Clinical condition Treatment Postexposure prophylaxis Inhalational anthrax Prophylaxis for 60 days c : Ciprofloxacin 10–15 mg/kg PO q12h OR Levofloxacin mg/kg PO q12h OR Doxycycline 2.2 mg/kg PO q12h Pneumonic plague d Ricin Tularemia (pneumonic) Smallpox Ciprofloxacin 10–15 mg/kg IV q12h OR Levofloxacin mg/kg PO q12h OR Doxycycline 2.2 mg/kg IV q12h AND Clindamycin a 10–15 mg/kg IV q8h AND Penicillin G b 400–600k U/kg/d IV ÷ q4h AND consider: Raxibacumab (>50 kg: 40 mg/kg IV; 15– 50 kg: 60 mg/kg IV; 40 kg: 16 mg/kg IV) Gentamicin 2.5 mg/kg IV q8h OR Doxycycline 2.2 mg/kg IV q12h OR Ciprofloxacin 15 mg/kg IV q12h OR Levofloxacin mg/kg IV/PO q12h Supportive therapy Same as for Plague e Doxycycline 2.2 mg/kg PO q12h OR Ciprofloxacin 20 mg/kg PO q12h OR Levofloxacin mg/kg PO q12h Supportive therapy Same as for Plague e Tecoviramat 200 mg PO Vaccination may be q12h (for children 13–25 effective if given within kg); 400 mg PO q12h (for 96 hours after exposure children 25–40 kg); 600 Viral hemorrhagic fever (e.g., Ebola) Botulism mg PO q12h (for children >40 kg) Supportive therapy; consider Supportive therapy ribavirin in select cases Supportive therapy; an antitoxin may prevent disease progression Supportive therapy a Rifampin or clarithromycin also targets bacterial protein synthesis may thus be acceptable alternatives to clindamycin If ciprofloxacin or another quinolone is employed, doxycycline may be used as a second agent, as it also targets protein synthesis b Ampicillin, imipenem, meropenem, or chloramphenicol penetrates the CSF well and may thus be acceptable alternatives to penicillin c Treatment for cutaneous anthrax would be the same as for postexposure prophylaxis Sixty days of treatment is indicated if concern for concomitant inhalation exposure d If signs/symptoms of sepsis, treatment of patient with bubonic plague is same as for pneumonic plague e Levofloxacin and moxifloxacin are licensed by the Food and Drug Administration for the prophylaxis and treatment of plague in the setting of a bioterror attack, but not tularemia GOALS OF TREATMENT The goals of emergency therapy include early recognition of a potential biologic agent attack, efficient and accurate triage of victims, rapid institution of proper isolation and infection control precautions to protect healthcare workers and other patients, and administration of proper antibiotics or antitoxins, when appropriate CLINICAL CONSIDERATIONS Clinical Recognition Recognition of a biologic agent exposure may be difficult because pediatricians and emergency department (ED) physicians rarely encounter victims of such attacks Considering three critical epidemiologic characteristics of such an attack might enhance early recognition: an epidemic number of patients, a common exposure history, and exotic disease presentations A large number of patients, out of proportion to time of year and expected clinical syndromes, might trigger suspicion Although some variations in the incubation period may occur after a biologic agent attack, most persons would initially be exposed at the same time, and thus become ill and present in a relatively compressed time frame In contrast, most natural epidemics evolve with a gradual rise in disease incidence because persons are progressively exposed to increased numbers of infectious patients, fomites, or vectors that spread the organism A history of geographic connection among patients, or some observation of an unusual source of exposure such as a powder in an envelope, might also trigger suspicion By exotic diseases, it is suggested that many infections caused by biologic weapons, particularly with advanced disease, are relatively unusual and unique Diseases that are rare, not endemic in the area of exposure, or that are normally spread by vectors that are not indigenous to the relevant geographic area would also be suspected, especially if numerous cases developed simultaneously FIGURE 132.1 Approach to the early recognition and diagnosis of an attack with an unknown biologic agent VEE, Venezuelan equine encephalitis; JE, Japanese encephalitis; Rx, treatment; CXR, chest x-ray; VHF, viral hemorrhagic fever (Reprinted from Henretig FM, Cieslak TJ, Kortepeter MG, et al Medical management of the suspected victim of bioterrorism: an algorithmic approach to the undifferentiated patient Emerg Med Clin N Amer 2002;20:351– 364 Copyright © 2002 Elsevier Science (USA) With permission.) Additional clues to a biologic agent attack might include especially high infection or intoxication rates among exposed persons, high numbers of patients with atypical pneumonia, unusually high morbidity or mortality, simultaneous epidemics caused by different pathogens, attack rates lower in persons sheltered from the suspected route of exposure, presence of infected or dying animals, and the discovery of suspicious actions or potential delivery systems Most of the primary biologic threat agents can be categorized as causing the subacute onset of effects (e.g., days after exposure); those effects can be divided into predominantly respiratory, neurologic, or dermatologic syndromes Thus, with a careful medical and epidemiologic history, physical examination, and limited, routine laboratory evaluation, an early suspicion of a biologic attack might be raised, and initial diagnostic impression considered, as outlined in Figure 132.1 This in turn could trigger appropriate requests for infectious disease consultation and more definitive laboratory testing, as well as early empiric therapy A similar approach, applied in the setting of unusual increases in patient volume or illness presentations, might also help practitioners to participate in the early recognition of a new or reemerging natural infectious disease (e.g., West Nile disease, severe acute respiratory syndrome [SARS], Middle East Respiratory Syndrome [MERS], monkeypox, Ebola, and pneumonic tularemia, to name some recent examples) If a pediatrician or emergency medicine physician recognizes, or even suspects, any such natural or intentional outbreak, immediate reporting to local and regional public health authorities is appropriate, even before a specific diagnosis can be confirmed Triage Considerations: Minimizing Spread of Infection As soon as ED staff suspect that a patient may be the victim of biologic terrorism, appropriate steps must take place to prevent or minimize exposure to limit the spread of disease The level of ED mitigation and preparedness activities will largely depend on the level of awareness of the disease outbreak For example, faced with a known release of smallpox by terrorists, EDs would need to take dramatic steps to protect staff and patients Such steps might include setting up screening stations outside of the hospital, staffed by clinicians wearing gowns, gloves, N-95 respirators, and eye protection If a child suspected to have smallpox were encountered at the screening station, he or she would need to be covered with a sheet, provided a mask, and escorted directly to a negative-pressure room for further evaluation and treatment Infection Prevention and Control specialists would need to provide guidance on specimen collection, handling, and testing Patients suspected to have smallpox should be moved to a specialized biocontainment facility as soon as possible In the event of a large outbreak, when the supply of scarce biocontainment beds is likely to be exhausted, airborne infection isolation rooms might be an acceptable alternative Should these also prove inadequate for the number of affected patients, the cohorting of patients in designated “smallpox wards” might be necessary ... [MERS], monkeypox, Ebola, and pneumonic tularemia, to name some recent examples) If a pediatrician or emergency medicine physician recognizes, or even suspects, any such natural or intentional outbreak,... Clinical Recognition Recognition of a biologic agent exposure may be difficult because pediatricians and emergency department (ED) physicians rarely encounter victims of such attacks Considering... plague in the setting of a bioterror attack, but not tularemia GOALS OF TREATMENT The goals of emergency therapy include early recognition of a potential biologic agent attack, efficient and