Anthrax prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Well-timed and effective postexposure prophylaxis can potentially save thousands of lives. Postexposure prophylaxis of asymptomatic persons should ideally start as soon as possible after exposure because its effectiveness decreases with delay in implementation. After exposure to anthrax, it is recommended 60 days of antibiotic drug prophylaxis for immediate protection and a 3-dose series of Anthrax Vaccine Adsorbed (AVA) for long-term protection. To ensure adequate and continued protection, everyone exposed to aerosolized Bacillus anthracis spores should receive a full 60 days of postexposure prophylaxis antibiotic drugs, whether they are unvaccinated, partially vaccinated, or fully vaccinated.

Primary Prevention

Antibiotic Drugs

Ciprofloxacin, levofloxacin, and doxycycline are FDA-approved for the antibiotic drug portion of postexposure prophylaxis for inhalation anthrax in adults ≥18 years of age.

No safety data are available for levofloxacin use beyond 30 days; thus, oral ciprofloxacin and doxycycline are recommended as first-line antibiotic drugs for postexposure prophylaxis. Alternative antibiotic drugs that might be used for postexposure prophylaxis, if first-line agents are not tolerated or are unavailable, include:

• Levofloxacin and moxifloxacin
• Amoxicillin and penicillin V Potassium if the isolate is penicillin susceptible
• Clindamycin.

Vaccine

There is evidence of seroconversion after 3 doses of AVA. The vaccine should be administered subcutaneously at diagnosis and 2 and 4 weeks later. AVA is not FDA-approved for postexposure prophylaxis and could be made available under an Investigational New Drug protocol or an Emergency Use Authorization in a declared emergency.

Prophylaxis Regimen

▸ Click on the following categories to expand treatment regimens.

PEP for Infection with B. anthracis   ▸  Adult Patients   ▸  Pediatric Patients   ▸  Pregnant Patients

Postexposure Prophylaxis, Adult Patients Preferred Regimen ▸ Ciprofloxacin 500 mg PO q12h OR ▸ Doxycycline 100 mg PO q12h OR ▸ Levofloxacin 750 mg PO q24h OR ▸ Moxifloxacin 400 mg PO q24h OR ▸ Clindamycin 600 mg PO q8h OR Alternative Regimen ▸ Amoxicillin 1 g PO q8h OR ▸ Penicillin VK 500 mg PO q6h Postexposure Prophylaxis, Pediatric Patients Preferred Regimen ▸ Ciprofloxacin 30 mg/kg/day PO q12h, max: 500 mg/dose OR ▸ Doxycycline 4.4 mg/kg/day PO q12h, max: 100 mg/dose (<45 kg) OR ▸ Doxycycline 100 mg/dose PO q12h (≥45 kg) OR ▸ Clindamycin 30 mg/kg/day PO q8h, max: 900 mg/dose OR ▸ Levofloxacin 16 mg/kg/day PO q12h, max: 250 mg/dose (<50 kg) OR ▸ Levofloxacin 500 mg PO q24h (≥50 kg) Alternative Regimen ▸ Amoxicillin 75 mg/kg/day PO q8h, max: 1 g/dose OR ▸ Penicillin VK 50–75 mg/kg/day PO q6–8h Postexposure Prophylaxis, Pregnant Patients Preferred Regimen ▸ Ciprofloxacin 500 mg PO q12h

Precautions

• If a person is suspected as having died from anthrax, every precaution should be taken to avoid skin contact with the potentially contaminated body and fluids exuded through natural body openings. The body should be put in strict quarantine and then cremated.

• Microscopic visualization of the encapsulated bacilli, usually in very large numbers, in a blood smear stained with polychrome methylene blue (McFadyean stain) is diagnostic, although culture of the organism is still the gold standard for diagnosis.

• Full isolation of the body is important to prevent possible contamination of others. Protective, impermeable clothing and equipment such as rubber gloves, rubber apron, and rubber boots with no perforations should be used when handling the body. No skin, especially if it has any wounds or scratches, should be exposed. Disposable personal protective equipment is preferable, but if not available, decontamination can be achieved by autoclaving. Disposable personal protective equipment and filters should be autoclaved, and/or burned and buried.

• Anyone working with anthrax in a suspected or confirmed victim should wear respiratory equipment capable of filtering this size of particle or smaller.

• All possibly contaminated bedding or clothing should be isolated in double plastic bags and treated as possible biohazard waste. The victim should be sealed in an airtight body bag. Dead victims who are opened and not burned provide an ideal source of anthrax spores. Cremating victims is the preferred way of handling body disposal. No embalming or autopsy should be attempted without a fully equipped biohazard laboratory and trained, knowledgeable personnel.

Delays of only a few days may make the disease untreatable, so treatment should be started even without symptoms if possible contamination or exposure is suspected.

• Initial symptoms may resemble a common cold—sore throat, mild fever, muscle aches, and malaise. After a few days, the symptoms may progress to severe breathing problems and shock, and ultimately death.

Early detection of sources of anthrax infection can allow preventive measures to be taken. In response to the anthrax attacks of October 2001, the United States Postal Service (USPS) installed biodetection systems (BDSs) in their large-scale mail cancellation facilities. BDS response plans were formulated by the USPS in conjunction with local responders including fire, police, hospitals and public health. Employees of these facilities have been educated about anthrax, response actions, and prophylactic medication. Because of the time delay inherent in getting final verification that anthrax has been used, prophylactic antibiotic treatment of possibly exposed personnel must be started as soon as possible.