PPT- notes on HPA guidelines on anthrax outbreak.

1. Anthrax!!!
21.8.12

2. Clinical picture
New in IVDU
Mixed presentation – not like typical cutaneous anthrax
Many cases did not have typical black eschar
SSI – localised, nec fasciitis
Swelling (all cases) > pain > malaise > fever
Some cases might have no localising sign but may present with
generalised symptoms suggestive of infection
GI symptoms – abdo pain, nausea, vomiting, diarrhoea, rectal bleeding
neuro symptoms - severe headache, hallucinations, fitting, collapse, coma
Fatality

3. Microbiology involvement
The clinicians may consult microbiology if anthrax is suspected eg.
Heroin user, presenting with
Severe soft tissue infection – nec fasc, cellulitis, abscess associated with oedema
Signs of severe sepsis without localizing soft tissue infection
meningitis, esp haemorrhagic meningitis
heroin user with clinical or CT evidence of SAH/IC bleed
Flu like symptoms  severe resp difficulty /shock
Chest x-ray signs – mediastinal widening, paratracheal fullness, hilar fullness, pleural effusions, parenchymal infiltrates
Progressively enlarging, haemorrhagic pleural effusions (biphasic – prodrome – remission for few days then chest sym)
Chest symp with s/s of meningitis/IC bleed
Drenching sweats
Skin lesion - lesion starts as a small bump and develops into a characteristic ulcer with a black centre , not painful,
oedema

4. Infection control
Person to person – rare
Person-to-person spread of inhalation anthrax does not occur.
Person-to-person spread of cutaneous anthrax is extremely rare. Transmission of cutaneous
anthrax has not been recorded in this current outbreak
Intestinal anthrax is very rare, but occurs from swallowing spores in contaminated meat from
and animal which has died from anthrax.
http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1267549743963

5. Standard Infection Control Precautions
All cuts and abrasions should be covered with water proof dressings
Personal protective equipment should be used in situations where there is potential for splashes and inoculation injuries.
wear gloves and aprons when handling the patient’s personal clothing and effects
Single room placement for anthrax transmission is not necessary
On removal of PPE, wash hands with liquid soap and water
Any potentially contaminated substance found on the patient, e.g. their personal heroin supply, should be sealed in a plastic bag to
prevent environmental and personal contamination (HCW to wear PPE).
Decontamination of blood and body fluid spillages - Higher then standard -
10,000 ppm av cl - 10 min (check - http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1267549743963 page 4-5)
Specimen – cat 3, NO pneumatic system, label “dangerous specimen/high risk” + “anthrax risk”, inform lab in advance
Needlestick, post mortem, last office – follow above link

6. BC
EDTA blood for PCR
Tissue/material from lesion for gram (urgent) and c/s
Serum for toxin/ab test
CRP may be normal/lowish – disproportionate to skin change, wcc may not rise, temp may be normal
Lab guidance - http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1265296979282)
Decreasing platelet = deterioration
Coagulopathy
IVT refractory renal impairment may occur

7. Timely surgical debridement
SSI – IV cip + clind + pen+ fluclox + metro
Disseminated – IV cip + clind + pen/vanc
Other agents with activity - rifampicin, imipenem, meropenem, chloramphenicol and gentamicin.
IVIg (for criteria see page 13 onwards )
Review 10-14 days ----?3 weeks
http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1259152399460
http://www.documents.hps.scot.nhs.uk/giz/anthrax-outbreak/clinical-guidance-for-use-of-anthrax-immune-globulin-v12-1-2010-03-19.pdf

8. Cutaneous anthrax evaluation
http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1249454483392
Inhalation anthrax evaluation
http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947368101