Anthrax

Anthrax - Acute

 

Definition  

A bacterial infectious disease of the skin, respiratory tract, or gastrointestinal tract caused by Bacillus anthracis

 

Medical History  

* Victim of bio-terrorism

* Occupational Exposure

 

Findings  

* Fever

* Abnormal breath sounds

* Chest pain - Acute

* Cough

* Dyspnea - Acute

* Nausea and vomiting - Acute

* Diaphoresis

* Headache

* Hypotension

* Increased heart rate

* Lymphadenopathy - Acute

* Tachypnea

* Focal neurological signs

* Nuchal rigidity

* Edematous skin

* Lesion of eyelid

* Pruritus - Acute

* Skin eschar

* Skin lesion

* Abdominal pain - Acute

* Ascites - Acute

* Diarrhea

* Cervical lymphadenopathy

* Localized edema

* Nasal symptom

* Pain in throat

 

Tests  

 

Suspected anthrax  

* Blood culture, Bacillus anthracis: Blood cultures in anthrax often show growth of large gram-positive bacilli which form tenacious, nonhemolytic colonies when inoculated on agar plates .

 

Suspected anthrax meningitis .  

* Cerebrospinal fluid examination: Hemorrhagic cerebrospinal fluid showing pleocytosis, low glucose, and gram-positive rods on Gram stain is highly suggestive of anthrax meningitis .

 

Suspected anthrax meningitis  

* Cerebrospinal fluid culture: Bacillus anthracis is often cultured from cerebrospinal fluid (CSF) in patients with anthrax meningitis .

 

Suspected inhalational anthrax  

* Plain chest X-ray: A widened or abnormal mediastinum on chest X-ray in a patient with clinical symptoms and a history of exposure strongly suggests inhalational anthrax .

 

Suspected inhalational anthrax  

* White blood cell count: An increased percentage of neutrophils with more band forms and a normal or mildly elevated WBC count may be seen in early inhalational anthrax .

 

Suspected cutaneous anthrax  

* Bacterial culture, Skin lesion sample, Bacillus anthracis: In patients with cutaneous anthrax, cultures of exudate from skin vesicles may reveal Bacillus anthracis organisms .

 

Suspected cutaneous anthrax  

* Gram stain microscopy, Skin lesion sample, Bacillus anthracis: A Gram stain of tissue revealing gram-positive, spore-forming, rod-shaped bacteria suggests Bacillus anthracis infection .

 

Suspected anthrax meningitis  

* CT of head: CT of the head in anthrax meningitis may reveal multiple hemorrhages in deep gray matter, ventricles, and the subarachnoid space .

 

Suspected inhalational anthrax  

* CT of chest: Chest CT findings in inhalational anthrax may include mediastinal lymphadenopathy, pleural effusions, and infiltrates, as well as other abnormalities .

 

Suspected inhalation anthrax and pleural effusion on chest x-ray  

* Pleural fluid examination, Bacillus anthracis

 

Differential Diagnosis  

* Influenza

* Tularemia - Acute

* Plague - Acute

* Community acquired pneumonia - Acute

* Bacterial meningitis - Acute

* NECROTIC ARACHNIDISM

* Respiratory tract infection

* Inhalational anthrax

* Anthrax meningitis

* Cutaneous anthrax

* Gastrointestinal anthrax

* Oropharyngeal anthrax

* Other specified anthrax manifestations

 

Treatment  

 

Drug Therapy  

 

 

Suspected or known inhalation anthrax  

 

CIPROFLOXACIN - CLINDAMYCIN PALMITATE HYDROCHLORIDE - RIFAMPIN  

Adults: Ciprofloxacin 400 mg IV every 12 hours AND clindamycin 900 mg IV every 8 hours AND rifampin 300 mg IV every 12 hours; switch to oral therapy when clinically appropriate: ciprofloxacin 500 mg orally twice daily AND clindamycin 450 mg orally every 8 hours AND rifampin 300 mg orally twice daily; total course, 60 days

Pediatrics: Ciprofloxacin [10 mg/kg IV every 12 hours OR 15 mg/kg orally every 12 hours (maximum 1 g/day)] AND clindamycin 7.5 mg/kg IV every 6 hours AND rifampin 20 mg/kg (maximum 600 mg) IV once daily; switch to oral therapy when clinically appropriate: ciprofloxacin 10 to 15 mg orally every 12 hours AND clindamycin 5 to 6 mg/kg orally every 8 hours AND rifampin 20 mg/kg (maximum 600 mg) once daily; total course, 60 days

 

DOXYCYCLINE - CLINDAMYCIN PALMITATE HYDROCHLORIDE - RIFAMPIN  

Adults: Doxycycline 100 mg IV every 12 hours AND clindamycin 900 mg IV every 8 hours AND rifampin 300 mg IV every 12 hours; switch to oral therapy when clinically appropriate: doxycycline 100 mg orally twice daily AND clindamycin 450 mg orally every 8 hours AND rifampin 300 mg orally twice daily; total course, 60 days

Pediatrics (?8 years): Doxycycline 2.2 mg/kg IV every 12 hours AND clindamycin 7.5 mg/kg IV every 6 hours AND rifampin 20 mg/kg (maximum 600 mg) IV once daily; switch to oral therapy when clinically appropriate: doxycycline 2.2 mg/kg orally twice daily AND clindamycin 5 to 6 mg/kg orally every 8 hours AND rifampin 20 mg/kg (maximum 600 mg) once daily; total course, 60 days

Pediatrics (>8 years and ?45 kg): Doxycycline 2.2 mg/kg IV every 12 hours AND clindamycin 7.5 mg/kg IV every 6 hours AND rifampin 20 mg/kg (maximum 600 mg) IV once daily; switch to oral therapy when clinically appropriate: doxycycline 2.2 mg/kg orally twice daily AND clindamycin 5 to 6 mg/kg orally every 8 hours AND rifampin 20 mg/kg (maximum 600 mg) once daily; total course, 60 days

Pediatrics (>8 years and >45 kg): Doxycycline 100 mg IV every 12 hours AND clindamycin 7.5 mg/kg IV every 6 hours AND rifampin 20 mg/kg (maximum 600 mg) IV once daily; switch to oral therapy when clinically appropriate: doxycycline 100 mg orally twice daily AND clindamycin 5 to 6 mg/kg orally every 8 hours AND rifampin 20 mg/kg (maximum 600 mg) once daily; total course, 60 days

 

 

Prevention of inhalation anthrax after a suspected or confirmed exposure to bioterrorist attack .  

 

LEVOFLOXACIN - ANTHRAX VACCINE ADSORBED  

Adults: Levofloxacin 500 mg orally every 24 hours for 60 days AND anthrax vaccine if available

 

CIPROFLOXACIN - ANTHRAX VACCINE ADSORBED  

Adults: Ciprofloxacin 500 mg orally every 12 hours for 60 days AND anthrax vaccine if available

Pediatrics: Ciprofloxacin 20-30 mg/kg orally in 2 divided doses (maximum 1 g/day) for 60 days AND anthrax vaccine if available

 

DOXYCYCLINE - ANTHRAX VACCINE ADSORBED  

Adults: Doxycycline 100 mg orally every 12 hours for 60 days AND anthrax vaccine if available

Pediatrics (?8 years): Doxycycline 2.2 mg/kg orally twice daily for 7-10 days or for 60 days in setting of bioterrorism AND anthrax vaccine if available

Pediatrics (>8 years and ?45 kg): Doxycycline 2.2 mg/kg orally twice daily for 7-10 days or for 60 days in setting of bioterrorism AND anthrax vaccine if available

Pediatrics (>8 years and >45 kg): Doxycycline 100 mg orally every 12 hours for 7-10 days or for 60 days in setting of bioterrorism AND anthrax vaccine if available

 

CIPROFLOXACIN - AMOXICILLIN - ANTHRAX VACCINE ADSORBED  

Adults: Ciprofloxacin 500 mg orally every 12 hours for 10-14 days, then amoxicillin 500 mg orally every 8 hours to complete a 60-day course AND anthrax vaccine if available

Pediatrics (<20 kg): Ciprofloxacin 20 to 30 mg/kg orally in 2 divided doses (maximum 1 g/day) for 10-14 days, then amoxicillin 40 mg/kg orally in 3 doses every 8 hours to complete a 60-day course AND anthrax vaccine if available

Pediatrics (?20 kg): Ciprofloxacin 20 to 30 mg/kg orally in 2 divided doses (maximum 1 g/day) for 10-14 days, then amoxicillin 500 mg/kg orally every 8 hours to complete a 60-day course AND anthrax vaccine if available

 

LEVOFLOXACIN - AMOXICILLIN - ANTHRAX VACCINE ADSORBED  

Adults: Levofloxacin 500 mg orally every 24 hours for 10-14 days, then amoxicillin 500 mg orally every 8 hours to complete a 60-day course AND anthrax vaccine if available

 

DOXYCYCLINE - AMOXICILLIN - ANTHRAX VACCINE ADSORBED  

Adults (pregnant and lactating women): Doxycycline 100 mg orally every 12 hours for 10-14 days, then amoxicillin 500 mg orally every 8 hours to complete a 60-day course AND anthrax vaccine if available

Pediatrics (?8 years): Doxycycline 2.2 mg/kg orally twice daily for 10-14 days, then amoxicillin 40 mg/kg orally in 3 doses every 8 hours to complete a 60-day course AND anthrax vaccine if available

Pediatrics (>8 years and ?45 kg): Doxycycline 2.2 mg/kg orally twice daily for 10-14 days, then amoxicillin 40 mg/kg orally in 3 doses every 8 hours to complete a 60-day course AND anthrax vaccine if available

Pediatrics (>8 years and >45 kg): Doxycycline 100 mg orally every 12 hours daily for 10-14 days, then amoxicillin 500 mg/kg orally every 8 hours to complete a 60-day course AND anthrax vaccine if available

 

 

Suspected anthrax meningitis  

 

CIPROFLOXACIN - MEROPENEM

Adults: Ciprofloxacin 400 mg IV every 8 hours AND meropenem 500-1,000 mg IV every 6-8 hours AND vancomycin [15 mg/kg IV, then 15 mg/kg IV every 12 hours OR 5-10 mg intrathecally every 48-72 hours] for 10-14 days or as long as indicated clinically; continue therapy for at least 60 days in setting of aerosol exposure

 

LEVOFLOXACIN - MEROPENEM

Adults: Levofloxacin 500 mg IV every 24 hours AND meropenem 500 to 1,000 mg IV every 6-8 hours AND vancomycin [15 mg/kg IV, then 15 mg/kg IV every 12 hours OR 5 to 10 mg intrathecally every 48-72 hours] for 10-14 days or as long as indicated clinically; continue therapy for at least 60 days in setting of aerosol exposure

 

CIPROFLOXACIN - RIFAMPIN - VANCOMYCIN HYDROCHLORIDE  

Adults: Ciprofloxacin 400 mg IV every 8 hours AND vancomycin [15 mg/kg IV, then 15 mg/kg IV every 12 hours OR 5 to 10 mg intrathecally every 48-72 hours] AND rifampin 300 mg IV every 12 hours for 10-14 days or as long as indicated clinically; continue therapy for at least 60 days in setting of aerosol exposure

 

LEVOFLOXACIN - RIFAMPIN - VANCOMYCIN HYDROCHLORIDE  

Adults: Levofloxacin 500 mg IV every 24 hours AND vancomycin [15 mg/kg IV, then 15 mg/kg IV every 12 hours OR 5 to 10 mg intrathecally every 48-72 hours] AND rifampin 300 mg IV every 12 hours for 10-14 days or as long as indicated clinically; continue therapy for at least 60 days in setting of aerosol exposure

 

 

Probable anthrax meningitis (clinical meningitis, gram-positive rods in cerebrospinal fluid) or culture-confirmed anthrax meningitis  

 

CIPROFLOXACIN - MEROPENEM

Adults: Ciprofloxacin 400 mg IV every 8 hours AND meropenem 500 to 1,000 mg IV every 6-8 hours AND vancomycin [15 mg/kg IV, then 15 mg/kg IV every 12 hours OR 5 to 10 mg intrathecally every 48-72 hours] for 10-14 days or as long as indicated clinically; continue therapy for at least 60 days in setting of aerosol exposure

 

LEVOFLOXACIN - MEROPENEM

Adults: Levofloxacin 500 mg IV every 24 hours AND meropenem 500 to 1,000 mg IV every 6-8 hours AND vancomycin [15 mg/kg IV, then 15 mg/kg IV every 12 hours OR 5 to 10 mg intrathecally every 48-72 hours] for 10-14 days or as long as indicated clinically; continue therapy for at least 60 days in setting of aerosol exposure

 

CIPROFLOXACIN - RIFAMPIN - VANCOMYCIN HYDROCHLORIDE  

Adults: Ciprofloxacin 400 mg IV every 8 hours AND vancomycin [15 mg/kg IV, then 15 mg/kg IV every 12 hours OR 5 to 10 mg intrathecally every 48-72 hours] AND rifampin 300 mg IV every 12 hours for 10-14 days or as long as indicated clinically; continue therapy for at least 60 days in setting of aerosol exposure

 

LEVOFLOXACIN - RIFAMPIN - VANCOMYCIN HYDROCHLORIDE  

Adults: Levofloxacin 500 mg IV every 24 hours AND vancomycin [15 mg/kg IV, then 15 mg/kg IV every 12 hours OR 5 to 10 mg intrathecally every 48-72 hours] AND rifampin 300 mg IV every 12 hours for 10-14 days or as long as indicated clinically; continue therapy for at least 60 days in setting of aerosol exposure

 

CIPROFLOXACIN - AMPICILLIN  

Adults: Ciprofloxacin 400 mg IV every 8 hours AND ampicillin 150 to 200 mg/kg IV every 24 hours for 10-14 days or as long as indicated clinically; continue therapy for at least 60 days in setting of aerosol exposure

 

LEVOFLOXACIN - AMPICILLIN  

Adults: Levofloxacin 500 mg IV every 24 hours AND ampicillin 150 to 200 mg/kg IV every 24 hours for 10-14 days or as long as indicated clinically; continue therapy for at least 60 days in setting of aerosol exposure

 

CIPROFLOXACIN - AMPICILLIN - MEROPENEM

Adults: Ciprofloxacin 400 mg IV every 8 hours AND ampicillin 150 to 200 mg/kg IV every 24 hours AND meropenem 500 to 1,000 mg IV every 6-8 hours for 10-14 days or as long as indicated clinically; continue therapy for at least 60 days in setting of aerosol exposure

 

LEVOFLOXACIN - AMPICILLIN - MEROPENEM

Adults: Levofloxacin 500 mg IV every 24 hours AND ampicillin 150 to 200 mg/kg IV every 24 hours AND meropenem 500 to 1,000 mg IV every 6-8 hours for 10-14 days or as long as indicated clinically; continue therapy for at least 60 days in setting of aerosol exposure

 

CIPROFLOXACIN - AMPICILLIN - RIFAMPIN  

Adults: Ciprofloxacin 400 mg IV every 8 hours AND ampicillin 150 to 200 mg/kg IV every 24 hours AND rifampin 300 mg IV every 12 hours for 10-14 days or as long as indicated clinically; continue therapy for at least 60 days in setting of aerosol exposure

 

LEVOFLOXACIN - AMPICILLIN - RIFAMPIN  

Adults: Levofloxacin 500 mg IV every 24 hours AND ampicillin 150 to 200 mg/kg IV every 24 hours AND rifampin 300 mg IV every 12 hours for 10-14 days or as long as indicated clinically; continue therapy for at least 60 days in setting of aerosol exposure

 

CIPROFLOXACIN - AMPICILLIN - VANCOMYCIN HYDROCHLORIDE  

Adults: Ciprofloxacin 400 mg IV every 8 hours AND ampicillin 150 to 200 mg/kg IV every 24 hours AND vancomycin [15 mg/kg IV, then 15 mg/kg IV every 12 hours OR 5 to 10 mg intrathecally every 48-72 hours] for 10-14 days or as long as indicated clinically; continue therapy for at least 60 days in setting of aerosol exposure

 

LEVOFLOXACIN - AMPICILLIN - VANCOMYCIN HYDROCHLORIDE  

Adults: Levofloxacin 500 mg IV every 24 hours AND ampicillin 150 to 200 mg/kg IV every 24 hours AND vancomycin [15 mg/kg IV, then 15 mg/kg IV every 12 hours OR 5 to 10 mg intrathecally every 48-72 hours] for 10-14 days or as long as indicated clinically; continue therapy for at least 60 days in setting of aerosol exposure

 

CIPROFLOXACIN - MEROPENEM

Adults: Ciprofloxacin 400 mg IV every 8 hours AND meropenem 500 to 1,000 mg IV every 6-8 hours for 10-14 days or as long as indicated clinically; continue therapy for at least 60 days in setting of aerosol exposure

 

LEVOFLOXACIN - MEROPENEM

Adults: Levofloxacin 500 mg IV every 24 hours AND meropenem 500 to 1,000 mg IV every 6-8 hours for 10-14 days or as long as indicated clinically; continue therapy for at least 60 days in setting of aerosol exposure

 

CIPROFLOXACIN - RIFAMPIN  

Adults: Ciprofloxacin 400 mg IV every 8 hours AND rifampin 300 mg IV every 12 hours for 10-14 days or as long as indicated clinically; continue therapy for at least 60 days in setting of aerosol exposure

 

LEVOFLOXACIN - RIFAMPIN  

Adults: Levofloxacin 500 mg IV every 24 hours AND rifampin 300 mg IV every 12 hours for 10-14 days for 10-14 days or as long as indicated clinically; continue therapy for at least 60 days in setting of aerosol exposure

 

CIPROFLOXACIN - VANCOMYCIN HYDROCHLORIDE  

Adults: Ciprofloxacin 400 mg IV every 8 hours AND vancomycin [15 mg/kg IV, then 15 mg/kg IV every 12 hours OR 5 to 10 mg intrathecally every 48-72 hours] for 10-14 days or as long as indicated clinically; continue therapy for at least 60 days in setting of aerosol exposure

 

LEVOFLOXACIN - VANCOMYCIN HYDROCHLORIDE  

Adults: Levofloxacin 500 mg IV every 24 hours AND vancomycin [15 mg/kg IV, then 15 mg/kg IV every 12 hours OR 5 to 10 mg intrathecally every 48-72 hours] for 10-14 days or as long as indicated clinically; continue therapy for at least 60 days in setting of aerosol exposure

 

 

Known or suspected cutaneous anthrax with signs of systemic involvement, extensive edema, or lesions of the head and neck  

 

CIPROFLOXACIN - CLINDAMYCIN PALMITATE HYDROCHLORIDE - RIFAMPIN  

Adults: Ciprofloxacin 400 mg IV every 12 hours AND clindamycin 900 mg IV every 8 hours AND rifampin 300 mg IV every 12 hours; switch to oral therapy when clinically appropriate: ciprofloxacin 500 mg orally twice daily AND clindamycin 450 mg orally every 8 hours AND rifampin 300 mg orally twice daily for 7-10 days (60 days in setting of bioterrorism)

Pediatrics: Ciprofloxacin [10 mg/kg IV every 12 hours OR 15 mg/kg orally every 12 hours (maximum 1 g/day)] AND clindamycin 7.5 mg/kg IV every 6 hours AND rifampin 20 mg/kg (maximum 600 mg) IV once daily; switch to oral therapy when clinically appropriate: ciprofloxacin 10 to 15 mg orally every 12 hours AND clindamycin 5 to 6 mg/kg orally every 8 hours AND rifampin 20 mg/kg (maximum 600 mg) once daily for 7-10 days (60 days in setting of bioterrorism)

 

DOXYCYCLINE - CLINDAMYCIN PALMITATE HYDROCHLORIDE - RIFAMPIN  

Adults: Doxycycline 100 mg IV every 12 hours AND clindamycin 900 mg IV every 8 hours AND rifampin 300 mg IV every 12 hours; switch to oral therapy when clinically appropriate: doxycycline 100 mg orally twice daily AND clindamycin 450 mg orally every 8 hours AND rifampin 300 mg orally twice daily for 7-10 days (60 days in setting of bioterrorism)

Pediatrics (?8 years): Doxycycline 2.2 mg/kg IV every 12 hours AND clindamycin 7.5 mg/kg IV every 6 hours AND rifampin 20 mg/kg (maximum 600 mg) IV once daily; switch to oral therapy when clinically appropriate: doxycycline 2.2 mg/kg orally twice daily AND clindamycin 5 to 6 mg/kg orally every 8 hours AND rifampin 20 mg/kg (maximum 600 mg) once daily for 7-10 days (60 days in setting of bioterrorism)

Pediatrics (>8 years and ?45 kg): Doxycycline 2.2 mg/kg IV every 12 hours AND clindamycin 7.5 mg/kg IV every 6 hours AND rifampin 20 mg/kg (maximum 600 mg) IV once daily; switch to oral therapy when clinically appropriate: doxycycline 2.2 mg/kg orally twice daily AND clindamycin 5 to 6 mg/kg orally every 8 hours AND rifampin 20 mg/kg (maximum 600 mg) once daily for 7-10 days (60 days in setting of bioterrorism)

Pediatrics (>8 years and >45 kg): Doxycycline 100 mg IV every 12 hours AND clindamycin 7.5 mg/kg IV every 6 hours AND rifampin 20 mg/kg (maximum 600 mg) IV once daily; switch to oral therapy when clinically appropriate: doxycycline 100 mg orally twice daily AND clindamycin 5 to 6 mg/kg orally every 8 hours AND rifampin 20 mg/kg (maximum 600 mg) once daily for 7-10 days (60 days in setting of bioterrorism)

 

 

Suspected or known mild to moderate cutaneous anthrax  

 

CIPROFLOXACIN  

Adults: Ciprofloxacin 500 mg orally twice daily for 7-10 days (60 days in setting of bioterrorism)

Pediatrics: Ciprofloxacin 10 to 15 mg/kg orally every 12 hours (maximum 1 g/day) for 7-10 days (60 days in setting of bioterrorism)

 

DOXYCYCLINE  

Adults: 100 mg orally twice daily for 7-10 days (60 days in setting of bioterrorism)

Pediatrics (?8 years): 2.2 mg/kg orally twice daily for 7-10 days (60 days in setting of bioterrorism)

Pediatrics (>8 years and ?45 kg): 2.2 mg/kg orally twice daily for 7-10 days (60 days in setting of bioterrorism)

Pediatrics (>8 years and >45 kg): 100 mg orally twice daily for 7-10 days (60 days in setting of bioterrorism)

 

AMOXICILLIN  

Adults: 500 mg orally three times daily for 7-10 days (60 days in setting of bioterrorism) if fluoroquinolone or doxycycline is contraindicated

Pediatrics (completion of therapy after clinical improvement): 80 mg/kg orally in 3 divided doses in 8-hour increments for 7-10 days (60 days in setting of bioterrorism)

 

 

Inhalation anthrax with extensive edema or respiratory compromise; anthrax meningitis; and cutaneous anthrax with extensive edema or swelling of the head and neck  

 

PREDNISONE  

Adults: 1-2 mg/kg/day orally

Pediatrics: 0.5-2 mg/kg/day orally

 

Procedural Therapy  

 

Reportable infectious diseases  

* Infectious disease notification: In the United States, specific infectious diseases must be reported to the state or local public health department .

 

Suspected or known anthrax  

* Standard precautions: Standard barrier isolation precautions and handwashing with soap and water are recommended in suspected or known infections with Bacillus anthracis.

 

Respiratory distress  

* Airway management: Airway management must assume the first priority in the management of any seriously ill or injured patient .

 

Severe sepsis or septic shock  

* Intravenous fluid replacement: Rapid fluid infusion assists in achieving early goals of mean blood pressure of 65 mmHg, urinary output above 1 mL/kg/hour, central venous pressure 8 to 12 mmHg, and central venous oxygen saturation above 70% within the first 6 hours.