Bioterrorism Agents

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Bioterrorism Agents PlagueLesson 5

• Medical Management

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Objectives

• Management of suspect and confirmed cases
• Medications Controlled Situation
• Medications Mass Casualty
• Infection Control

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Overview

• Prompt treatment required
• Y. pestis enterobacteriaceae
• Responsive to most antimicrobials

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Overview

• Aerosol exposure plague pneumonia
• Medical Management
• Prompt antimicrobial administration
• Respiratory droplet precautions
• Intensive respiratory support
• Management of consequences

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Treatment Issues

• Clinical improvement 36 to 48 hours, if
  responding to treatment
• Cannot recover Y. pestis after 36 hours of
  treatment
• All US strains have been sensitive to current
  treatments, to date

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Treatment in Bioterrorism

• BT Plague High suspicion of resistance
• Perform testing rapidly
• Watch for Health Alerts
• Treatment/Prophylaxis recommendations may change

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Streptomycin

• Historically preferred
• FDA-approved
• Not widely and immediately available
• Floroquinolones?

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Treating an Outbreak

• Gentamicin IND protocol
• Contained Casualty parenteral antimicrobial
  therapy
• Mass Casualty oral therapy

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Recommended Plague TreatmentNotes on Options

• Based on consensus of working group and not FDA
• Choose one agent.
• Treatment for 10 days
• Substitute oral therapy when condition improves

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Recommended Plague TreatmentContained Casualty -
Adults
Preferred Preferred
Streptomycin 1g IM BID
Gentamicin 5 mg/kg IM or IV daily OR 2 mg/kg loading with 1.7 mg/kg IM or IV TID
Alternative Alternative
Doxycycline 100mg IV BID or 200mg IV
Ciprofloxacin 400mg IV BID
Chloramphenicol 25 mg/kg IV QID
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Recommended Plague TreatmentContained Casualty -
Children
Preferred Preferred
Streptomycin 15 mg/kg IM BID (max 2g daily)
Gentamicin 2.5 mg/kg IM or IV daily TID
Alternative Alternative
Doxycycline ?45kg - 100mg IV BID or 200mg IV
Ciprofloxacin 15 mg/kg BID
Chloramphenicol 25 mg/kg IV QID
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Recommended Plague TreatmentMass Casualty -
Adults
Preferred Preferred
Doxycycline 100 mg PO BID
Ciprofloxacin 500 mg PO BID
Alternative Alternative
Chloramphenicol 25 mg/kg PO QID
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Recommended Plague TreatmentChildren Mass
Casualty
Preferred Preferred
Doxycycline ?45kg - 100 mg PO BID lt45kg 2.2mg/kg PO BID
Ciprofloxacin 20 mg/kg PO BID
Alternative Alternative
Chloramphenicol 25 mg/kg IV QID
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Recommended Plague TreatmentNotes on Gentamicin

• Streptomycin preferred, but hard to find
• Frequency at discretion of clinician
• Initial loading dose 2 mg/kg standard when given
  three times per day
• Not FDA-approved
• Refer to package insert re renal insufficiency

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Recommended Plague TreatmentNotes on Children

• Gentamicin may be efficacious, but not widely
  accepted clinical practice
• Neonates up to 1 wk 2.5 mg/kg IV BID
• Can substitute other fluoroquinolones
• Ciprofloxacin dosage no more than 1 g/d,
  concentrations between 5 20 µg/ml
• Chloramphenicol dosage no more than 4g/d. No
  one younger than 2 years.

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Plague Infection Control Precautions
Bubonic Standard
Pneumonic Standard and Respiratory
Septicemic Standard
Suspect Respiratory and Isolation

• Isolation for 48 hours of antibiotic treatment or
  until clinical improvement

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Plague Infection Control

• Cohort and Droplet precautions if no isolation
  available
• Isolation of contacts may increase in importance
  for outbreak control
• Corpses Standard Precautions

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Occupational ExposureHospital and Laboratory

• Skin Exposures Nonabrasive soap and water,
  standard workplace exposure policy
• Eye Exposures Flush with water or eye wash
  solution x 15 minutes
• Post-Exposure doxycycline or ciprofloxacin x 7
  days
• Laboratory avoid aerosolization

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Occupational ExposuresLaboratory Spills

• Cover in absorbent materials
• 1100 bleach x 30 minutes
• Wipe with absorbent materials soaked in 1100
  bleach
• Clean with nonabrasive soap and water
• Dispose all materials biohazard
• BSL2 for all suspect materials

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Occupational ExposuresField Workers

• Incident Commander assigns PPE levels
• Minimum of Level B PPE
• Tyvek outer clothing
• Gloves
• Booties
• Positive pressure HEPA filtered respirators
• All PPE decontaminated or disposed of as
  biohazardous waste

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Review Questions - PlagueLesson 5

• Medical Management

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Plague Review QuestionsLesson 5, Question 1

• News report 75 cases of plague in area
• Ambulances arriving at ER
• Exposed to intentional plague bacteria release
• Which antibiotic would you choose?

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Plague Review QuestionsLesson 5, Question 1

• Which antibiotic would you choose?
• Streptomycin 1g IM BID
• Doxycycline 100 mg PO BID
• Gentamicin 5 mg/kg IM or IV daily
• Any of the above

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Plague Review QuestionsLesson 5, Question 1

• Which antibiotic would you choose?
• B. Doxycycline 100 mg PO BID

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Plague Review QuestionsLesson 5, Question 2

• Suspect pneumonic plague patient
• What precautions would you take immediately?

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Plague Review QuestionsLesson 5, Question 2

• What precautions would you take immediately?
• Standard precautions
• Standard and contact precautions
• Standard and respiratory droplet precautions
• Negative pressure room

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Plague Review QuestionsLesson 5, Question 2

• What precautions would you take immediately?
• C. Standard and respiratory droplet precautions

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Plague Review QuestionsLesson 5, Question 3

• Pneumonia patient
• Lab unable to rule out plague
• What medication do you prescribe for a controlled
  casualty situation?

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Plague Review QuestionsLesson 5, Question 3

• What medication do you prescribe for a controlled
  casualty situation?
• Penicillin
• Gentamicin
• Zithromicin
• Biaxin

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Plague Review QuestionsLesson 5, Question 3

• What medication do you prescribe for a controlled
  casualty situation?
• B. Gentamicin

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Plague Review QuestionsLesson 5, Question 4

• Pneumonic plague patient
• Gentamicin x 48 hours
• How would you expect the patient to progress?

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Plague Review QuestionsLesson 5, Question 4

• How would you expect the patient to progress?
• Spike in temperature, toxic
• Still infectious, remain in isolation
• Showing signs of clinical improvement
• Signs of inflammatory response

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Plague Review QuestionsLesson 5, Question 4

• How would you expect the patient to progress?
• C. Showing signs of clinical improvement