Department of Health and Human Services
Centers for Disease = Control and=20 Prevention

Emerging Infectious Diseases

ISSN: 1080-6059

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Article Contents

PEP for = Inhalation Anthrax=20
Duration of=20 Prophylaxis Regimen=20
Treatment of=20 Severe Disease, including Inhalation and Gastrointestinal Anthrax, = Anthrax=20 Meningitis, and Bacteremia=20
Treatment of=20 Cutaneous Anthrax=20
Immunotherapeutic= s=20
Special = Populations=20
Acknowledgments=20
Meeting = Participants=20
References=20
Figure=20
Table=20
Suggested=20 Citation

EID Journal=20 Home > Volume = 14, Number=20 4=96April 2008

Volume 14, Number 4=96April 2008

Conference Report

Conference Report on Public Health and Clinical Guidelines for = Anthrax

Eric Jacob Stern,* Kristin Broome Uhde,* Sean Vincent = Shadomy,* and Nancy Messonnier*
*Centers = for Disease=20 Control and Prevention, Atlanta, Georgia, USA

On March 13=9614, 2006, a meeting on anthrax, sponsored by the = Centers for=20 Disease Control and Prevention (CDC) in collaboration with the = Southeastern=20 Center for Emerging Biologic Threats, was held at Emory University in = Atlanta,=20 Georgia, USA. The meeting's agenda included discussion of postexposure=20 prophylaxis (PEP), screening and evaluation, and treatment of the = various=20 manifestations of human anthrax. The goal was to convene subject matter = experts=20 for a review of research developments and clinical experience with = anthrax=20 prophylaxis and treatment and to make consensus recommendations for = updating=20 guidelines for PEP, treatment, and clinical evaluation of patients with = anthrax.=20 A 2001 conference on guidelines for anthrax has previously been = summarized in=20 this journal (1). This = article=20 summarizes the meeting's presentations and discussion. Consensus = recommendations=20 are summarized in the Table. Updated CDC guidelines for treatment and=20 prophylaxis of anthrax will be published in detail in other CDC = publications and=20 are available on CDC's website at http://www.bt.cdc.gov/agent/anthrax/index.asp.

Figure

Figure. Revisions to = the Centers=20 for Disease Control and Prevention (CDC) interim inhalation = anthrax=20 screening guidelines...

Participants included representatives and members of academic = research and=20 clinical institutions, the Health Protection Agency of the United = Kingdom, the=20 Health Protection Agency and Armed Forces of Canada, the US Department = of=20 Defense, the US Department of Homeland Security, the US Department of = Health and=20 Human Services Office of Research and Development Coordination, the Food = and=20 Drug Administration, the National Institutes of Health, the Council of = State and=20 Territorial Epidemiologists, the American Board of Obstetricians and=20 Gynecologists, the Infectious Diseases Society of America, and CDC. = Among these=20 participants were researchers, health department personnel, and = clinicians,=20 including the Pennsylvania pulmonologist who treated the 2006 case of = inhalation=20 anthrax (IA), the first naturally occurring case of IA in the United = States=20 since 1976 (2).

PEP for Inhalation Anthrax

During the 2001 US outbreak of bioterrorism-related anthrax, 22 = confirmed or=20 suspected anthrax cases occurred after envelopes containing Bacillus = anthracis spores in powder were sent through the mail (3). = Approximately=20 10,000 persons were offered at least 60 days of antimicrobial PEP = (4). = Current CDC=20 recommendations for PEP following potential inhalation exposure to = aerosolized=20 B. anthracis spores are 60 days of oral antimicrobial therapy = in=20 combination with a 3-dose series of anthrax vaccine adsorbed (AVA),=20 BioThrax(BioPort Corporation, Lansing, MI, USA) administered = at time=20 zero, 2 weeks, and 4 weeks (5,6). AVA = is not=20 FDA-approved for PEP and therefore would be available under an = Investigational=20 New Drug (IND) protocol.

Antimicrobial Agent Selection

Selection of the antimicrobial agent for PEP should involve = consideration of=20 antimicrobial resistance. Variable β-lactam resistance, = particularly to the=20 cephalosporins, has been reported among naturally occurring B.=20 anthracis isolates (7=969). = β-lactamase=20 genes have been identified in the B. anthracis chromosome = (10,11), and = evaluation of isolates from the 2001 event indicated the presence of = both=20 cephalosporinase and penicillinase enzymes (12). = Additionally,=20 resistance can be readily induced in vitro in B. anthracis to a = variety=20 of antimicrobial classes including fluoroquinolones, tetracyclines,=20 macrolides, penicillins, and other β-lactams (8,13=9616).=

Ciprofloxacin, doxycycline, and penicillin G procaine have = demonstrated=20 efficacy for PEP in a nonhuman primate model (17) and = are=20 FDA-approved for "inhalational anthrax (postexposure)" in all age groups = (18). = Meeting=20 participants reiterated existing CDC recommendations for ciprofloxacin = and=20 doxycycline as equivalent first-line antimicrobial agents for PEP, as = they are=20 equally efficacious for PEP and have similar susceptibility profiles = among=20 naturally occurring isolates (9,17). = Both have=20 similar safety profiles, with a low rate of anaphylactic reactions = (19,20). = Following=20 the bioterrorism event of 2001, there were no differences in = self-reported=20 symptoms with use of either drug for PEP, and no serious adverse events = could be=20 definitely related to their use (21). =

Levofloxacin is FDA-approved for "inhalational anthrax = (postexposure)" in=20 adults 18 years of age and older (22). = There are=20 safety data for up to 28 days of use, but safety data on extended use up = to 60=20 days are limited (22). = Therefore,=20 levofloxacin is recommended as a second-line PEP antimicrobial agent, to = be=20 reserved for instances where medical issues may call for its use.

Penicillins should not be initially used for PEP of anthrax, due to = concern=20 for penicillin resistance, which has been found in naturally occurring = isolates,=20 and because of the low concentrations achieved with oral penicillins in=20 pulmonary secretions, tissue, and within alveolar macrophages (23,24).=20 Amoxicillin can be used for PEP once the B. anthracis strain = has been=20 proven penicillin susceptible, when other antimicrobial agents are not=20 considered safe to use, such as for pediatric patients and for nursing = or=20 pregnant women. However, amoxicillin is not FDA-approved for this = indication,=20 and this use is considered "off-label." Therefore, amoxicillin use for = PEP in a=20 mass-exposure event might be provided under an IND or under an Emergency = Use=20 Authorization in a declared emergency. Amoxicillin use for PEP is = discussed=20 further in the section below on special populations. Other antimicrobial = agents,=20 including clindamycin, chloramphenicol, rifampin, vancomycin, and other=20 fluoroquinolones, may be considered for off-label use in patients unable = to=20 tolerate FDA-approved antimicrobial agents for PEP.

Duration of Prophylaxis Regimen

The PEP antimicrobial regimen should remain for 60 days, combined = with 3=20 doses of AVA. This duration is supported by data from the 1979 = Sverdlovsk=20 anthrax outbreak (25): = illness up to=20 58 days following inhalation exposure to anthrax in nonhuman primates = receiving=20 antibiotics alone for 30 days (17), and = demonstrated efficacy of the PEP combination of antimicrobial therapy = and=20 vaccination with AVA (17). =

Participants discussed whether a shortened course of antimicrobial = therapy=20 plus a 3-dose AVA series would be effective, based on recent nonhuman = primate=20 research of a successful 14-day PEP course of ciprofloxacin combined = with 3 AVA=20 doses, and demonstrated immune response to AVA (26), and = on=20 evidence of seroconversion among clinical trial participants following 3 = doses=20 of AVA (27). = However,=20 there are no well-defined serologic correlates of protection to = demonstrate that=20 AVA vaccination has conferred adequate protective immunity in a person = receiving=20 PEP. Additionally, there are no human clinical trial data supporting any = reduction in the duration of antimicrobial PEP, and there are = isolated AVA=20 study participants who have failed to seroconvert following vaccination = (CDC,=20 unpub. data). Therefore, it was deemed prudent to maintain the = recommended=20 60-day course of antimicrobial therapy combined with the 3-dose AVA = series to=20 ensure adequate protection for all persons requiring PEP after = aerosolized=20 B. anthracis exposure.

Duration of Prophylaxis Regimen

Since 2001, when CDC guidelines for the clinical evaluation of = patients with=20 possible IA in the event of possible mass exposure were published in the = MMWR=20 (28),=20 several alternative screening algorithms have been suggested including = the Inova=20 Fairfax protocol proposed by Mayer et al (29), and = the=20 3-tier screening protocol from Hupert et al (30). =

The goal of all IA screening algorithms should be to evaluate large = numbers=20 of patients seeking treatment in emergency departments and identify = potential IA=20 cases: 1) during a potential or confirmed mass event; 2) when there is a = known=20 threat or epidemiologic data suggesting an increased risk for anthrax; = or 3)=20 when there is clinical suspicion of anthrax based on symptoms consistent = with=20 IA, including fever and persistent tachycardia, among others (28,29). = The low=20 sensitivity and specificity of such screening algorithms may not detect = an=20 isolated IA case; therefore, these algorithms are not meant to serve as = general=20 guidance for identifying IA without appropriate epidemiologic or = clinical data.=20 For example, neither the original CDC guidelines nor the proposed Inova = Fairfax=20 guidelines would have detected the solitary 2006 IA case (2). Nor = should IA=20 screening algorithms replace existing emergency department (ED) = screening=20 guidelines for patients with symptoms of community-acquired pneumonia = (CAP);=20 routine CAP cases are likely to be selected as potential IA cases when = using=20 these algorithms; additional diagnostics will be required to rule out = IA.

Mayer et al retrospectively evaluated CDC's screening guidelines, = using the=20 11 IA cases from 2001 included among an ED patient population from the = same=20 period. On the basis of their analysis, they proposed revised screening=20 guidelines. CDC guidelines successfully identified only 1 of the 11 = cases,=20 whereas the Inova Fairfax algorithm modified from CDC guidelines = successfully=20 identified 9 of the 11 cases (29). = Participants=20 debated whether the recommendation to reduce the number of clinical = symptoms=20 required by the Inova Fairfax guidelines warranted further evaluation = (Table)=20 because IA case-patients who seek treatment early in the course of the = disease=20 could be missed as they may not yet have all of the required symptoms. = Including=20 fever and tachycardia as necessary symptoms to begin the algorithm, = timing=20 public health notification, and reducing the stringency of the = requirement for=20 an epidemiologic link were discussed. Participants agreed that elements = of the=20 Inova Fairfax protocol should be incorporated into future = CDC-recommended=20 screening algorithms. They further recommended that validation studies = be=20 conducted and feedback collected to determine the accuracy and = effectiveness of=20 the algorithm in identifying cases of IA in an outbreak setting.

Hupert et al proposed a 3-tier screening protocol to identify = potential early=20 IA case-patients in the setting of a large-scale anthrax exposure, to = aid ED=20 physicians in decisions regarding PEP, and to support the clinical = treatment=20 decision process (30). = Participants=20 agreed that such a large-scale screening algorithm for persons with = potential=20 aerosol exposure to anthrax in a mass exposure setting should be = addressed in=20 CDC's guidelines; however, such an algorithm was not adequately = validated for=20 adoption as a CDC recommendation.

Clinicians considering IA as a differential diagnosis should alert = hospital=20 microbiology staff of their suspicions and obtain blood cultures as = early as=20 possible before antimicrobial treatment. Gram-stain analyses of blood = samples=20 have previously detected bacteremia in systemic anthrax cases and in = animal=20 models (31,32) and = may be=20 informative.

Thoracic imaging remains a critical tool for the diagnosis of IA. = Thoracic=20 imaging studies were abnormal in all 11 of the IA cases from 2001 (8/11 = with=20 widened mediastinum, 9/11 with pleural effusions, and 7/11 with = pulmonary=20 infiltrates). However, initial ED thoracic radiographs may not reveal = the=20 classic widened mediastinum described for IA in all cases (33,34). = In severe=20 IA cases, thoracic computerized tomography without contrast was = suggested as=20 having utility for viewing hemorrhagic mediastinal lymph nodes.

Sensitivity and specificity analyses were recommended for evaluating = any=20 proposed IA screening algorithms, using historical IA cases incorporated = into ED=20 populations from annual influenza seasons or other periods with = increased=20 numbers of respiratory illness cases. Neither current CDC nor proposed=20 alternative guidelines are applicable for pediatric patients because of = lack of=20 data on pediatric IA cases. Participants called for development of = screening=20 guidelines for children in collaboration with the American Association = of=20 Pediatrics and other pediatric care partners.

Treatment of Severe Disease, including = Inhalation and=20 Gastrointestinal Anthrax, Anthrax Meningitis, and Bacteremia

Current CDC recommendations for the treatment of anthrax were = published in=20 October 2001 specifically for cases resulting from the 2001 anthrax = bioterrorist=20 attack. After presentations on the clinical course of IA cases from 2001 = and=20 2006 and discussion of the limited treatment success of IA cases from = 2001 (5/11=20 patients died despite aggressive therapy), participants recommended = revision of=20 CDC treatment protocols for IA and serious systemic illness from = anthrax.

Clinical or subclinical meningitis in patients with IA is likely. = Meningitis=20 is reported with all 3 clinical forms of anthrax and likely results from = hematogenous spread across the blood-brain barrier when bacteremia is = present.=20 During the 2001 outbreak, although only 1 of the 11 IA case-patients had = meningitis, 4 others had symptoms suggesting meningeal involvement. = Confirmation=20 of meningitis was not obtained in these 4 case-patients, and = cerebrospinal fluid=20 was not examined in all patients. If these 4 case-patients did have = subclinical=20 or early meningitis, then 45% of the 2001 IA case-patients had meningeal = involvement (33). = Additionally,=20 hemorrhagic leptomeningitis was reported from autopsies in 21 (50%) of = 42 IA=20 fatalities from the 1979 Sverdlovsk outbreak (35);=20 meningoencephalitis was reported in 44% of fatal cases in a review of 82 = IA=20 cases from 1900 to 2005 (including the 11 bioterrorism (BT)-related = cases from=20 2001) (34).=20 Furthermore, IA studies of nonhuman primates have demonstrated meningeal = involvement in up to 77% of experimental animal cases (32). = Therefore,=20 meningeal involvement should be suspected in IA or other cases of = systemic=20 anthrax.

For treatment of anthrax cases with severe systemic or = life-threatening=20 disease (including IA and gastrointestinal anthrax), and for cases with=20 fulminant bacteremia, IV ciprofloxacin is recommended over doxycycline = as the=20 primary antimicrobial agent unless ciprofloxacin use is contraindicated=20 (fluoroquinolones are bactericidal while tetracyclines are = bacteriostatic).=20 Additionally, because meningeal involvement is likely in systemic = anthrax cases,=20 ciprofloxacin is theoretically favored over doxycycline; central nervous = system=20 (CNS) penetration of ciprofloxacin in the presence of meningeal = inflammation is=20 much higher than the poor CNS penetration of doxycycline (31). = Although=20 ciprofloxacin is the only fluoroquinolone for which data are = available,=20 other fluoroquinolones with similar spectrums of activity and CNS = penetration=20 may also be appropriate.

At least 1 or more additional agents with adequate CNS penetration = and in=20 vitro activity against B. anthracis (e.g., ampicillin or = penicillin,=20 meropenem, rifampin, or vancomycin) should be used in the treatment of = systemic=20 cases of anthrax regardless of clinical suspicion of meningeal = involvement.=20 Clindamycin is strongly recommended for inclusion in the antimicrobial = regimen=20 because of its ability to inhibit protein synthesis, which may reduce = exotoxin=20 production. Participants recommended continuing the current 60-day = course of=20 antimicrobial therapy, with adjustment of the regimen based on the = clinical=20 course of the disease in the patient (36). The = use of=20 corticosteroids as an adjunct to antimicrobial therapy may benefit = patients with=20 anthrax meningitis (31); = however, with=20 no efficacy data from controlled clinical trials, this adjunctive = treatment may=20 be of no benefit for toxin-mediated tissue edema.

Early and aggressive pleural fluid drainage is recommended for all IA = case-patients and is consistent with the standard of care for empyema or = complicated pneumonia. This recommendation is based on the experience = that chest=20 tubes or early serial drainage of pleural effusions seemed to be = beneficial in=20 the successful clinical therapy of the surviving IA patients in 2001 and = in the=20 recent 2006 IA case (2,33). = Evaluation of=20 the treatment of IA cases from 1900 to 2005 showed pleural fluid = drainage to be=20 significantly associated with decreased mortality (34). = Analysis of=20 serial pleural fluid samples from the 2006 IA case showed high pleural = fluid=20 lethal toxin levels. The positive outcome of this case likely resulted = from a=20 combination of the mechanical effects on respiration from fluid drainage = and the=20 reduction in lethal toxin levels by removing pleural effusions (2).

Treatment of Cutaneous Anthrax

Treatment with oral ciprofloxacin or doxycycline for 7=9610 days is = recommended=20 for localized or uncomplicated cases of naturally acquired cutaneous = anthrax,=20 such as that associated with exposure to animals with anthrax, or to = products=20 such as hides from animals with anthrax. If susceptibility testing is=20 supportive, oral therapy with penicillin V or amoxicillin may be used to = complete the course of treatment. For severe cases of naturally acquired = cutaneous anthrax with signs of systemic involvement, extensive edema, = or=20 lesions of the head and neck, IV therapy for 7=9610 days using = ciprofloxacin or=20 doxycycline is preferred; IV penicillin G, if supported by = susceptibility=20 testing, may be used to finish the 7- to 10-day course. It was = considered widely=20 accepted knowledge that penicillin is very effective against B.=20 anthracis, can render cutaneous lesions culture-negative within 24 = hours,=20 and has long been the treatment of choice in many parts of the world. = Therefore,=20 despite reports of penicillin-resistant isolates and the potential for = inducible=20 beta-lactamases, participants agreed that 7=9610 days of penicillin is = usually=20 sufficient for treatment of uncomplicated naturally acquired cutaneous = anthrax.=20 However, adequate dosages of penicillins must be used, patients must be=20 monitored for clinical response, and susceptibility testing must be = conducted to=20 confirm the appropriateness of the antimicrobial choice. Other = fluoroquinolones=20 such as levofloxacin are recommended as additional options for = antimicrobial=20 treatment of naturally acquired cutaneous anthrax.

For bioterrorism (BT)-related cutaneous anthrax, any patient is at = risk for=20 IA because of potential aerosol exposure; the duration of antimicrobial = therapy=20 should remain 60 days to provide a full course of PEP. For localized or=20 uncomplicated cases of BT-related cutaneous anthrax, oral ciprofloxacin = or=20 doxycycline is recommended. Patients with BT-related cutaneous anthrax = with=20 signs of systemic involvement, extensive edema, or lesions of the head = or neck=20 should be treated with IV ciprofloxacin using a multidrug approach, as=20 previously described for IA and severe disease. Patients may be switched = to oral=20 therapy when clinically appropriate to complete the 60-day regimen; in=20 uncomplicated cases amoxicillin may be used to complete the regimen if = the=20 B. anthracis strain is proven susceptible (36).

There is insufficient evidence to conclude that the immune response = to=20 cutaneous anthrax is sufficient to justify shortening the 60-day = duration of=20 antimicrobial therapy. However, severe local reactions to anthrax = vaccine were=20 reported in 2 vaccine recipients with a previous history of cutaneous = anthrax=20 during a trial of an earlier protective antigen-based anthrax vaccine = (37). For = BT-related cutaneous anthrax in patients without a prior history of = cutaneous=20 disease, the recommended regimen should remain 60 days of antimicrobial = therapy=20 plus 3 doses of AVA; for BT-related cutaneous anthrax in patients with a = previous history of cutaneous disease, 60 days of antimicrobial therapy = is=20 recommended but vaccine should not be used because of the risk of = adverse events=20 (37). =

Immunotherapeutics

Immune globulin of animal origin has been used with some success in = the=20 treatment of human anthrax for many years (34,38), = and=20 human-derived anthrax immune globulin (AIG) was part of the successful = treatment=20 of the 2006 IA case-patient under an emergency IND protocol. (2). = Although=20 participants agreed that clinical data are insufficient to develop = general=20 recommendations for the use of AIG and other targeted immunotherapeutics = for the=20 treatment of severe anthrax, they did recommend that CDC continue to = offer AIG=20 under emergency IND on a patient-by-patient basis.

Timing of immune globulin administration is critically important = given the=20 small window in which AIG can be effective as anthrax toxins bind and = move=20 intracellularly quickly; early administration to prevent toxin binding = was=20 stressed. However, data on the optimal timing to initiate immune therapy = are=20 lacking. Immunotherapeutics should continue to be considered for = patients with=20 severe systemic illness, for example in patients with evidence of organ=20 dysfunction in >2 organ systems or lack of clinical response = to=20 standard therapy. A high research priority should be to continue to = evaluate=20 immunotherapeutics as they are developed for inclusion in future=20 recommendations.

Special Populations

Treatment of anthrax during pregnancy should remain the same as for = adults=20 because of the severity of the disease. Ciprofloxacin is recommended as = the=20 first-line oral antimicrobial agent for PEP or treatment of anthrax = during=20 pregnancy (39). = Doxycycline=20 should not be used for PEP or treatment during pregnancy unless started = in the=20 third trimester. Transition to amoxicillin for PEP remains recommended = when the=20 isolate involved is susceptible to penicillin.

Although the Department of Defense has published safety data on AVA = during=20 pregnancy (40), the = statistical power of the study was limited. Meeting participants = indicated that=20 additional safety data are needed to support appropriate decisions = regarding=20 recommendations for this population. It was proposed that AVA be = included in the=20 PEP protocol for pregnancy if there is strong evidence of risk for IA or = if the=20 benefit outweighs risks from vaccination. Vaccination may also be = deferred to=20 immediately postpartum if the risk of IA persists because of limited = safety data=20 on AVA use during pregnancy.

For breastfeeding mothers, if the infant was also exposed, the = mother's=20 antimicrobial regimen should match the child's regimen when possible. = When not=20 possible, the mother can pump and discard her breast milk while being = treated,=20 and resume breastfeeding after completing her course of PEP.

Recommendations for treatment of BT-related anthrax in pediatric = patients=20 should be consistent with adult antimicrobial agents, with ciprofloxacin = favored=20 for severe disease. Ciprofloxacin or doxycycline is recommended as the=20 first-line oral antimicrobial agent for PEP. Amoxicillin is recommended = as an=20 alternative in pediatric treatment when the isolate involved is = susceptible to=20 penicillin. Participants discussed the need to determine the appropriate = amoxicillin PEP dose for pediatric patients to resolve differences = between CDC=20 and FDA recommendations. The consensus was that the amoxicillin PEP dose = should=20 err on the higher end in favor of ensuring efficacy. Data are lacking on = the=20 safety of long-term use of high-dosage amoxicillin in pediatric = patients;=20 participants recommended additional research and Pediatric Advisory = Committee=20 input to determine the most appropriate pediatric amoxicillin PEP = dosage.=20 Currently, anthrax vaccination cannot be recommended for use in children = because=20 safety and efficacy data are lacking.

Finally, for special populations such as geriatric patients or = patients with=20 special medical conditions, standard medical practice should prevail. = Physicians=20 should perform standard medical screening for potential drug = interactions and=20 for underlying diseases such as renal failure before initiating = treatment or=20 PEP; drug selection and dosage should be adjusted accordingly.

Research into the evaluation, prevention, and therapy of anthrax is = ongoing,=20 and CDC guidelines for anthrax are subject to change based on new = information=20 and expert recommendation. When available, updated CDC guidelines for = treatment=20 and prophylaxis of anthrax will be published in detail in other CDC=20 publications.

Acknowledgments

We thank the meeting's scientific chair panel: Arthur = Friedlander,=20 Brad Leissa, David Stephens, Mary Wright, and Ivy Adekoya, as well as=20 Antoinette Seright for organizational contributions.

Meeting Participants

Luciana Borio, University of Pittsburgh Medical Center; Phil = Brachman, Emory=20 University; Eddy Bresnitz, NJ Department of Health and Senior = Services/Council=20 of State and Territorial Epidemiologists (DHSS/ CSTE); Jeff Brady, = Drusilla=20 Burns, Cynthia Kelley, Eileen Navarro-Almario, Roxanne G. Shively, US = Food and=20 Drug Administration/Center for Biologics Evaluation and Research = (FDA/CBER); Dan=20 Hanfling, Thom A. Mayer, Inova Fairfax Hospital; Phil Hanna, University = of=20 Michigan College of Medicine; Scott A. Harper, NYC Department of Health = and=20 Mental Hygiene (DHMH); Nathaniel Hupert, Weill Medical College, Cornell=20 University; Dan Lucey, Washington Institute/Institute for Defense = Studies and=20 Analyses (IDSA); Lt Col H.C. MacKay MD MHSc, Department of National = Defense of=20 Canada; Mark Martens, Gilles Monif, University of Oklahoma; Robert C = Spencer,=20 Health Protection Agency, UK; Peter Turnbull, Porton Down, UK; Peter = Uhthoff,=20 Office of Public Health Security of Canada; James Walsh, = Guthrie=96Robert Packer=20 Hospital, Sayre, PA; John Carney, Noreen Hynes, US Department of Health = and=20 Human Services (DHHS); COL Steve Ford, COL John Grabenstein, US = Department of=20 Defense, Office of the Surgeon General (DOD/OTSG); Ed Nuzum, US National = Institutes of Health (NIH); Segaran Pilai, US Department of Homeland = Security=20 (DHS); and Clare Dykewicz, Arnold Kaufmann, Nina Marano, Ken Martinez, = Conrad=20 Quinn, Nicki Pesik, Nancy R. Messonnier, Lisa Rotz, Sean Shadomy, Dan = Sosin,=20 Eric Stern, Fred Tenover, Tracee Treadwell, Kristin Uhde, and Patty = Wilkins, US=20 Centers for Disease Control and Prevention (CDC).

Dr Stern, a member of CDC's Epidemic Intelligence Service at CDC from = 2005=962007, has conducted medical research in numerous foreign = countries,=20 including Cuba, Peru, and Vietnam, and served as an Albert Schweitzer = fellow in=20 pediatrics in Lambarene, Gabon. He is currently completing a pediatric=20 infectious diseases fellowship at Children's Hospital San Diego.

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Figure

Figure. Revisions to the Centers = for=20 Disease Control and Prevention (CDC) interim inhalation anthrax = screening=20 guidelines...

Table

Table. Summary of recommended=20 modifications to Centers for Disease Control and Prevention guidelines = for=20 postexposure prophylaxis and treatment of anthrax

Emerging Infectious Diseases

Article Contents

Volume 14, Number 4=96April 2008

Conference Report

Conference Report on Public Health and Clinical Guidelines for = Anthrax

PEP for Inhalation Anthrax

Antimicrobial Agent Selection

Duration of Prophylaxis Regimen

Duration of Prophylaxis Regimen

Treatment of Severe Disease, including = Inhalation and=20 Gastrointestinal Anthrax, Anthrax Meningitis, and Bacteremia

Treatment of Cutaneous Anthrax

Immunotherapeutics

Special Populations

Acknowledgments

Meeting Participants

References

Figure

Table

Suggested Citation for this Article

Journal Contents

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