Anthrax

1. Anthrax Bacillus anthracis

2. Microbiology • Bacillus anthracis

3. Microbiology • Bacillus anthracis • Aerobic, large Gram positive bacillus

4. Microbiology • Bacillus anthracis • Aerobic, large Gram positive bacillus • Non-motile, non-hemolytic

5. Microbiology • Bacillus anthracis • Aerobic, large Gram positive bacillus • Non-motile, non-hemolytic

6. Microbiology • Bacillus anthracis • Aerobic, large Gram positive bacillus • Non-motile, non-hemolytic • Forms hardy spores • Triggered by harsh environment • Inert but infectious • 1m size

7. Jernigan, et al. EID. 2001;7:933-944.

8. Dixon, et al. NEJM. 1999;341:815-26.

9. Borio, et al. JAMA. 2001;286:2554-2559

10. Photo courtesy of the Tropical Medicine Institute, UPCH

11. Diagnosis of Anthrax • High index of suspicion necessary • No readily available rapid test • Gold Standard - culture blood, fluids • Prior to antibiotics

12. Diagnosis of Anthrax • High index of suspicion necessary • No readily available rapid test • Gold Standard - culture blood, fluids • Prior to antibiotics • Confirmation by reference labs • PCR, special stains, serology, etc

13. Diagnosis of Anthrax • High index of suspicion necessary • No readily available rapid test • Gold Standard - culture blood, fluids • Prior to antibiotics • Confirmation by reference labs • PCR, special stains, serology, etc • Nasal swabs not a diagnostic tool

14. Treatment • Hospitalization • IV antibiotics • Empiric until sensitivities known • Intensive supportive care • Electrolyte and acid-base imbalances • Mechanical ventilation • Hemodynamic support

15. Treatment • Hospitalization • IV antibiotics • Empiric until sensitivities known • Intensive supportive care • Electrolyte and acid-base imbalances • Mechanical ventilation • Hemodynamic support • Steroids • Consider for severe disease

16. Treatment • Empiric therapy for inhalational (Adults)

17. Treatment • Empiric therapy for inhalational (Adults) • Ciprofloxacin 400 mg IV q12° OR Doxycycline 100 mg IV q12° AND One or two other antibiotics - clindamycin - penicillin - vancomycin - chloramphenicol - rifampin - imipenem

18. Treatment • Empiric therapy for inhalational (Adults) • Ciprofloxacin 400 mg IV q12° OR Doxycycline 100 mg IV q12° AND One or two other antibiotics - clindamycin - penicillin - vancomycin - chloramphenicol - rifampin - imipenem • Avoid macrolides, cephalosporins, sulfa

19. Treatment • Empiric therapy for inhalational (Children) Ciprofloxacin 10-15 mg/kg/d IV q12° (max 1 g/d)

20. Treatment • Empiric therapy for inhalational (Children) Ciprofloxacin 10-15 mg/kg/d IV q12° (max 1 g/d) OR Doxycycline 2.2 mg/kg IV q12° (adult dose >8yo/45 kg)

21. Treatment • Empiric therapy for inhalational (Children) Ciprofloxacin 10-15 mg/kg/d IV q12° (max 1 g/d) OR Doxycycline 2.2 mg/kg IV q12° (adult dose >8yo/45 kg) AND One or two antibiotics (same as adult)

22. Treatment • Empiric therapy for inhalational(Children) Ciprofloxacin 10-15 mg/kg/d IV q12° (max 1 g/d) OR Doxycycline 2.2 mg/kg IV q12° (adult dose >8yo/45 kg) AND One or two antibiotics (same as adult) • Weigh risks (arthropathy, dental enamel)

23. Treatment • Empiric therapy for cutaneous • Same as inhalational regimen if: • Systemic disease • Extensive edema • Head/neck lesions

24. Treatment • Empiric therapy for cutaneous • Same as inhalational regimen if: • Systemic disease • Extensive edema • Head/neck lesions • Localized cutaneous • Ciprofloxacin 500mg po bid OR • Doxycycline 100mg po bid

25. Treatment • Empiric therapy for cutaneous • Same as inhalational regimen if: • Systemic disease • Extensive edema • Head/neck lesions • Localized cutaneous • Ciprofloxacin 500mg po bid OR • Doxycycline 100mg po bid • Empiric therapy for GI • Same as inhalational

26. Treatment • Antibiotic therapy – all forms • Adjust per sensitivities • Duration • 60 days - delayed spore germination • Follow closely after cessation

27. Treatment • Antibiotic therapy – all forms • Adjust per sensitivities • Duration • 60 days - delayed spore germination • Follow closely after cessation • Switch to oral • Clinical improvement, able to tolerate po • 1 or 2 drugs including cipro or doxy initially • Children can complete course with amoxicillin

28. Treatment • Antibiotic therapy – all forms • No role for vaccine in treatment

29. Post-Exposure Prophylaxis

30. Post-Exposure Prophylaxis • Indications • Exposure to anthrax spores • Not for contacts of cases

31. Post-Exposure Prophylaxis • Indications • Exposure to anthrax spores • Not for contacts of cases • Oral antibiotics • Ciprofloxacin 500mg po bid OR • Doxycycline 100mg po bid • Duration 60-100 days

32. Post-Exposure Prophylaxis • Indications • Exposure to anthrax spores • Not for contacts of cases • Oral antibiotics • Ciprofloxacin 500mg po bid OR • Doxycycline 100mg po bid • Duration 60-100 days • +/- Vaccination • May reduce PEP duration to 30 days

33. Vaccination

34. Vaccination • Limited supply

35. Vaccination • Limited supply • Inactivated, cell-free vaccine

36. Vaccination • Limited supply • Inactivated, cell-free vaccine • Effective • >95% animals vs. inhalational • Protective for humans vs. cutaneous

37. Vaccination • Limited supply • Inactivated, cell-free vaccine • Effective • >95% animals vs. inhalational • Protective for humans vs. cutaneous • Well-tolerated • Uncommon adverse effects • No reported deaths

38. Infection Control • Person-to-person transmission • None for inhalational • Rarely reported for cutaneous

39. Infection Control • Person-to-person transmission • None for inhalational • Rarely reported for cutaneous • Patient handling • Standard precautions • Gloves for draining lesions

40. Infection Control • Person-to-person transmission • None for inhalational • Rarely reported for cutaneous • Patient handling • Standard precautions • Gloves for draining lesions • Laboratory safety • BSL-2 for clinical specimens • BSL-3 for environmental or large volume