Expert Guidance on Managing Plague Outbreaks: Treatment & Control Methods

1. Bioterrorism Agents – PlagueLesson 5 Medical Management

2. Objectives • Management of suspect and confirmed cases • Medications – Controlled Situation • Medications – Mass Casualty • Infection Control

3. Overview • Prompt treatment required • Y. pestis – enterobacteriaceae • Responsive to most antimicrobials

4. Overview • Aerosol exposure – plague pneumonia • Medical 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 treatment • Cannot recover Y. pestis after 36 hours of treatment • All US strains have been sensitive to current treatments, to date

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

7. Streptomycin • Historically preferred • FDA-approved • Not widely and immediately available • Floroquinolones?

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

9. 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

10. Recommended Plague TreatmentContained Casualty - Adults

11. Recommended Plague TreatmentContained Casualty - Children

12. Recommended Plague TreatmentMass Casualty - Adults

13. Recommended Plague TreatmentChildren – Mass Casualty

14. 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

15. 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.

16. Plague Infection Control Precautions • Isolation for 48 hours of antibiotic treatment or until clinical improvement

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

18. 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

19. 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

20. 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

21. Review Questions - PlagueLesson 5 Medical Management

22. 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?

23. 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

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

25. Plague Review QuestionsLesson 5, Question 2 • Suspect pneumonic plague patient What precautions would you take immediately?

26. 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

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

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

29. Plague Review QuestionsLesson 5, Question 3 What medication do you prescribe for a controlled casualty situation? • Penicillin • Gentamicin • Zithromicin • Biaxin

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

31. Plague Review QuestionsLesson 5, Question 4 • Pneumonic plague patient • Gentamicin x 48 hours How would you expect the patient to progress?

32. 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

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