West Virginia Department of Health and Human
Resources Information for Physicians - Anthrax
These guidelines are provided to assist health care
providers in assessing and reassuring the "worried well" and
others who may be seeking care based upon concern about anthrax. There
have been NO known anthrax exposures in West Virginia since the
events of 11 September, and historically, the last reported human cases of
anthrax occurred in our state in 1947.
Asymptomatic patient WITHOUT known exposure
- Provide reassurance about the rarity of anthrax
infection without known exposure.
- Explain that there is no screening test available
for the detection of anthrax disease in asymptomatic persons.
- Discourage requests for nasal swab and blood
serum tests. These tests are for epidemiologic investigation of populations
in the setting of confirmed or suspected exposure. They have no
utility in the management of individual patients.
- Recommend that the patient return IF they become
ill with symptoms that would prompt them to seek medical care under
normal circumstances.
- Do not prescribe even a short course of
antibiotics to asymptomatic patients to allay their fears.
Asymptomatic patient with contact with powdery
material
- Since September 11, 2001, the West Virginia
Department of Health and Human Resources has tested hundreds of
"suspicious" powders, letters, and other substances. None
have tested positive for anthrax. Nonetheless, every incident should
be evaluated individually.
- If the exposure was associated with a threat, the
incident should be reported to the FBI.
- The local health department in collaboration with
the Infectious Disease Epidemiology Program can assist with
recommendations on patient management.
Asymptomatic patient WITH highly likely or verified
exposure
- Any allegation of exposure to BT agents should be
reported immediately to the local health department and the FBI.
- Consult the local health department to perform an
individual risk assessment. If high risk status is confirmed, begin
prophylactic medication (see Post-Exposure Prophylaxis Recommendations
below).
- Although no screening tests are available for
detection of anthrax in an asymptomatic individual, public
health officials may request a nasal swab and/or a serum sample to
assist in epidemiological evaluation of an exposed or potentially
exposed population.
Post-Exposure Prophylaxis (PEP) Recommendations (MMWR,
2001; 50:893)
Post-Exposure Prophylaxis (PEP)
Recommendations
|
| Patient |
Initial Therapy |
Duration |
| Adults (including
immunocompromised persons)* |
Ciprofloxacin 500 mg po BID
OR
Doxycycline 100 mg po BID |
60 days |
| Children |
Ciprofloxacin 10-15
mg/kg po Q 12 H
(not to exceed 1 gram per day)
OR
Doxycycline
> 8 yrs and > 45 kg: 100 mg po BID
> 8 yrs and < 45 kg: 2.2 mg/kg po BID
< 8 yrs: 2.2 mg/kg po BID
OR
Amoxicillin 80 mg/kg/day PO
divided Q 8 H; maximum 500 mg/dose
IF B. anthracis is known to be susceptible** |
60 days |
* The antimicrobial of choice for initial
prophylactic therapy among asymptomatic pregnant women exposed to B.
anthracis is ciprofloxacin, 500 mg po BID for 60 days. In instances in
which the specific B. anthracis strain has been shown to be
penicillin-sensitive, prophylactic therapy with amoxicillin, 500 mg TID
for 60 days may be considered. Doxycycline should be used with caution in
asymptomatic pregnant women and only when contraindications are present to
other appropriate drugs (MMWR, 2001; 50:960).
** Amoxicillin is an option for
antimicrobial prophylaxis of children and pregnant women when B.
anthracis is known to be susceptible to penicillin (MMWR, 2001;
50:1014).
Patients with "flu-like" symptoms
- In the early stages, anthrax presents with an
influenza-like prodrome. In an individual patient, no one symptom,
symptom complex, or laboratory test reliably distinguishes anthrax
from influenza in the early stages; however:
- Anthrax is rare in patients without known
exposure.
- In a population, patients with influenza
are more likely to have rhinorrhea, and patients with anthrax are
more likely to have shortness of breath and/or nausea or vomiting
(see table below).
- All recent patients in the U.S. with anthrax
presented with abnormalities on chest X-ray. In some cases,
abnormalities were subtle.
- Any cluster of severe respiratory illness
should always raise suspicion of a bioterrorist event, especially if
it is occurring in previously healthy individuals or out-of-season.
The local health department should be alerted to begin investigation
immediately.
- Sensitivity and specificity of rapid tests for
influenza range from 45% to 90%, and 60% to 95%, respectively. Rapid
tests confirmed with culture are very useful for determining if
influenza is circulating in specific populations (e.g. a group of
patients with similar symptoms in a nursing home, physician's office,
or emergency room). Rapid tests for influenza may have limited
utility in diagnosis of influenza in individual patients.
However, knowing whether influenza is circulating in the community is
extremely useful in diagnosis of influenza-like illness. Contact your
local health department or Infectious Disease Epidemiology Program at
304-558-5358 (8:30 to 5:00) or pager 1-888-882-5235 at any time for
information on influenza surveillance.
- Nasal swabs and/or serum samples for anthrax
testing should not be used for screening purposes.
- Do not prescribe an antibiotic for viral illness.
- For additional information on influenza in West
Virginia, visit the Infectious Disease Epidemiology Program's
influenza website at wvdhhr.org/bph/oehp/sdc/flu_surv.htm
- For additional information on diagnosis of
influenza and anthrax, see MMWR, 2001; 50(44):984-6.
Symptoms and signs of inhalational anthrax,
laboratory-confirmed influenza, and influenza-like illness (ILI) from
other causes (MMWR, 2001; 50 (44):984-6)
Symptom/Sign
|
Inhalational anthrax
(n=10)
|
Laboratory-confirmed
influenza
|
ILI from other causes
|
| Elevated temperature |
70% |
68% - 77% |
40% - 73% |
| Fever or chills |
100% |
83% - 90% |
75% - 89% |
| Fatigue/malaise |
100% |
75% - 94% |
62% - 94% |
| Cough (minimal or
non-productive) |
90% |
84% - 93% |
72% - 80% |
| Shortness of breath |
80% |
6% |
6% |
| Chest discomfort or
pleuritic chest pain |
60% |
35% |
23% |
| Headache |
50% |
84% - 91% |
74% - 89% |
| Myalgias |
50% |
67% - 94% |
73% - 94% |
| Sore throat |
20% |
64% - 84% |
64% - 84% |
| Rhinorrhea |
10% |
79% |
68% |
| Nausea or vomiting |
80% |
12% |
12% |
| Abdominal pain |
30% |
22% |
22% |
Patients with signs and symptoms compatible with
anthrax – CDC Interim Guidelines (MMWR, 2001; 50:941)
Inhalational Anthrax:
History
of exposure, or occupational/
environmental risk with two to five day illness of:
Symptoms
- Fever with or without chills
- Sweats, often drenching
- Fatigue, malaise
- Cough (usually nonproductive),
shortness of breath
- Chest discomfort, pleuritic pain
- Nausea, vomiting, diarrhea,
abdominal pain
- Headache, myalgias
- Sore throat
Signs
|
NO
 |
- Observe closely
- Provide antimicrobial prophylaxis
if exposure is confirmed
|
|
YES
 |
|
Initial
evaluation
- Obtain white blood cell count (WBC),
chest radiograph (CR), and blood cultures
- WBC: normal to elevated;
neutrophilia with bands
- CR: Mediastinal widening;
pleural effusion, pulmonary infiltrate
- Consider chest computerized
tomography (CT) if CR is normal
- Consider rapid diagnostic testing
for influenza
- Notify public health authorities
|
|
|
|
WBC,
CR, CT within normal limits and patient mildly ill
- Observe closely for development of
new symptoms
- Await blood cultures
- Initiate or continue prophylaxis
(if exposure confirmed)
|
Either
WBC, CR, CT abnormal or patient moderately or severely ill
- Begin antimicrobial therapy
- If pleural effusion present,
obtain fluid for gram stain and culture, polymerase chain
reaction, and cell block for immunohistochemistry
- If meningeal signs or altered
mental status present, perform lumbar puncture
- Other diagnostic tests (consult
IDEP)
|
Cutaneous Anthrax:
|
Typical appearance and
progression of cutaneous anthrax
Painless or pruritic papule or
pustule
Vesicular or ulcerative lesion
Black eschar |
|
- Obtain gram stain and culture of skin
lesion
- Unroofed vesicle fluid (dry swab)
- Base of ulcer (moist swab)
- Edges of or underneath eschar (moist
swab)
- Obtain blood cultures
- Consider skin (punch) biopsy if patient is
on antimicrobial drugs OR if gram stain and culture are negative
for B. anthracis and clinical suspicion remains high
- Start empiric therapy for cutaneous B.
anthracis
- Notify public health authorities
|
|
|
|
|
|
|
|
Culture
negative and no progression of papule to eschar, cutaneous anthrax
unlikely |
Culture
positive |
Progression
to eschar |
|
|
|
|
|
|
|
|
Continue
antimicrobial therapy |
Treatment of anthrax
- Initial treatment of inhalational or GI anthrax
requires ciprofloxacin or doxycycline IV and one or two other
antimicrobial agents in children, adults, and pregnant women;
including the immunocompromised.
- Susceptibility testing of the isolate is
imperative.
- Consultation with an infectious disease
specialist is advised.
- After recovery, treatment may be continued with
oral doxycycline or ciprofloxacin for a total of 60 days of therapy.
- Oral ciprofloxacin or doxycycline are the options
for initial treatment of uncomplicated cutaneous anthrax. If there is
systemic involvement, edema, or if the lesions are on the head or
neck, intravenous therapy is required. If the isolate is known to be
penicillin-sensitive, treatment may be completed with amoxicillin.
- See MMWR, 2001;50:909-919 and MMWR, 2001;
50:1014-1016 for additional details.
For more information or to report a confirmed or
suspect case of anthrax or a cluster of severe respiratory disease,
contact your local health department or the Infectious Disease
Epidemiology Program at 304-558-5358 or pager 1-888-882-5235.
|
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