Anthrax as a biological weapon, 2002: updated recommendations for management.
TL;DR: This revised consensus statement presents new information based on the analysis of the anthrax attacks of 2001, including developments in the investigation of the Anthrax Attacks of 2001; important symptoms, signs, and laboratory studies; new diagnostic clues that may help future recognition of this disease; updated antibiotic therapeutic considerations; and judgments about environmental surveillance and decontamination.
Abstract: ObjectiveTo review and update consensus-based recommendations for medical and
public health professionals following a Bacillus anthracis attack against a civilian population.ParticipantsThe working group included 23 experts from academic medical centers,
research organizations, and governmental, military, public health, and emergency
management institutions and agencies.EvidenceMEDLINE databases were searched from January 1966 to January 2002, using
the Medical Subject Headings anthrax, Bacillus anthracis, biological weapon, biological terrorism, biological warfare, and biowarfare. Reference review identified
work published before 1966. Participants identified unpublished sources.Consensus ProcessThe first draft synthesized the gathered information. Written comments
were incorporated into subsequent drafts. The final statement incorporated
all relevant evidence from the search along with consensus recommendations.ConclusionsSpecific recommendations include diagnosis of anthrax infection, indications
for vaccination, therapy, postexposure prophylaxis, decontamination of the
environment, and suggested research. This revised consensus statement presents
new information based on the analysis of the anthrax attacks of 2001, including
developments in the investigation of the anthrax attacks of 2001; important
symptoms, signs, and laboratory studies; new diagnostic clues that may help
future recognition of this disease; current anthrax vaccine information; updated
antibiotic therapeutic considerations; and judgments about environmental surveillance
and decontamination.
Citations
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TL;DR: The ability of hospital ventilation systems to filter Aspergillus and other fungi following a building implosion and the impact of bedside design and furnishing on nosocomial infections are investigated.
2,632 citations
01 Jan 2007
TL;DR: The ability of hospital ventilation systems to filter Aspergillus and other fungi following a building implosion and the impact of bedside design and furnishing on nosocomial infections are investigated.
Abstract: 146. In: 16th Annual Society for Healthcare Epidemiology of America. Chicago, Ill; 2006. 950. Harvey MA. Critical-care-unit bedside design and furnishing: impact on nosocomial infections. Infect Control Hosp Epidemiol 1998;19(8):597 601. 951. Srinivasan A, Beck C, Buckley T, et al. The ability of hospital ventilation systems to filter Aspergillus and other fungi following a building implosion. Infect Control Hosp Epidemiol 2002;23(9):520-4. 952. Maragakis LL, Bradley KL, Song X, et al. Increased catheter-related bloodstream infection rates after the introduction of a new mechanical valve intravenous access port. Infect Control Hosp Epidemiol 2006;27(1):67-70. 953. Organizations JCoAoH. Comprehensive Accredication Manual for Hospitals: The Official Handbook. Oakbrook Terrace: JCAHO; 2007. 954. Peterson LR, Noskin GA. New technology for detecting multidrug resistant pathogens in the clinical microbiology laboratory. Emerg Infect Dis 2001;7(2):306-11. 955. Diekema DJ, Doebbeling BN. Employee health and infection control. Infect Control Hosp Epidemiol 1995;16(5):292-301. 956. Rutala WA, Weber DJ, Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for Disinfection and Sterilization in Health-Care Facilities. In preparation. 957. Weems JJ, Jr. Nosocomial outbreak of Pseudomonas cepacia associated with contamination of reusable electronic ventilator temperature probes. Infect Control Hosp Epidemiol 1993;14(10):583-6. 958. Berthelot P, Grattard F, Mahul P, et al. Ventilator temperature sensors: an unusual source of Pseudomonas cepacia in nosocomial infection. J Hosp Infect 1993;25(1):33-43. 959. 959. CDC. Bronchoscopy-related infections and pseudoinfections--New York, 1996 and 1998. MMWR Morb Mortal Wkly Rep 1999;48(26):557 60. 960. Heeg P, Roth K, Reichl R, Cogdill CP, Bond WW. Decontaminated single-use devices: an oxymoron that may be placing patients at risk for cross-contamination. Infect Control Hosp Epidemiol 2001;22(9):542-9. 961. www.fda.gov/cdrh/reprocessing/ 962. CDC. Prevention and Control of Influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morbidity & Mortality Weekly Report 2003;52(RR08):1-36.
961 citations
Cites background from "Anthrax as a biological weapon, 200..."
...Anthrax Environmental: aerosolizable spore-containing powder or other substance Until environment completely decontaminated Until decontamination of environment complete [203]....
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TL;DR: It was decided that all of the information dealing with the initial empiric treatment regimens should be in tabular format with footnotes, and the topics selected for updating have been organized according to the headings used in the August 2000 CAP guidelines.
Abstract: The Infectious Diseases Society of America (IDSA) produced guidelines for community-acquired pneumonia (CAP) in immunocompetent adults in 1998 and again in 2000 [1, 2]. Because of evolving resistance to antimicrobials and other advances, it was felt that an update should be provided every few years so that important developments could be highlighted and pressing questions answered. We addressed those issues that the committee believed were important to the practicing physician, including suggestions for initial empiric therapy for CAP. In some cases, only a few paragraphs were needed, whereas, in others, a somewhat more in-depth discussion was provided. Because many physicians focus on the tables rather than on the text of guidelines, it was decided that all of the information dealing with the initial empiric treatment regimens should be in tabular format with footnotes (tables 1–3). The topics selected for updating have been organized according to the headings used in the August 2000 CAP guidelines pub-
949 citations
Cites background from "Anthrax as a biological weapon, 200..."
...The mortality rates in this and prior inhalation anthrax cases in the antibiotic era were 45%–80% [95]....
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...aureus, and category A bacterial agents of bioterrorism [91, 92, 95, 97, 102, 106]....
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...It should be emphasized that the last case of naturally occurring inhalation anthrax in the United States occurred in 1976, so any case of established or suspected inhalation anthrax should prompt notification of public health authorities [95]....
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...Treatment and prophylaxis should be prolonged, because animal studies have shown in vivo persistence of spores [95]....
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TL;DR: An estimate of the reproductive number for 1918 pandemic influenza is obtained by fitting a deterministic SEIR (susceptible-exposed-infectious-recovered) model to pneumonia and influenza death epidemic curves from 45 US cities, which suggests that the median value is less than three.
Abstract: The 1918 influenza pandemic killed 20-40 million people worldwide, and is seen as a worst-case scenario for pandemic planning. Like other pandemic influenza strains, the 1918 A/H1N1 strain spread extremely rapidly. A measure of transmissibility and of the stringency of control measures required to stop an epidemic is the reproductive number, which is the number of secondary cases produced by each primary case. Here we obtained an estimate of the reproductive number for 1918 influenza by fitting a deterministic SEIR (susceptible-exposed-infectious-recovered) model to pneumonia and influenza death epidemic curves from 45 US cities: the median value is less than three. The estimated proportion of the population with A/H1N1 immunity before September 1918 implies a median basic reproductive number of less than four. These results strongly suggest that the reproductive number for 1918 pandemic influenza is not large relative to many other infectious diseases. In theory, a similar novel influenza subtype could be controlled. But because influenza is frequently transmitted before a specific diagnosis is possible and there is a dearth of global antiviral and vaccine stores, aggressive transmission reducing measures will probably be required.
795 citations
TL;DR: A national investigation was initiated to identify additional cases and determine possible exposures to Bacillus anthracis, and 22 cases of anthrax were identified; 5 of the inhalational cases were fatal.
Abstract: In October 2001, the first inhalational anthrax case in the United States since 1976 was identified in a media company worker in Florida. A national investigation was initiated to identify additional cases and determine possible exposures to Bacillus anthracis. Surveillance was enhanced through health-care facilities, laboratories, and other means to identify cases, which were defined as clinically compatible illness with laboratory-confirmed B. anthracis infection. From October 4 to November 20, 2001, 22 cases of anthrax (11 inhalational, 11 cutaneous) were identified; 5 of the inhalational cases were fatal. Twenty (91%) case-patients were either mail handlers or were exposed to worksites where contaminated mail was processed or received. B. anthracis isolates from four powder-containing envelopes, 17 specimens from patients, and 106 environmental samples were indistinguishable by molecular subtyping. Illness and death occurred not only at targeted worksites, but also along the path of mail and in other settings. Continued vigilance for cases is needed among health-care providers and members of the public health and law enforcement communities.
634 citations
Cites background from "Anthrax as a biological weapon, 200..."
...Before the bioterrorismrelated anthrax cases in 2001, clinician recognition of clinical findings suggestive of cutaneous or inhalational anthrax is presumed to have been very low (43,44)....
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References
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TL;DR: The potential value of using pharmacokinetic/pharmacodynamic parameters as guides for establishing optimal dosing regimens for new and old drugs and for new emerging pathogens and resistant organisms should make the continuing search for the therapeutic rationale of antibacterial dosing of mice and men worthwhile.
Abstract: Investigations over the past 20 years have demonstrated that antibacterials can vary markedly in the time course of antimicrobial activity. These differences in pharmacodynamic activity have implications for optimal dosage regimens. The results of more recent studies suggest that the magnitude of the pharmacokinetic/pharmacodynamic parameters required for efficacy are relatively similar in animal infection models and in human infections. However, there is still much to learn. Additional studies are needed to further correlate pharmacokinetic/pharmacodynamic parameters for many antibacterials with therapeutic efficacy in a variety of animal infection models and in human infections. The potential value of using pharmacokinetic/pharmacodynamic parameters as guides for establishing optimal dosing regimens for new and old drugs and for new emerging pathogens and resistant organisms, for setting susceptibility breakpoints, and for reducing the cost of drug development should make the continuing search for the therapeutic rationale of antibacterial dosing of mice and men worthwhile.
2,719 citations
01 Sep 1994
TL;DR: AHFS (R) Drug Information 2017 is the most comprehensive evidence-based source of drug information complete with therapeutic guidelines and off-label uses and helps protect your patients and your practice.
Abstract: With extensive updated information on everything from treatment of hypertension to hepatitis C, AHFS (R) Drug Information (R) 2017 is a necessary addition to your pharmacy's resources. With content supported by more than 89,000 total references and reviewed by over 500 professionals, it helps you protect your patients and your practice. The only print compendium designated by the U.S. Congress, AHFS (R) Drug Information 2017 is also the only reference published by a professional and scientific society - ensuring it is the most authoritative and best-selling reference trusted by pharmacists for 59 years. AHFS (R) Drug Information 2017 contains the most trustworthy drug information available - all in one place. It is the most comprehensive evidence-based source of drug information complete with therapeutic guidelines and off-label uses.
1,108 citations
TL;DR: Clinical presentation and course of cases of bioterrorism-related inhalational anthrax, in the District of Columbia, Florida, New Jersey, and New York, are described; survival of patients was markedly higher than previously reported.
Abstract: From October 4 to November 2, 2001, the first 10 confirmed cases of inhalational anthrax caused by intentional release of Bacillus anthracis were identified in the United States. Epidemiologic investigation indicated that the outbreak, in the District of Columbia, Florida, New Jersey, and New York, resulted from intentional delivery of B. anthracis spores through mailed letters or packages. We describe the clinical presentation and course of these cases of bioterrorism-related inhalational anthrax. The median age of patients was 56 years (range 43 to 73 years), 70% were male, and except for one, all were known or believed to have processed, handled, or received letters containing B. anthracis spores. The median incubation period from the time of exposure to onset of symptoms, when known (n=6), was 4 days (range 4 to 6 days). Symptoms at initial presentation included fever or chills (n=10), sweats (n=7), fatigue or malaise (n=10), minimal or nonproductive cough (n=9), dyspnea (n=8), and nausea or vomiting (n=9). The median white blood cell count was 9.8 X 10(3)/mm(3) (range 7.5 to 13.3), often with increased neutrophils and band forms. Nine patients had elevated serum transaminase levels, and six were hypoxic. All 10 patients had abnormal chest X-rays; abnormalities included infiltrates (n=7), pleural effusion (n=8), and mediastinal widening (seven patients). Computed tomography of the chest was performed on eight patients, and mediastinal lymphadenopathy was present in seven. With multidrug antibiotic regimens and supportive care, survival of patients (60%) was markedly higher (<15%) than previously reported.
928 citations
"Anthrax as a biological weapon, 200..." refers background in this paper
...Data are insufficient to identify factors associated with survival although early recognition and initiation of treatment and use of more than 1 antibiotic have been suggested as possible factors.(61) For the 6 patients for whom such information is known, the median period from presumed time of exposure to the onset of symptoms was 4 days (range, 4-6 days)....
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...Limited early information following the attacks suggested that persons with inhalational anthrax treated intravenously with 2 or more antibiotics active against B anthracis had a greater chance of survival.(61) Given the limited number of persons who developed inhalational anthrax, the paucity of comparative data, and other uncertainties, it remains unclear whether the use of 2 or more antibiotics confers a survival advantage, but combination therapy is a reasonable therapeutic approach in the face of life-threatening illness....
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...All 4 patients exhibiting signs of fulminant illness prior to antibiotic administration died.(61) Of note, the incubation period of the 2 fatal cases from New York City and Connecticut is not known....
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...Each of the 8 patients who had blood cultures obtained prior to initiation of antibiotics had positive blood cultures.(61) However, blood cultures appear to be sterilized after even 1 or 2 doses of antibiotics, underscoring the importance of obtaining cultures prior to initiation of antibiotic therapy (J....
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...Although anthrax does not cause a classic bronchopneumonia pathologically, it can cause widened mediastinum, massive pleural effusions, air bronchograms, necrotizing pneumonic lesions, and/or consolidation, as has been noted above.(36,55,56,61,64-66) The result can be hypoxemia and chest imaging abnormalities that may or may not be clinically distinguishable from pneumonia....
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TL;DR: It is concluded that the escape of an aerosol of anthrax pathogen at the military facility caused the outbreak of Sverdlovsk and that most victims worked or lived in a narrow zone extending from a military facility to the southern city limit.
Abstract: In April and May 1979, an unusual anthrax epidemic occurred in Sverdlovsk, Union of Soviet Socialist Republics. Soviet officials attributed it to consumption of contaminated meat. U.S. agencies attributed it to inhalation of spores accidentally released at a military microbiology facility in the city. Epidemiological data show that most victims worked or lived in a narrow zone extending from the military facility to the southern city limit. Farther south, livestock died of anthrax along the zone's extended axis. The zone paralleled the northerly wind that prevailed shortly before the outbreak. It is concluded that the escape of an aerosol of anthrax pathogen at the military facility caused the outbreak.
891 citations
TL;DR: A consensus-based recommendation for measures to be taken by medical and public health professionals following the use of anthrax as a biological weapon against a civilian population was developed by a working group of 21 representatives from staff of major academic medical centers and research as mentioned in this paper.
Abstract: Objective To develop consensus-based recommendations for measures to be taken by medical and public health professionals following the use of anthrax as a biological weapon against a civilian population. Participants The working group included 21 representatives from staff of major academic medical centers and research, government, military, public health, and emergency management institutions and agencies. Evidence MEDLINE databases were searched from January 1966 to April 1998, using the Medical Subject Headings anthrax, Bacillus anthracis, biological weapon, biological terrorism, biological warfare, and biowarfare. Review of references identified by this search led to identification of relevant references published prior to 1966. In addition, participants identified other unpublished references and sources. Consensus Process The first draft of the consensus statement was a synthesis of information obtained in the formal evidence-gathering process. Members of the working group provided formal written comments which were incorporated into the second draft of the statement. The working group reviewed the second draft on June 12, 1998. No significant disagreements existed and comments were incorporated into a third draft. The fourth and final statement incorporates all relevant evidence obtained by the literature search in conjunction with final consensus recommendations supported by all working group members. Conclusions Specific consensus recommendations are made regarding the diagnosis of anthrax, indications for vaccination, therapy for those exposed, postexposure prophylaxis, decontamination of the environment, and additional research needs.
835 citations