Anthrax medical therapy: Difference between revisions
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==Medical Therapy== | ==Medical Therapy== | ||
The treatment of [[anthrax]] infection includes [[antimicrobial]] and [[antitoxin]] agents. This treatment and postexposure [[prophylaxis]] differs from other [[bacterial infections]] because: | The treatment of [[anthrax]] infection includes [[antimicrobial]] and [[antitoxin]] agents. This treatment and postexposure [[prophylaxis]] differs from other [[bacterial infections]] because:<ref name=CDC>{{cite web | title = Centers for Disease Control and Prevention Expert Panel Meetings on Prevention and Treatment of Anthrax in Adults | url = http://wwwnc.cdc.gov/eid/article/20/2/13-0687_article }}</ref> | ||
* Production of [[toxin]] | * Production of [[toxin]] | ||
* Potential [[antibiotic resistance]] | * Potential [[antibiotic resistance]] | ||
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Hospitalized patients for systemic [[anthrax]] should be immediately treated with a combination of [[broad-spectrum]] [[intravenous]] [[antimicrobial drug]] treatment pending confirmatory test results because any delay may prove fatal. | Hospitalized patients for systemic [[anthrax]] should be immediately treated with a combination of [[broad-spectrum]] [[intravenous]] [[antimicrobial drug]] treatment pending confirmatory test results because any delay may prove fatal. | ||
Because [[meningitis]] and hemorrhagic brain parenchymal [[infection]] was observed in ≤50% of cases, [[meningitis]] must be considered in all cases of systemic [[anthrax]]. Therefore [[antibiotics]] to treat possible [[meningitis]] must have good penetration of the [[central nervous system]] (CNS). | Because [[meningitis]] and hemorrhagic brain parenchymal [[infection]] was observed in ≤50% of cases, [[meningitis]] must be considered in all cases of systemic [[anthrax]]. Therefore [[antibiotics]] to treat possible [[meningitis]] must have good penetration of the [[central nervous system]] (CNS).<ref name=CDC>{{cite web | title = Centers for Disease Control and Prevention Expert Panel Meetings on Prevention and Treatment of Anthrax in Adults | url = http://wwwnc.cdc.gov/eid/article/20/2/13-0687_article }}</ref> | ||
[[Empiric therapy]] for [[anthrax]] in which anthrax [[meningitis]] is suspected or cannot be ruled out should include ≥3 [[antibiotics]] with activity against [[Bacillus anthracis]], in which:<ref name=CDC>{{cite web | title = Centers for Disease Control and Prevention Expert Panel Meetings on Prevention and Treatment of Anthrax in Adults | url = http://wwwnc.cdc.gov/eid/article/20/2/13-0687_article }}</ref> | |||
[[Empiric therapy]] for [[anthrax]] in which anthrax [[meningitis]] is suspected or cannot be ruled out should include ≥3 [[antibiotics]] with activity against [[Bacillus anthracis]], in which: | |||
* ≥1 drug should have bactericidal activity | * ≥1 drug should have bactericidal activity | ||
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* All should have good [[CNS]] penetration | * All should have good [[CNS]] penetration | ||
Given the high [[mortality rate]] associated with [[meningitis]], 3 weeks of treatment for patients in whom [[meningitis]] could not be ruled out, is preferred. Because of the presence of a [[spore]] form of [[Bacillus anthracis]], [[antibiotic therapy]] should be continued for 60 days to clear germinating organisms. | Given the high [[mortality rate]] associated with [[meningitis]], 3 weeks of treatment for patients in whom [[meningitis]] could not be ruled out, is preferred. Because of the presence of a [[spore]] form of [[Bacillus anthracis]], [[antibiotic therapy]] should be continued for 60 days to clear germinating organisms.<ref name=CDC>{{cite web | title = Centers for Disease Control and Prevention Expert Panel Meetings on Prevention and Treatment of Anthrax in Adults | url = http://wwwnc.cdc.gov/eid/article/20/2/13-0687_article }}</ref> | ||
==Antibiotic Treatment== | ==Antibiotic Treatment== | ||
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[[Raxibacumab]] is a recombinant, fully humanized, IgG1λ [[monoclonal antibody]]. It appeared safe and well tolerated in 333 healthy adults who received the recommended dose of 40 mg/kg. | [[Raxibacumab]] is a recombinant, fully humanized, IgG1λ [[monoclonal antibody]]. It appeared safe and well tolerated in 333 healthy adults who received the recommended dose of 40 mg/kg. | ||
Most [[adverse events]] were transient and mild to moderate in severity. [[Pruritis]] was noted in 2.1% of persons treated with [[raxibacumab]] and in none treated with [[placebo]]. Although [[raxibacumab]] has not been given to patients with systemic anthrax, it is FDA-approved for postexposure [[prophylaxis]] PEP and | Most [[adverse events]] were transient and mild to moderate in severity. [[Pruritis]] was noted in 2.1% of persons treated with [[raxibacumab]] and in none treated with [[placebo]]. Although [[raxibacumab]] has not been given to patients with systemic anthrax, it is FDA-approved for postexposure [[prophylaxis]] PEP.<ref name=CDC>{{cite web | title = Centers for Disease Control and Prevention Expert Panel Meetings on Prevention and Treatment of Anthrax in Adults | url = http://wwwnc.cdc.gov/eid/article/20/2/13-0687_article }}</ref> | ||
===Anthrax Immune Globulin=== | ===Anthrax Immune Globulin=== | ||
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The most frequently reported [[adverse events]] were [[headache]] pharyngolaryngeal pain, and [[nausea]]. | The most frequently reported [[adverse events]] were [[headache]] pharyngolaryngeal pain, and [[nausea]]. | ||
AIGIV is not [[FDA]] approved and could be made available under an Investigational New Drug protocol or an Emergency Use Authorization during a declared emergency. | AIGIV is not [[FDA]] approved and could be made available under an Investigational New Drug protocol or an Emergency Use Authorization during a declared emergency.<ref name=CDC>{{cite web | title = Centers for Disease Control and Prevention Expert Panel Meetings on Prevention and Treatment of Anthrax in Adults | url = http://wwwnc.cdc.gov/eid/article/20/2/13-0687_article }}</ref> | ||
==Supportive Treatment== | ==Supportive Treatment== | ||
Revision as of 16:01, 17 July 2014
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]
Overview
Medical Therapy
The treatment of anthrax infection includes antimicrobial and antitoxin agents. This treatment and postexposure prophylaxis differs from other bacterial infections because:[1]
- Production of toxin
- Potential antibiotic resistance
- Frequent occurrence of meningitis
- Presence of latent spores must be taken into account when selecting postexposure prophylaxis or a combination of antibiotics for treatment of anthrax
Hospitalized patients for systemic anthrax should be immediately treated with a combination of broad-spectrum intravenous antimicrobial drug treatment pending confirmatory test results because any delay may prove fatal.
Because meningitis and hemorrhagic brain parenchymal infection was observed in ≤50% of cases, meningitis must be considered in all cases of systemic anthrax. Therefore antibiotics to treat possible meningitis must have good penetration of the central nervous system (CNS).[1] Empiric therapy for anthrax in which anthrax meningitis is suspected or cannot be ruled out should include ≥3 antibiotics with activity against Bacillus anthracis, in which:[1]
- ≥1 drug should have bactericidal activity
- ≥1 should be a protein synthesis inhibitor
- All should have good CNS penetration
Given the high mortality rate associated with meningitis, 3 weeks of treatment for patients in whom meningitis could not be ruled out, is preferred. Because of the presence of a spore form of Bacillus anthracis, antibiotic therapy should be continued for 60 days to clear germinating organisms.[1]
Antibiotic Treatment
Antimicrobial Treatment for Systemic Disease with Possible Meningitis
Antimicrobial Treatment for Systemic Disease If Meningitis Is Ruled Out
Follow-up Oral Treatment for Systemic Disease
Once patients with systemic illness who were exposed to aerosolized spores have completed initial combination treatment, they should be transitioned to single-agent oral treatment to prevent relapse from surviving Bacillus anthracis spores.
Treatment for Cutaneous Anthrax without Systemic Involvement
Antitoxins
An antitoxin should be added to combination antibiotic treatment for any patient for whom there is a high level of clinical suspicion for systemic anthrax. Given that systemic anthrax has a high case-fatality rate and the risk for antitoxin treatment appears to be low, the potential benefit achieved by adding antitoxin to combination antibiotic treatment outweighs the potential risk.
Currently there are 2 antitoxins in the CDC Strategic National Stockpile: raxibacumab and Anthrax Immune Globulin Intravenous (AIGIV). Both antitoxins inhibit binding of Protective Antigen (PA) to anthrax toxin receptors and translocation of the 2 primary toxins (Lethal Toxin (LT) and Edema Toxin (ET)) into cells.
Raxibacumab
Raxibacumab is a recombinant, fully humanized, IgG1λ monoclonal antibody. It appeared safe and well tolerated in 333 healthy adults who received the recommended dose of 40 mg/kg.
Most adverse events were transient and mild to moderate in severity. Pruritis was noted in 2.1% of persons treated with raxibacumab and in none treated with placebo. Although raxibacumab has not been given to patients with systemic anthrax, it is FDA-approved for postexposure prophylaxis PEP.[1]
Anthrax Immune Globulin
AIGIV is a human polyclonal antiserum made from plasma of persons immunized with Anthrax Vaccine Absorbed (AVA), which might have some direct effect on Lethal Factor (LF) and Edema Factor (EF). It was evaluated in 74 healthy adult volunteers and appears safe and well tolerated at all doses tested.
The most frequently reported adverse events were headache pharyngolaryngeal pain, and nausea.
AIGIV is not FDA approved and could be made available under an Investigational New Drug protocol or an Emergency Use Authorization during a declared emergency.[1]