Confirmation may be obtained by blood culture State health laboratories, USAMRIID, and the CDC can also confirm a diagnosis of anthrax by polymerase chain reaction (PCR) and immunohistochemical assay Management As anthrax has little potential for person to person transmission, standard precautions are adequate for healthcare workers caring for anthrax victims Given the usual 1- to 5-day incubation period, decontamination of victims presenting days after exposure is unwarranted Aerosolization of organisms from skin or clothing likewise poses little threat under typical circumstances, but bathing and laundry with soap and water would seem prudent soon after direct physical contact with a suspect substance Although naturally occurring strains of B anthracis are usually quite sensitive to penicillin G, penicillin-resistant strains of B anthracis are known; thus, many experts consider ciprofloxacin, levofloxacin, or doxycycline as essential components of first-line treatment for victims of intentional anthrax Infectious Disease and Emergency Preparedness experts can provide advice regarding postexposure prophylaxis See Table 132.3B for detailed treatment recommendations for children Newer treatments include the recently licensed monoclonal antibodies raxibacumab and obiltoxaximab, as well as investigational anthrax immune globulin preparations Plague Background Plague, caused by infection with the gram-negative bipolar-staining rod Yersinia pestis, is usually transmitted in nature via the bite of fleas Endemic disease is still seen in areas of the southwestern United States, South and Southeast Asia, as well as in South America and Africa Plague has long appeared attractive as an agent of bioterrorism Testimony to its extreme lethality and infectivity can be obtained by considering that the “Black Death” eliminated onethird of the population of Europe during the Middle Ages Pathophysiology Y pestis is a facultative intracellular pathogen that is able to survive temporarily within macrophages, thus aiding its dissemination to distant sites following inoculation or inhalation It is lymphotropic, and significantly tender regional lymphadenopathy (e.g., in the distribution of a flea bite) is a prominent feature of bubonic plague Pneumonic plague (along with smallpox) is one of the few bioterrorist threats readily transmissible from person to person via the respiratory route, and coughing patients are often highly contagious