Anthrax prevention

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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

Prevention of anthrax infection is made with antibiotic postexposure prophylaxis and vaccination. Antibiotics can prevent anthrax from developing in people who have been exposed but have not developed symptoms, and should be given in combination and for a period of 60 days.

Primary Prevention

Well-timed and effective postexposure prophylaxis can potentially save thousands of lives. Postexposure prophylaxis of asymptomatic persons should start as soon as possible after exposure because its effectiveness decreases with delay in implementation. Initial symptoms may resemble a common cold, including sore throat, mild fever, myalgia, and malaise. After a few days, the symptoms may progress to severe breathing problems shock, and ultimately death.

Antibiotic Drugs

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.

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

Despite the existence of a vaccine licensed to prevent anthrax, it is not typically available for the general public. It protects against cutaneous and inhalation anthrax. There is evidence of seroconversion after 3 doses of Anthrax Vaccine Adsorbed [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

Dealing with Victims

In order to prevent infection and transmission of the virus, several measures should be implemented, particularly when handling victims of Ebola infection, including:

• All possibly contaminated bedding or clothing of infected patients should be isolated in double plastic bags and treated as possible biohazard waste.
• If a person is suspected of having died from anthrax, every precaution should be taken to avoid skin contact with the potentially contaminated body. The body should be put in strict quarantine, sealed in an airtight body bag and then cremated. No embalming or autopsy should be attempted without a fully equipped biohazard laboratory and trained, knowledgeable personnel.
• 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.
• Anyone working with anthrax in a suspected or confirmed victim should wear respiratory equipment capable of filtering this size of particle or smaller.