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CDC panels establish anthrax prevention, treatment guidelines
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The CDC recently updated its guidelines for anthrax postexposure prophylaxis and treatment, and also drafted guidance relating specifically to pregnant and postpartum women in the setting of anthrax exposure during a bioterrorist attack.
The CDC’s Expert Panel Meetings on Prevention and Treatment of Anthrax in Adults included anthrax and critical care experts based on recommendations from the CDC, NIH, FDA and university medical centers.
The panel determined that the initial assessment of patients with suspected anthrax should prioritize obtaining pretreatment blood samples and other cultures. The panel also recommended that hemodynamic monitoring should be maintained, including continuous pulse oximetry and telemetry, for patients hospitalized with suspected anthrax. Patients with inhalation anthrax may require mechanical ventilation for breathing difficulties or airway swelling.
The experts advised that anyone exposed to inhalation Bacillus anthracis spores should undergo a 30-day postexposure prophylaxis (PEP) regimen of antimicrobial drugs, regardless of vaccination status. Oral doxycycline and ciprofloxacin are the first-line antimicrobial treatments for anthrax PEP.
The panel members said antitoxin drugs such as raxibacumab (GlaxoSmithKline) and anthrax immune globulin also appear to be effective; however, antimicrobial drugs are effective alone if given early enough in the disease process.
For anthrax cases in which anthrax meningitis is suspected, the panel recommended treatment with at least three antimicrobial drugs . The drugs of choice are ciprofloxacin , meropenem and linezolid (Zyvox, Pharmacia & Upjohn).
This IV combination treatment should be maintained for at least 2 weeks or until the patient’s symptoms have stabilized.
The panel members said anthrax vaccine adsorbed is a possible agent of seroconversion and could be given at diagnosis and at 2 and 4 weeks after diagnosis. However, it is not FDA approved for PEP but may be available under an investigational new drug protocol or emergency use authorization.
In the clinical information update for physicians specifically dealing with pregnant, postpartum and lactating women, the CDC panel — in a separate meeting consisting of a compendium of experts in obstetrics, infectious disease and maternal fetal medicine — discussed established guidelines for this unique population because it may require different treatment protocols for anthrax.
One deviation from protocol is that doxycycline is contraindicated in pregnancy due to a small risk for orofacial clefts in the fetus. Ciprofloxacin is the suggested first-line antimicrobial for pregnant women. Some panel members suggested that higher antimicrobial drug doses might be indicated for this patient demographic.
The experts also recommended a maternal regimen of corticosteroids to reduce the risk of preterm labor and improve fetal outcome.
For more information:
Hendricks KA. Emerg Infect Dis. 2014;doi:10.3201/eid2002.130687 .
Meaney-Delman D. Emerg Infect Dis. 2014;doi:10.3201/eid2002.130611.
Disclosure: The authors report no relevant financial disclosures.
Perspective
Back to TopD.A. Henderson, MD, MPH
Two authoritative clinical papers published in Emerging Infectious Diseases review in comprehensive detail current guidelines for post-exposure prevention and treatment of adult anthrax cases. The paper by Hendricks and colleagues deals explicitly with non-pregnant adults. It is co-authored by 19 specialists and a 48-person Workgroup on Anthrax. Included were civilian and military anthrax experts and clinicians with experience treating anthrax patients. According to the paper, "Specialties represented included internal medicine, pediatrics, obstetrics, infectious disease, emergency medicine, critical care, pulmonology, hematology, and nephrology." No mention is made of public health specialists. Three meetings were convened. The authors report that reviews and recommendations were based on a review of all available published, unpublished and proprietary data regarding antimicrobial drugs, anthrax antitoxins and critical care measures of potential benefit to patients with anthrax.
D. A. Henderson
The second paper by Meaney-Delman, co-authored by 12 specialists and a workgroup of 77 experts, deals explicitly with prophylaxis and treatment of anthrax in pregnant and post-partum women. This group also held a special meeting following multiple pre-meeting conference calls.
As the authors note, anthrax is a genuine threat to this country but only if it were it to be used as a biological weapon. Thus, the public health preparedness and response issues are inextricably related to the clinical issues. Yet, the subject of public health is never mentioned by the authors. As I reviewed the affiliations, in fact, I was struck by the apparent absence of state or public health participants. What are the alternatives and realities with a respect to a public health response? What antibiotics should be available? What are the trade-offs with respect to efficacy, costs and reactogenicity? What about vaccine for widespread use? Is it fiscally and practically feasible or desirable to try to provide the three doses of vaccine that CDC recommended so long ago? What do we do about children? How might antitoxins be used?
The only sentence acknowledging that there are other critical factors appears as the last sentence of the Meany-Delman paper. "Health care providers, public health responders, and local, state, and national partners must work together to develop these plans, stand ready to implement them, and ensure uniformity of messages and effective communications with each other and with the general public."
It is 12 years since the anthrax attack. There is much yet to be comprehended.
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