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Bioterrorism Agents – Plague Lesson 5. Medical Management. Objectives. Management of suspect and confirmed cases Medications – Controlled Situation Medications – Mass Casualty Infection Control. Overview. Prompt treatment required Y. pestis – enterobacteriaceae

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Presentation Transcript
objectives
Objectives
  • Management of suspect and confirmed cases
  • Medications – Controlled Situation
  • Medications – Mass Casualty
  • Infection Control
overview
Overview
  • Prompt treatment required
  • Y. pestis – enterobacteriaceae
  • Responsive to most antimicrobials
overview4
Overview
  • Aerosol exposure – plague pneumonia
  • Medical Management
    • Prompt antimicrobial administration
    • Respiratory droplet precautions
    • Intensive respiratory support
    • Management of consequences
treatment issues
Treatment Issues
  • Clinical improvement 36 to 48 hours, if responding to treatment
  • Cannot recover Y. pestis after 36 hours of treatment
  • All US strains have been sensitive to current treatments, to date
treatment in bioterrorism
Treatment in Bioterrorism
  • BT Plague – High suspicion of resistance
  • Perform testing rapidly
  • Watch for Health Alerts
  • Treatment/Prophylaxis recommendations may change
streptomycin
Streptomycin
  • Historically preferred
  • FDA-approved
  • Not widely and immediately available
  • Floroquinolones?
treating an outbreak
Treating an Outbreak
  • Gentamicin – IND protocol
  • Contained Casualty – parenteral antimicrobial therapy
  • Mass Casualty – oral therapy
recommended plague treatment notes on options
Recommended Plague TreatmentNotes on Options
  • Based on consensus of working group and not FDA
  • Choose one agent.
  • Treatment for 10 days
  • Substitute oral therapy when condition improves
recommended plague treatment notes on gentamicin
Recommended Plague TreatmentNotes on Gentamicin
  • Streptomycin preferred, but hard to find
  • Frequency at discretion of clinician
  • Initial loading dose 2 mg/kg standard when given three times per day
  • Not FDA-approved
  • Refer to package insert re renal insufficiency
recommended plague treatment notes on children
Recommended Plague TreatmentNotes on Children
  • Gentamicin may be efficacious, but not widely accepted clinical practice
  • Neonates up to 1 wk – 2.5 mg/kg IV BID
  • Can substitute other fluoroquinolones
  • Ciprofloxacin – 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.
plague infection control precautions
Plague Infection Control Precautions
  • Isolation for 48 hours of antibiotic treatment or until clinical improvement
plague infection control
Plague Infection Control
  • Cohort and Droplet precautions if no isolation available
  • Isolation of contacts may increase in importance for outbreak control
  • Corpses – Standard Precautions
occupational exposure hospital and laboratory
Occupational ExposureHospital and Laboratory
  • Skin Exposures – Nonabrasive soap and water, standard workplace exposure policy
  • Eye Exposures – Flush with water or eye wash solution x 15 minutes
  • Post-Exposure doxycycline or ciprofloxacin x 7 days
  • Laboratory – avoid aerosolization
occupational exposures laboratory spills
Occupational ExposuresLaboratory Spills
  • Cover in absorbent materials
  • 1:100 bleach x 30 minutes
  • Wipe with absorbent materials soaked in 1:100 bleach
  • Clean with nonabrasive soap and water
  • Dispose all materials biohazard
  • BSL2 for all suspect materials
occupational exposures field workers
Occupational ExposuresField Workers
  • Incident Commander assigns PPE levels
  • Minimum of Level B PPE
    • Tyvek outer clothing
    • Gloves
    • Booties
    • Positive pressure HEPA filtered respirators
  • All PPE decontaminated or disposed of as biohazardous waste
plague review questions lesson 5 question 1
Plague Review QuestionsLesson 5, Question 1
  • News report – 75 cases of plague in area
  • Ambulances arriving at ER
  • Exposed to intentional plague bacteria release

Which antibiotic would you choose?

plague review questions lesson 5 question 123
Plague Review QuestionsLesson 5, Question 1

Which antibiotic would you choose?

  • Streptomycin – 1g IM BID
  • Doxycycline – 100 mg PO BID
  • Gentamicin – 5 mg/kg IM or IV daily
  • Any of the above
plague review questions lesson 5 question 124
Plague Review QuestionsLesson 5, Question 1

Which antibiotic would you choose?

B. Doxycycline – 100 mg PO BID

plague review questions lesson 5 question 2
Plague Review QuestionsLesson 5, Question 2
  • Suspect pneumonic plague patient

What precautions would you take immediately?

plague review questions lesson 5 question 226
Plague Review QuestionsLesson 5, Question 2

What precautions would you take immediately?

  • Standard precautions
  • Standard and contact precautions
  • Standard and respiratory droplet precautions
  • Negative pressure room
plague review questions lesson 5 question 227
Plague Review QuestionsLesson 5, Question 2

What precautions would you take immediately?

C. Standard and respiratory droplet precautions

plague review questions lesson 5 question 3
Plague Review QuestionsLesson 5, Question 3
  • Pneumonia patient
  • Lab unable to rule out plague

What medication do you prescribe for a controlled casualty situation?

plague review questions lesson 5 question 329
Plague Review QuestionsLesson 5, Question 3

What medication do you prescribe for a controlled casualty situation?

  • Penicillin
  • Gentamicin
  • Zithromicin
  • Biaxin
plague review questions lesson 5 question 330
Plague Review QuestionsLesson 5, Question 3

What medication do you prescribe for a controlled casualty situation?

B. Gentamicin

plague review questions lesson 5 question 4
Plague Review QuestionsLesson 5, Question 4
  • Pneumonic plague patient
  • Gentamicin x 48 hours

How would you expect the patient to progress?

plague review questions lesson 5 question 432
Plague Review QuestionsLesson 5, Question 4

How would you expect the patient to progress?

  • Spike in temperature, toxic
  • Still infectious, remain in isolation
  • Showing signs of clinical improvement
  • Signs of inflammatory response
plague review questions lesson 5 question 433
Plague Review QuestionsLesson 5, Question 4

How would you expect the patient to progress?

C. Showing signs of clinical improvement