1. Bioterrorism Agents – Plague Lesson 5 Medical Management

2. Objectives Management of suspect and confirmed casesManagement of suspect and confirmed cases Medications – Controlled SituationMedications – Controlled Situation Medications – Mass CasualtyMedications – Mass Casualty Infection ControlInfection Control

3. Overview Prompt treatment requiredPrompt treatment required Y. pestis – enterobacteriaceaeY. pestis – enterobacteriaceae Responsive to most antimicrobialsResponsive to most antimicrobials

4. Overview Aerosol exposure – plague pneumoniaAerosol exposure – plague pneumonia Medical ManagementMedical Management –Prompt antimicrobial administration –Respiratory droplet precautions –Intensive respiratory support –Management of consequences

5. Treatment Issues Clinical improvement 36 to 48 hours, if responding to treatmentClinical improvement 36 to 48 hours, if responding to treatment Cannot recover Y. pestis after 36 hours of treatmentCannot recover Y. pestis after 36 hours of treatment All US strains have been sensitive to current treatments, to dateAll US strains have been sensitive to current treatments, to date

6. Treatment in Bioterrorism BT Plague – High suspicion of resistanceBT Plague – High suspicion of resistance Perform testing rapidlyPerform testing rapidly Watch for Health AlertsWatch for Health Alerts Treatment/Prophylaxis recommendations may changeTreatment/Prophylaxis recommendations may change

7. Streptomycin Historically preferredHistorically preferred FDA-approvedFDA-approved Not widely and immediately availableNot widely and immediately available Floroquinolones?Floroquinolones?

8. Treating an Outbreak Gentamicin – IND protocolGentamicin – IND protocol Contained Casualty – parenteral antimicrobial therapyContained Casualty – parenteral antimicrobial therapy Mass Casualty – oral therapyMass Casualty – oral therapy

9. Recommended Plague Treatment Notes on Options Based on consensus of working group and not FDABased on consensus of working group and not FDA Choose one agent.Choose one agent. Treatment for 10 daysTreatment for 10 days Substitute oral therapy when condition improvesSubstitute oral therapy when condition improves

10. Recommended Plague Treatment Contained Casualty - Adults Preferred Streptomycin 1g IM BID Gentamicin 5 mg/kg IM or IV daily OR 2 mg/kg loading with 1.7 mg/kg IM or IV TID Alternative Doxycycline 100mg IV BID or 200mg IV Ciprofloxacin 400mg IV BID Chloramphenicol 25 mg/kg IV QID

11. Recommended Plague Treatment Contained Casualty - Children Preferred Streptomycin 15 mg/kg IM BID (max 2g daily) Gentamicin 2.5 mg/kg IM or IV daily TID Alternative Doxycycline  45kg - 100mg IV BID or 200mg IV Ciprofloxacin 15 mg/kg BID Chloramphenicol 25 mg/kg IV QID

12. Recommended Plague Treatment Mass Casualty - Adults Preferred Doxycycline 100 mg PO BID Ciprofloxacin 500 mg PO BID Alternative Chloramphenicol 25 mg/kg PO QID

13. Recommended Plague Treatment Children – Mass Casualty Preferred Doxycycline  45kg - 100 mg PO BID <45kg – 2.2mg/kg PO BID Ciprofloxacin 20 mg/kg PO BID Alternative Chloramphenicol 25 mg/kg IV QID

14. Streptomycin preferred, but hard to findStreptomycin preferred, but hard to find Frequency at discretion of clinicianFrequency at discretion of clinician Initial loading dose 2 mg/kg standard when given three times per dayInitial loading dose 2 mg/kg standard when given three times per day Not FDA-approvedNot FDA-approved Refer to package insert re renal insufficiencyRefer to package insert re renal insufficiency Recommended Plague Treatment Notes on Gentamicin

15. Recommended Plague Treatment Notes on Children Gentamicin may be efficacious, but not widely accepted clinical practiceGentamicin may be efficacious, but not widely accepted clinical practice Neonates up to 1 wk – 2.5 mg/kg IV BIDNeonates up to 1 wk – 2.5 mg/kg IV BID Can substitute other fluoroquinolonesCan substitute other fluoroquinolones Ciprofloxacin – dosage no more than 1 g/d, concentrations between 5 – 20 µg/mlCiprofloxacin – dosage no more than 1 g/d, concentrations between 5 – 20 µg/ml Chloramphenicol –dosage no more than 4g/d. No one younger than 2 years.Chloramphenicol –dosage no more than 4g/d. No one younger than 2 years.

16. Plague Infection Control Precautions Isolation for 48 hours of antibiotic treatment or until clinical improvementIsolation for 48 hours of antibiotic treatment or until clinical improvement BubonicStandard Pneumonic Standard and Respiratory SepticemicStandard Suspect Respiratory and Isolation

17. Plague Infection Control Cohort and Droplet precautions if no isolation availableCohort and Droplet precautions if no isolation available Isolation of contacts may increase in importance for outbreak controlIsolation of contacts may increase in importance for outbreak control Corpses – Standard PrecautionsCorpses – Standard Precautions

18. Occupational Exposure Hospital and Laboratory Skin Exposures – Nonabrasive soap and water, standard workplace exposure policySkin Exposures – Nonabrasive soap and water, standard workplace exposure policy Eye Exposures – Flush with water or eye wash solution x 15 minutesEye Exposures – Flush with water or eye wash solution x 15 minutes Post-Exposure doxycycline or ciprofloxacin x 7 daysPost-Exposure doxycycline or ciprofloxacin x 7 days Laboratory – avoid aerosolizationLaboratory – avoid aerosolization

19. Occupational Exposures Laboratory Spills Cover in absorbent materialsCover in absorbent materials 1:100 bleach x 30 minutes1:100 bleach x 30 minutes Wipe with absorbent materials soaked in 1:100 bleachWipe with absorbent materials soaked in 1:100 bleach Clean with nonabrasive soap and waterClean with nonabrasive soap and water Dispose all materials biohazardDispose all materials biohazard BSL2 for all suspect materialsBSL2 for all suspect materials

20. Occupational Exposures Field Workers Incident Commander assigns PPE levelsIncident Commander assigns PPE levels Minimum of Level B PPEMinimum of Level B PPE –Tyvek outer clothing –Gloves –Booties –Positive pressure HEPA filtered respirators All PPE decontaminated or disposed of as biohazardous wasteAll PPE decontaminated or disposed of as biohazardous waste

21. Review Questions - Plague Lesson 5 Medical Management

22. Plague Review Questions Lesson 5, Question 1 News report – 75 cases of plague in areaNews report – 75 cases of plague in area Ambulances arriving at ERAmbulances arriving at ER Exposed to intentional plague bacteria releaseExposed to intentional plague bacteria release Which antibiotic would you choose?

23. Plague Review Questions Lesson 5, Question 1 Which antibiotic would you choose? A.Streptomycin – 1g IM BID B.Doxycycline – 100 mg PO BID C.Gentamicin – 5 mg/kg IM or IV daily D.Any of the above

24. Plague Review Questions Lesson 5, Question 1 Which antibiotic would you choose? B. Doxycycline – 100 mg PO BID

25. Plague Review Questions Lesson 5, Question 2 Suspect pneumonic plague patientSuspect pneumonic plague patient What precautions would you take immediately?

26. Plague Review Questions Lesson 5, Question 2 What precautions would you take immediately? A.Standard precautions B.Standard and contact precautions C.Standard and respiratory droplet precautions D.Negative pressure room

27. Plague Review Questions Lesson 5, Question 2 What precautions would you take immediately? C. Standard and respiratory droplet precautions

28. Plague Review Questions Lesson 5, Question 3 Pneumonia patientPneumonia patient Lab unable to rule out plagueLab unable to rule out plague What medication do you prescribe for a controlled casualty situation?

29. Plague Review Questions Lesson 5, Question 3 What medication do you prescribe for a controlled casualty situation? A.Penicillin B.Gentamicin C.Zithromicin D.Biaxin

30. Plague Review Questions Lesson 5, Question 3 What medication do you prescribe for a controlled casualty situation? B. Gentamicin

31. Plague Review Questions Lesson 5, Question 4 Pneumonic plague patientPneumonic plague patient Gentamicin x 48 hoursGentamicin x 48 hours How would you expect the patient to progress?

32. Plague Review Questions Lesson 5, Question 4 How would you expect the patient to progress? A.Spike in temperature, toxic B.Still infectious, remain in isolation C.Showing signs of clinical improvement D.Signs of inflammatory response

33. Plague Review Questions Lesson 5, Question 4 How would you expect the patient to progress? C. Showing signs of clinical improvement