���������������
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.
�
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.
�
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.
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