Vidyya Medical News Service

This guideline is informational only and is not intended or designed as a substitute for the reasonable exercise of independent clinical judgment by providers in any particular set of circumstances.

Significant change: Nasal swabs are no longer recommended, per Mid-Atlantic Permanente Medical Group infectious disease specialists and based on conversations with the Centers for Disease Control and Prevention (CDC).

Patients from a designated exposure site
Brentwood mail facility, Air Mail facility near BWI, Shady Grove bulk mail facility, Merrifield bulk mail facility, any postal worker or mail room employee who handles federal mail in Maryland, Virginia, or Washington D.C., contracted employees who pick up bulk mail from Brentwood, children who visited a parent in the mail handling area at Brentwood

If the patient is symptomatic and unstable (headache, profuse sweating, achiness, fever, coughing, chest pain, or difficulty breathing):

blood cultures and serology for Bacillus anthracis IgG and IgM
swab of skin lesion for gram stain and culture
start IV Cipro 400mg
send to ER

If the patient is symptomatic and stable (skin lesion with black center, nasal congestion, rhinorrhea, and/or sore throat:

blood cultures
draw 1 red top tube to hold in lab for possible future serology
STAT CBC, electrolytes, BUN, Creatinine
pulse oximetry
chest X-ray (attention to mediastinum)

Patient who is afebrile with normal chest X-ray, normal CBC, and normal pulse oximetry may be sent home with 10-day supply of Cipro 500-mg po bid. Review pharmacy profile for potential drug interactions with Cipro prior to prescribing drug.

If the patient is pregnant or pediatric, consult infectious disease physician on call to discuss drug treatment.

Send to the Washington D.C. evaluation site: D.C. General Hospital, 1900 Massachusetts Ave, SE.
Postal employees can call: 1-866-545-8777.
By day 7, the public health department will notify workers who have positive nasal swabs, who will receive additional Cipro if needed.
Workers who have not had nasal swabs done and who are on Cipro will receive additional Cipro by day 7 if their workplace tests positive for anthrax spores.
The public health department will not notify workers who have negative nasal swabs.

Physicians who have questions about individual patients with symptoms should consult with the infectious disease physician on call.

For information on clinical features, diagnoses, and medical management of anthrax, refer to document titled "Anthrax" that was emailed on October 17, 2001.

Patients not admitted to the hospital should have appointment with primary care physician the next day.

If you suspect anthrax infection, you must call the appropriate public health department. You should also notify the local law enforcement agency.

Guidelines for advice nurses who receive calls from patients regarding anthrax
Advice nurse reviews the patients’ symptoms and the patients’ environment:

Does the patient have symptoms consistent with an anthrax exposure?
Where does patient work? Is it a known exposure? Is patient a postal worker?
Has the patient had contact with a suspicious substance?

If the patient is symptomatic and unstable by 911 criteria (headache, profuse sweating, achiness, fever, coughing, chest pain, and/or difficulty breathing):

If the patient is symptomatic and stable by 911 criteria (headache, profuse sweating, achiness, fever, coughing, chest pain, and/or difficulty breathing):

Send to the Washington D.C. evaluation site: D.C. General Hospital, 1900 Massachusetts Ave, SE.
Postal employees can call: 1-866-545–8777.
By day 7, the public health department will notify workers who have positive nasal swabs, who will receive additional Cipro if needed.
Workers who have not had nasal swabs done and who are on Cipro will receive additional Cipro by day 7 if their workplace tests positive for anthrax spores.
The public health department will not notify workers who have negative nasal swabs.
Note: Workers at the Shady Grove bulk mail facility will receive prophylactic antibiotics from the health department on Thursday, Friday, and Saturday; they will distribute at the work site.

Postal worker from non-designated exposure site
If the patient is symptomatic with fever, headache, sweating, achiness, coughing, chest pain, difficulty breathing:

If the patient is symptomatic with skin lesion with black center, nasal congestion, rhinorrhea, and/or sore throat:

Chemoprophylaxis is only prescribed based on a confirmed anthrax exposure and/or threat assessment under the direction of the public health department and law enforcement agencies. CDC surveillance protocols are in place to help identify potential exposure sites.
If you would like more information about anthrax, please visit the CDC Web site.

Patient has had contact with a suspicious substance (i.e., brown granular substance in mail or packages)
If the patient is symptomatic with fever, headache, sweating, achiness, coughing, chest pain, difficulty breathing:

If the patient is symptomatic with nasal congestion, rhinorrhea, sore throat, and/or skin lesion:

Direct the patient to notify local health and law enforcement officials.
Chemoprophylaxis is only prescribed based on a confirmed anthrax exposure and/or threat assessment under the direction of the public health department and law enforcement agencies. CDC surveillance protocols are in place to help identify potential exposure sites.

Patient is not from a designated exposure site
Patient is not symptomatic and is not from a designated exposure site:

Chemoprophylaxis is only prescribed based on a confirmed anthrax exposure and/or threat assessment under the direction of the public health department and law enforcement agencies.

Volume 3 Issue 204 Published - 14:00 UTC 08:00 EST 27-Oct-2001 Next Update - 14:00 UTC 08:00 EST 28-Oct-2001	Editor: Susan K. Boyer, RN © RAmEx Ars Medica, Inc. All rights reserved.

	Kaiser Permanente Issues Anthrax Clinical Guidelines Update For Physicians And Nurses This guideline is informational only and is not intended or designed as a substitute for the reasonable exercise of independent clinical judgment by providers in any particular set of circumstances. Significant change: Nasal swabs are no longer recommended, per Mid-Atlantic Permanente Medical Group infectious disease specialists and based on conversations with the Centers for Disease Control and Prevention (CDC). Outpatient triage/treatment guidelines for physicians Triage guidelines for advice nurses For more information about anthrax Outpatient triage/treatment guidelines for physicians Patients from a designated exposure site Brentwood mail facility, Air Mail facility near BWI, Shady Grove bulk mail facility, Merrifield bulk mail facility, any postal worker or mail room employee who handles federal mail in Maryland, Virginia, or Washington D.C., contracted employees who pick up bulk mail from Brentwood, children who visited a parent in the mail handling area at Brentwood Note: Customer postal access areas are not considered at risk If the patient is symptomatic and unstable (headache, profuse sweating, achiness, fever, coughing, chest pain, or difficulty breathing): blood cultures and serology for Bacillus anthracis IgG and IgM swab of skin lesion for gram stain and culture start IV Cipro 400mg send to ER If the patient is symptomatic and stable (skin lesion with black center, nasal congestion, rhinorrhea, and/or sore throat: blood cultures draw 1 red top tube to hold in lab for possible future serology STAT CBC, electrolytes, BUN, Creatinine pulse oximetry chest X-ray (attention to mediastinum) Patient who is afebrile with normal chest X-ray, normal CBC, and normal pulse oximetry may be sent home with 10-day supply of Cipro 500-mg po bid. Review pharmacy profile for potential drug interactions with Cipro prior to prescribing drug. If the patient is pregnant or pediatric, consult infectious disease physician on call to discuss drug treatment. If the patient is asymptomatic: Send to the Washington D.C. evaluation site: D.C. General Hospital, 1900 Massachusetts Ave, SE. Postal employees can call: 1-866-545-8777. By day 7, the public health department will notify workers who have positive nasal swabs, who will receive additional Cipro if needed. Workers who have not had nasal swabs done and who are on Cipro will receive additional Cipro by day 7 if their workplace tests positive for anthrax spores. The public health department will not notify workers who have negative nasal swabs. Physicians who have questions about individual patients with symptoms should consult with the infectious disease physician on call. For information on clinical features, diagnoses, and medical management of anthrax, refer to document titled "Anthrax" that was emailed on October 17, 2001. Patients not admitted to the hospital should have appointment with primary care physician the next day. If you suspect anthrax infection, you must call the appropriate public health department. You should also notify the local law enforcement agency. Back to top of page Triage guidelines for advice nurses Guidelines for advice nurses who receive calls from patients regarding anthrax Advice nurse reviews the patients’ symptoms and the patients’ environment: Does the patient have symptoms consistent with an anthrax exposure? Where does patient work? Is it a known exposure? Is patient a postal worker? Has the patient had contact with a suspicious substance? Patients from a designated exposure site Brentwood mail facility, Air Mail facility near BWI, Shady Grove bulk mail facility, Merrifield bulk mail facility, any postal worker or mail room employee who handles federal mail in Maryland, Virginia, or Washington D.C., contracted employees who pick up bulk mail from Brentwood, children who visited a parent in the mail handling area at Brentwood Note: Customer postal access areas are not considered at risk If the patient is symptomatic and unstable by 911 criteria (headache, profuse sweating, achiness, fever, coughing, chest pain, and/or difficulty breathing): send patient to nearest ER document which ER notify ER If the patient is symptomatic and stable by 911 criteria (headache, profuse sweating, achiness, fever, coughing, chest pain, and/or difficulty breathing): send patient to ER document which ER notify ER If the patient is asymptomatic: Send to the Washington D.C. evaluation site: D.C. General Hospital, 1900 Massachusetts Ave, SE. Postal employees can call: 1-866-545–8777. By day 7, the public health department will notify workers who have positive nasal swabs, who will receive additional Cipro if needed. Workers who have not had nasal swabs done and who are on Cipro will receive additional Cipro by day 7 if their workplace tests positive for anthrax spores. The public health department will not notify workers who have negative nasal swabs. Note: Workers at the Shady Grove bulk mail facility will receive prophylactic antibiotics from the health department on Thursday, Friday, and Saturday; they will distribute at the work site. Postal worker from non-designated exposure site If the patient is symptomatic with fever, headache, sweating, achiness, coughing, chest pain, difficulty breathing: send patient to ER document which ER notify ER If the patient is symptomatic with skin lesion with black center, nasal congestion, rhinorrhea, and/or sore throat: send to medical center for clinical evaluation within 12 hours If the patient is asymptomatic: Chemoprophylaxis is only prescribed based on a confirmed anthrax exposure and/or threat assessment under the direction of the public health department and law enforcement agencies. CDC surveillance protocols are in place to help identify potential exposure sites. If you would like more information about anthrax, please visit the CDC Web site. Patient has had contact with a suspicious substance (i.e., brown granular substance in mail or packages) If the patient is symptomatic with fever, headache, sweating, achiness, coughing, chest pain, difficulty breathing: send patient to ER (advise patient not to bring substance) document which ER notify ER If the patient is symptomatic with nasal congestion, rhinorrhea, sore throat, and/or skin lesion: send to medical center ASAP (within 1-3 hours; advise patient not to bring substance) If the patient is asymptomatic: Direct the patient to notify local health and law enforcement officials. Chemoprophylaxis is only prescribed based on a confirmed anthrax exposure and/or threat assessment under the direction of the public health department and law enforcement agencies. CDC surveillance protocols are in place to help identify potential exposure sites. Patient is not from a designated exposure site Patient is not symptomatic and is not from a designated exposure site: Chemoprophylaxis is only prescribed based on a confirmed anthrax exposure and/or threat assessment under the direction of the public health department and law enforcement agencies. Back to top of page If you would like more information about anthrax Call local public health department hotlines: Washington D.C.: (202) 442-9196 Fairfax: (703) 246-3796 (person on phone from 7 a.m. - 11 p.m.) Montgomery: (240) 777-4200 (person on phone from 7 a.m. - 10 p.m.) Or visit the CDC Web site. Back to top of page Updated October 26, 2001

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