation.  Please consult physician after the 6th month of gestation for recommendations.

3.       Use of tetracyclines and fluoroquinolones in children has adverse effects.  These risks must be weighed carefully against the risk for developing life-threatening disease.  If a release of B. anthracis is confirmed, children should be treated initially with ciprofloxacin or doxycycline as prophylaxis but therapy should be changed to oral amoxicillin 40 mg/kg of body mass per day divided every 8 hours (not to exceed 500 mg three times daily) as soon as penicillin susceptibility of the organism has been confirmed.

4.       Ciprofloxacin dose should not exceed 1 gram/day in children.

5.      In 1991, the American Academy of Pediatrics amended their recommendation to allow treatment of young children with tetracyclines for serious infections, such as, Rocky Mountain Spotted Fever, for which doxycycline may be indicated.  Doxycycline is preferred for its twice-a-day dosing and low incidence of gastrointestinal side effects.

 

Postexposure prophylaxis may be discontinued if laboratory studies and investigation have ruled out the presence of B. anthracis.

 

Hospitalized Patients with Symptoms Compatible with Anthrax* (see below)

·        Immediately notify local, district, and state public health officials so that rapid epidemiologic investigation can be initiated.

·        Confirm the diagnosis: Obtain the appropriate laboratory specimens based on clinical form of anthrax (inhalational, gastrointestinal, or cutaneous) suspected.

-        Specimens for possible cutaneous anthrax: vesicular fluid (Gram stain & culture) and/or blood cultures

-        Specimens for possible gastrointestinal anthrax: vomitus, feces, and/or blood cultures

-        Specimens for possible inhalational anthrax: nasal swab, blood, CSF, and/or sputum cultures

-        For further information on specimen collection and handling, refer to attached protocol, “Laboratory Procedures for the identification of Bacillus anthracis”.

·        Note: A widened mediastinum on chest radiograph with respiratory distress in a previously healthy patient with antecedent flu-like illness is highly suspect for advanced inhalational anthrax.

·        Initial microbiologic testing for presumptive anthrax diagnosis should be performed in hospital clinical laboratories according to the attached protocol.

 

*Signs and Symptoms of Anthrax Infection

 

Inhalational anthrax:  A brief prodrome resembling a viral respiratory illness followed by development of hypoxia and dyspnea, with radiographic evidence of mediastinal widening.  This, the most lethal, form of anthrax results from inspiration of 8,000-40,000 spores of B. anthracis. The incubation of inhalational anthrax among humans is unclear, but it is reported to range between 1 and 7 days possibly ranging up to 42 days.  Host factors, dose of exposure and chemoprophylaxis may play a role. Initial symptoms include sore throat, mild fever, muscle aches and malaise. These may progress to respiratory failure and shock. Meningitis frequently develops. Case-fatality estimates for inhalational anthrax are based on incomplete information regarding exposed populations and infected populations in the few case series and studies that have been published. However, case-fatality is extremely high, even with all possible supportive care including appropriate antibiotics. Records of industrially acquired inhalational anthrax in the United Kingdom before antibiotics were available reveal that 97% of cases were fatal.  With antibiotic treatment the fatality rate is estimated to be at least 75%.  Though estimates of the impact of the delay in postexposure prophylaxis or treatment on survival can only be approximated, it has been suggested that or each day of delay postexposure in initiating prophylaxis the case-fatality rate increases by 5 to 10%.

 

Gastrointestinal anthrax:  Severe abdominal distress followed by fever and signs of septicemia.  This form of anthrax usually follows the consumption of raw or undercooked contaminated meat and is considered to have an incubation period of 1-7 days. An oropharyngeal and an abdominal form of the disease have been described in this category. Involvement of the pharynx is usually characterized by lesions at the base of the tongue, sore throat, dysphagia, fever, and regional lymphadenopathy. Lower bowel inflammation usually causes nausea, loss of appetite, vomiting and fever, followed by abdominal pain, vomiting blood and bloody diarrhea. The case-fatality is estimated to be 25-60%, and the effect of early antibiotic treatment on that case-fatality is not defined.

 

Cutaneous anthrax:  A skin lesion evolving from a papule, through a vesicular stage, to a depressed black eschar.  This is the most common naturally occurring type of infection (>95%) and usually occurs after skin contact with contaminated meat, wool, hides or leather from infected animals.  Incubation period ranges from 1-12 days. Skin infection begins as a small papule, progresses to a vesicle in 1-2 days followed by a necrotic ulcer.  The lesion is usually painless, but patients also may have fever, malaise, headache and regional lymphadenopathy.  The case fatality for cutaneous anthrax is 20% without and 1% with antibiotic treatment.

 

 

Important Contact Information

 

During business hours:                                                          Non-business hours

Dr. Cherie Drenzek                  404-657-6452                         Answering service

Dr. Susan Lance-Parker           404-657-2617                         770-578-4104

Dr. Julie Fletcher                      404-657-2629

Dr. Travis Sanchez                   404-657-1105

Dr. Katie Arnold                      404-657-6438

Dr. Paul Blake              404-657-2609

Lee Smith                                 404-463-2743

 

 

For further information, please call the Georgia Division of Public Health Event Information Line, operated by the Georgia Poison Center, at 1-866-752-3442 (toll-free, 24 hours/day, 7 days/week).

 

Also, please visit the Georgia Division of Public Health Bioterrorism webpage at http://health.state.ga.us/programs/emerprep/bioterrorism.shtml