Just-in-Case Training: Updated Recommendations for Prevention and Treatment of Anthrax

William A. Bower, MD


May 27, 2014

Editorial Collaboration

Medscape &

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Editor's Note: The guidance for the appropriate response to anthrax exposure and inhalation anthrax infection in adults has just been updated and is summarized below. Expanded guidance is also available on the prevention and management of anthrax during pregnancy and the postpartum period and for anthrax in children.

Bacillus anthracis, the spore-forming bacterium that causes anthrax, tops the list of potential threat agents in the United States. It's available and easy to disseminate, and inhalation anthrax carries a high mortality. Because anthrax is rarely seen in the United States, it is especially important for clinicians to know how to quickly access treatment and prevention recommendations should an unlikely -- but not impossible -- bioterrorist event involving anthrax ever occur.

Hello. I'm Dr. William Bower, with the Bacterial Special Pathogens Branch at the Centers for Disease Control and Prevention. I am pleased to speak with you today about updated recommendations for preventing and treating anthrax as part of the CDC Expert Commentary series on Medscape.

Depending on where B anthracis spores enter the body, they can lead to cutaneous, gastrointestinal, or injection anthrax, a new type recently reported in heroin-injecting drug users in northern Europe. But I want to focus today on the most deadly type: inhalation anthrax.

Presentation and treatment. Patients with inhalation anthrax often present with fever and chills, headache, chest pain, cough, and difficulty breathing. Except for those with small, localized cutaneous lesions, patients with any form of anthrax will need to be hospitalized. The initial evaluation of patients suspected of having anthrax should be similar to evaluation of patients with any acute febrile illness.

But here is an important caveat: Patients with systemic anthrax initially might not appear critically ill. Because of the potential for sudden decline, hospitalized patients should have careful hemodynamic monitoring. Chest CT might be needed to identify the characteristic widened mediastinum and pleural effusions associated with inhalation anthrax (Figure).

Figure 1. This anteroposterior chest radiograph, taken 22 hours before the patient's death, shows a widened mediastinum, characteristic of inhalation anthrax.

These updated recommendations reflect what we have learned since the anthrax attacks of 2001. Prior to 2001, mortality rates for patients with inhalation anthrax approached 90%. Since then, 8 of 15 (53%) of patients with inhalation anthrax have survived. What did they have in common?

They were diagnosed early;

They began a combination antimicrobial treatment to eradicate the bacteria and inhibit toxin production; and

They had aggressive pleural effusion management.

Other critical care measures and procedures include hemodynamic support, mechanical ventilation, and antitoxin treatment.

Prophylaxis. Let's talk about prevention. For people who have been exposed but have no signs of systemic anthrax, postexposure prophylaxis (PEP) should start as soon as possible after exposure. Oral ciprofloxacin and doxycycline are recommended as first-line antimicrobials for PEP. A 3-dose series of anthrax vaccine is also recommended for long-term protection following exposure to anthrax.

Here is the key prevention take-away: Everyone exposed should receive a full 60 days of PEP antimicrobials -- whether they are unvaccinated, partially vaccinated, or fully vaccinated.

Pregnant, postpartum, and lactating women. I would like to briefly summarize recommendations for pregnant, postpartum, and lactating women. These women require special consideration with respect to the prevention and treatment of infectious diseases. However, given the severity of anthrax, even this unique population of women should receive the same PEP and treatment as other adults. A key distinction is that ciprofloxacin is preferred over doxycycline for first-line anthrax PEP for pregnant, postpartum, and lactating women. Antimicrobial drug treatment for any of these women with a clinical or laboratory diagnosis of anthrax would be the same as for other adults.

Please visit the links at the end of this page to see the complete updated recommendations for the prevention and treatment of anthrax in adults and special considerations for pregnant and postpartum women and children.

Figure 2. Patient educational materials describing anthrax transmission.

Web Resources

CDC: Anthrax

Centers for Disease Control and Prevention Expert Panel Meetings on Prevention and Treatment of Anthrax in Adults

Special Considerations for Treatment of Anthrax in Pregnant and Postpartum Women

Pediatric Anthrax Clinical Management

Captain William A. Bower, MD, FIDSA, serves as the Epidemiology Team Lead in the Bacterial Special Pathogens Branch in the Division of High-Consequence Pathogens and Pathology (DHCPP) at the National Center for Emerging and Zoonotic Infectious Diseases in the US Centers for Disease Control and Prevention (CDC). He is located in CDC's headquarters in Atlanta, Georgia.

William Bower received his MD from Bowman Gray School of Medicine in 1992. Following completion of his training in internal medicine at the University of Virginia at Charlottesville, CAPT Bower first began working on public health issues with CDC during an infectious diseases fellowship through Emory University. He joined CDC full time in June 2000. At CDC, Dr. Bower has also worked in the Division of Viral Hepatitis, Division of Bioterrorism Preparedness and Response, and Office of Blood, Organ, and Other Tissue Safety.