Title: Bioterrorism Agents
1Bioterrorism Agents PlagueLesson 5
2Objectives
- Management of suspect and confirmed cases
- Medications Controlled Situation
- Medications Mass Casualty
- Infection Control
3Overview
- Prompt treatment required
- Y. pestis enterobacteriaceae
- Responsive to most antimicrobials
4Overview
- Aerosol exposure plague pneumonia
- Medical Management
- Prompt antimicrobial administration
- Respiratory droplet precautions
- Intensive respiratory support
- Management of consequences
5Treatment 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
6Treatment in Bioterrorism
- BT Plague High suspicion of resistance
- Perform testing rapidly
- Watch for Health Alerts
- Treatment/Prophylaxis recommendations may change
7Streptomycin
- Historically preferred
- FDA-approved
- Not widely and immediately available
- Floroquinolones?
8Treating an Outbreak
- Gentamicin IND protocol
- Contained Casualty parenteral antimicrobial
therapy - Mass Casualty oral therapy
9Recommended 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
10Recommended 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
11Recommended 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
12Recommended Plague TreatmentMass Casualty -
Adults
Preferred Preferred
Doxycycline 100 mg PO BID
Ciprofloxacin 500 mg PO BID
Alternative Alternative
Chloramphenicol 25 mg/kg PO QID
13Recommended 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
14Recommended 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
15Recommended 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.
16Plague 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
17Plague Infection Control
- Cohort and Droplet precautions if no isolation
available - Isolation of contacts may increase in importance
for outbreak control - Corpses Standard Precautions
18Occupational 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
19Occupational 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
20Occupational 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
21Review Questions - PlagueLesson 5
22Plague 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?
23Plague 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
24Plague Review QuestionsLesson 5, Question 1
- Which antibiotic would you choose?
- B. Doxycycline 100 mg PO BID
25Plague Review QuestionsLesson 5, Question 2
- Suspect pneumonic plague patient
- What precautions would you take immediately?
26Plague 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
27Plague Review QuestionsLesson 5, Question 2
- What precautions would you take immediately?
- C. Standard and respiratory droplet precautions
28Plague Review QuestionsLesson 5, Question 3
- Pneumonia patient
- Lab unable to rule out plague
- What medication do you prescribe for a controlled
casualty situation?
29Plague Review QuestionsLesson 5, Question 3
- What medication do you prescribe for a controlled
casualty situation? - Penicillin
- Gentamicin
- Zithromicin
- Biaxin
30Plague Review QuestionsLesson 5, Question 3
- What medication do you prescribe for a controlled
casualty situation? - B. Gentamicin
31Plague Review QuestionsLesson 5, Question 4
- Pneumonic plague patient
- Gentamicin x 48 hours
- How would you expect the patient to progress?
32Plague 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
33Plague Review QuestionsLesson 5, Question 4
- How would you expect the patient to progress?
- C. Showing signs of clinical improvement