Treatment of anthrax
- Kenneth H Wilson, MD
Kenneth H Wilson, MD
- Professor of Medicine, Division of Infectious Diseases
- Duke University Medical Center
The incidence of anthrax in humans has decreased during the past century, and it is now very rare in developed countries including the United States. However, anthrax remains a concern in the developed world because of its potential as an agent of bioterrorism. Anthrax meningitis and the fulminant phase of inhalation anthrax are associated with extremely high mortality rates.
The treatment of anthrax will be reviewed here. The microbiology, pathogenesis, epidemiology, clinical manifestations, diagnosis, and prevention of anthrax are discussed separately. (See "Microbiology, pathogenesis, and epidemiology of anthrax" and "Clinical manifestations and diagnosis of anthrax" and "Prevention of anthrax".)
The treatment recommendations presented here are in agreement with the recommendations of the United States Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) [1-3].
Important caveats — Treatment of patients suspected of having systemic anthrax should be started urgently and should include intravenous antimicrobial combination therapy, an antitoxin (raxibacumab or anthrax immunoglobulin), drainage of pleural effusions, supportive care, and consideration of adjunctive glucocorticoids . Each of these therapies is discussed in detail below. When selecting an antimicrobial regimen for anthrax, the production of toxin, the potential for antimicrobial drug resistance, the frequent occurrence of meningitis, and the presence of latent spores must be taken into account.
●Initial evaluation – Patients suspected of having systemic anthrax should undergo similar testing as is done in other patients with an acute febrile illness, including pretreatment blood cultures and other appropriate cultures . Unless it is contraindicated, all patients suspected of having systemic anthrax should undergo lumbar puncture to evaluate for meningitis. Other diagnostic testing is discussed separately. (See "Clinical manifestations and diagnosis of anthrax", section on 'Diagnosis'.)
- Hendricks KA, Wright ME, Shadomy SV, et al. Centers for disease control and prevention expert panel meetings on prevention and treatment of anthrax in adults. Emerg Infect Dis 2014; 20.
- Bradley JS, Peacock G, Krug SE, et al. Pediatric anthrax clinical management. Pediatrics 2014; 133:e1411.
- Meaney-Delman D, Zotti ME, Creanga AA, et al. Special considerations for prophylaxis for and treatment of anthrax in pregnant and postpartum women. Emerg Infect Dis 2014; 20.
- Pillai SK, Huang E, Guarnizo JT, et al. Antimicrobial Treatment for Systemic Anthrax: Analysis of Cases from 1945 to 2014 Identified Through a Systematic Literature Review. Health Secur 2015; 13:355.
- Lightfoot N, Scott R, Turnbull B. Antimicrobial susceptibility of Bacillus anthracis. Salisbury Med Bull Suppl 1990; 68:95.
- Doğanay M, Aydin N. Antimicrobial susceptibility of Bacillus anthracis. Scand J Infect Dis 1991; 23:333.
- Turnbull PC, Sirianni NM, LeBron CI, et al. MICs of selected antibiotics for Bacillus anthracis, Bacillus cereus, Bacillus thuringiensis, and Bacillus mycoides from a range of clinical and environmental sources as determined by the Etest. J Clin Microbiol 2004; 42:3626.
- Luna VA, King DS, Gulledge J, et al. Susceptibility of Bacillus anthracis, Bacillus cereus, Bacillus mycoides, Bacillus pseudomycoides and Bacillus thuringiensis to 24 antimicrobials using Sensititre automated microbroth dilution and Etest agar gradient diffusion methods. J Antimicrob Chemother 2007; 60:555.
- Bakici MZ, Elaldi N, Bakir M, et al. Antimicrobial susceptibility of Bacillus anthracis in an endemic area. Scand J Infect Dis 2002; 34:564.
- Ross CL, Thomason KS, Koehler TM. An extracytoplasmic function sigma factor controls beta-lactamase gene expression in Bacillus anthracis and other Bacillus cereus group species. J Bacteriol 2009; 191:6683.
- Bower WA, Hendricks K, Pillai S, et al. Clinical Framework and Medical Countermeasure Use During an Anthrax Mass-Casualty Incident. MMWR Recomm Rep 2015; 64:1.
- Katharios-Lanwermeyer S, Holty JE, Person M, et al. Identifying Meningitis During an Anthrax Mass Casualty Incident: Systematic Review of Systemic Anthrax Since 1880. Clin Infect Dis 2016; 62:1537.
- Holty JE, Bravata DM, Liu H, et al. Systematic review: a century of inhalational anthrax cases from 1900 to 2005. Ann Intern Med 2006; 144:270.
- Sejvar JJ, Tenover FC, Stephens DS. Management of anthrax meningitis. Lancet Infect Dis 2005; 5:287.
- Lanska DJ. Anthrax meningoencephalitis. Neurology 2002; 59:327.
- Meaney-Delman D, Rasmussen SA, Beigi RH, et al. Prophylaxis and treatment of anthrax in pregnant women. Obstet Gynecol 2013; 122:885.
- Villani P, Regazzi MB, Marubbi F, et al. Cerebrospinal fluid linezolid concentrations in postneurosurgical central nervous system infections. Antimicrob Agents Chemother 2002; 46:936.
- Food and Drug Administration. Prescription Drug Products: Doxycycline and penicillin G procaine administration for inhalational anthrax (post-exposure). In: Federal Register, November 2, 2001.
- Food and Drug Administration. Cipro (ciprofloxacin hydrochloride) for inhalation anthrax. http://www.fda.gov/Drugs/EmergencyPreparedness/BioterrorismandDrugPreparedness/ucm130709.htm (Accessed on July 09, 2014).
- Stern EJ, Uhde KB, Shadomy SV, Messonnier N. Conference report on public health and clinical guidelines for anthrax. Emerg Infect Dis 2008; 14.
- Artenstein AW, Opal SM. Novel approaches to the treatment of systemic anthrax. Clin Infect Dis 2012; 54:1148.
- Huang E, Pillai SK, Bower WA, et al. Antitoxin Treatment of Inhalation Anthrax: A Systematic Review. Health Secur 2015; 13:365.
- Lucchesi, PF. Serum treatment of 19 cases of anthrax including one of external, internal and bacteremic type. Am J Med Sci 1932; 183:795.
- Lucchesi, PF, Gildersleeve, N. The treatment of anthrax. JAMA 1941; 116:1506.
- Knudson GB. Treatment of anthrax in man: history and current concepts. Mil Med 1986; 151:71.
- Migone TS, Subramanian GM, Zhong J, et al. Raxibacumab for the treatment of inhalational anthrax. N Engl J Med 2009; 361:135.
- Barochia AV, Cui X, Sun J, et al. Protective antigen antibody augments hemodynamic support in anthrax lethal toxin shock in canines. J Infect Dis 2012; 205:818.
- US Food and Drug Administration. FDA News Release. FDA approves raxibacumab to treat inhalational anthrax. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm332341.htm (Accessed on January 02, 2013).
- Raxibacumab prescribing information. http://www.accessdata.fda.gov/drugsatfda_docs/label/2012/125349s000lbl.pdf (Accessed on January 03, 2013).
- Nabel GJ. Protecting against future shock--inhalational anthrax. N Engl J Med 2009; 361:191.
- US Food and Drug Adminisration. FDA News Release. FDA approves new treatment for inhalation anthrax. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm491470.htm (Accessed on April 04, 2016).
- ANTHIM (obiltoxaximab) injection, for intravenous use - Highlights of prescribing information. http://www.anthim.com/download/pdf/ANTHIM-prescribing-information.pdf (Accessed on April 04, 2016).
- FDA news release. FDA approves treatment for inhalation anthrax. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm439752.htm (Accessed on March 27, 2015).
- ANTHRASIL [Anthrax Immune Globulin Intravenous (Human)]. http://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM439812.pdf (Accessed on April 06, 2015).
- Kammanadiminti S, Patnaikuni RK, Comer J, et al. Combination therapy with antibiotics and anthrax immune globulin intravenous (AIGIV) is potentially more effective than antibiotics alone in rabbit model of inhalational anthrax. PLoS One 2014; 9:e106393.
- Demirdag K, Ozden M, Saral Y, et al. Cutaneous anthrax in adults: a review of 25 cases in the eastern Anatolian region of Turkey. Infection 2003; 31:327.
- Tahernia AC. Treatment of anthrax in children. Arch Dis Child 1967; 42:181.
- Important caveats
- Antimicrobial therapy
- - Meningitis
- - Systemic anthrax without meningitis
- - Cutaneous anthrax without systemic involvement
- - Raxibacumab
- - Obiltoxaximab
- - Anthrax immunoglobulin
- Adjunctive therapies
- - Glucocorticoids
- - Pleural fluid drainage
- - Other invasive procedures
- Supportive care
- PUBLIC HEALTH REPORTING
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS