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Lombarte Espinosa E, Villuendas Usón MC, Arribas García J, Jado García I, Huarte Lacunza R, Zárate Chug P, Claraco Vega LM, Jesús Santed Andrés M, Ríos MJ, Cook R, Simard JM, Boyer AE, Rezusta A. Survival of Patient With Hemorrhagic Meningitis Associated With Inhalation Anthrax. Clin Infect Dis 2022; 75:S364-S372. [PMID: 36251557 DOI: 10.1093/cid/ciac531] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/21/2022] [Accepted: 06/24/2022] [Indexed: 11/05/2022] Open
Abstract
This report describes a 49-year-old male construction worker who acquired a Bacillus anthracis infection after working on a sheep farm. He experienced a severe respiratory infection, septic shock, and hemorrhagic meningoencephalitis with severe intracranial hypertension. After several weeks with multiple organ dysfunction syndrome, he responded favorably to antibiotic treatment. Three weeks into his hospitalization, an intracranial hemorrhage and cerebral edema led to an abrupt deterioration in his neurological status. A single dose of raxibacumab was added to his antimicrobial regimen on hospital day 27. His overall status, both clinical and radiographic, improved within a few days. He was discharged 2 months after admission and appears to have fully recovered.
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Affiliation(s)
- Evelyn Lombarte Espinosa
- Servicio Medicina Intensiva, UCI Polivalente, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | | | - Isabel Jado García
- Laboratorio de Referencia e Investigación en Patógenos Especiales, Centro Nacional de Microbiología. Instituto de Salud Carlos III, Madrid, Spain
| | - Rafael Huarte Lacunza
- Servicio de Farmacia Hospitalaria, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Paola Zárate Chug
- Servicio Medicina Intensiva, UCI Polivalente, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Luis Manuel Claraco Vega
- Servicio Medicina Intensiva, UCI Polivalente, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - María Jiménez Ríos
- Servicio Medicina Intensiva, UCI Polivalente, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Rachel Cook
- Oak Ridge Institute for Science and Education, CDC Fellowship Program, Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - J Marc Simard
- Departments of Neurosurgery, Pathology and Physiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Anne E Boyer
- Division of Laboratory Sciences, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Antonio Rezusta
- Servicio Microbiología, Hospital Universitario Miguel Servet, IIS Aragón, Zaragoza, Spain
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Slay RM, Hatch GJ, Hewitt JA. Evaluation of Amoxicillin and Amoxicillin-Clavulanate (Augmentin) for Antimicrobial Postexposure Prophylaxis Following Bacillus anthracis Inhalational Exposure in Cynomolgus Macaques. Clin Infect Dis 2022; 75:S402-S410. [PMID: 36251552 PMCID: PMC9649419 DOI: 10.1093/cid/ciac572] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Amoxicillin is a broad-spectrum antibiotic used to treat a variety of gram-positive and gram-negative infections, such as infections of the ear, nose, and throat, genitourinary tract, skin, and lower respiratory tract; gonorrhea; and Helicobacter pylori. The prophylactic benefit of both amoxicillin and Augmentin (amoxicillin-clavulanate for use against β-lactamase-expressing bacteria) was evaluated for inhalation anthrax in cynomolgus macaques in 2 studies. A pilot study on amoxicillin-clavulanate that used a portion of the study animals demonstrated empirically that dosing twice a day was efficacious. In a subsequent study on both amoxicillin and amoxicillin-clavulanate that used the remaining study animals, the animals were treated orally every 12 hours on days 1-28 postchallenge and followed for an additional 60 days (total of 88 days from day of aerosol challenge to when the animals were culled). The animals from each treatment arm of the 2 studies were completely protected. All untreated animals succumbed to the infection. The degree of protection observed in this study suggests that both amoxicillin and amoxicillin-clavulanate, administered prophylactically over a period of 28 days after a lethal exposure to Bacillus anthracis spores, is sufficient for full protection.
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Affiliation(s)
- Raymond M Slay
- Correspondence: R. M. Slay, National Institute of Allergy and Infectious Diseases, 5601 Fishers Lane, 8G57, Bethesda, MD 20892-9825, USA ()
| | - Graham J Hatch
- Centre for Emergency Preparedness and Response, Public Health England, Porton Down, Wilton, United Kingdom
| | - Judith A Hewitt
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
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Slay RM, Hewitt JA, Crumrine M. Determination of the Postexposure Prophylactic Benefit of Oral Azithromycin and Clarithromycin Against Inhalation Anthrax in Cynomolgus Macaques. Clin Infect Dis 2022; 75:S411-S416. [PMID: 36251550 PMCID: PMC9989359 DOI: 10.1093/cid/ciac569] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Sufficient and diverse medical countermeasures against severe pathogenic infections, such as inhalation anthrax, are a critical need. Azithromycin and clarithromycin are antimicrobials commonly used for both upper and lower respiratory infections. They inhibit protein synthesis by blocking the formation of the 50S ribosomal subunit. To expand the armamentarium, these 2 antibiotics were evaluated in a postexposure prophylactic model of inhalation anthrax in cynomolgus macaques. METHODS This prophylaxis study had 4 test arms: azithromycin, clarithromycin, a levofloxacin control, and a placebo. Beginning 24 hours after exposure to a target challenge dose of 200 lethal dose 50 (LD50) of Bacillus anthracis Ames spores, animals were treated orally until 30 days postchallenge and then observed until 75 days postchallenge. RESULTS The test group that received clarithromycin had a survival rate of 67%. The test group that received azithromycin had a survival rate of 50%, but the peak azithromycin plasma levels achieved were <30 ng/mL-much lower than the expected 410 ng/mL. The levofloxacin positive control had a survival rate of 50%; all of the negative controls succumbed to infection. CONCLUSIONS The efficacy of clarithromycin prophylaxis was statistically significant compared with placebo, while azithromycin prophylaxis was indistinguishable from placebo. Given the low plasma concentrations of azithromycin achieved in the study, it is not surprising that half the animals succumbed to anthrax during the dosing period; the animals that survived beyond the time during which placebo control animals succumbed survived to the end of the observation period.
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Affiliation(s)
- Raymond M Slay
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Judith A Hewitt
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Martin Crumrine
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
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Hendricks K, Person MK, Bradley JS, Mongkolrattanothai T, Hupert N, Eichacker P, Friedlander AM, Bower WA. Clinical Features of Patients Hospitalized for All Routes of Anthrax, 1880-2018: A Systematic Review. Clin Infect Dis 2022; 75:S341-S353. [PMID: 36251560 PMCID: PMC9649428 DOI: 10.1093/cid/ciac534] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Anthrax is a toxin-mediated zoonotic disease caused by Bacillus anthracis, with a worldwide distribution recognized for millennia. Bacillus anthracis is considered a potential biowarfare agent. METHODS We completed a systematic review for clinical and demographic characteristics of adults and children hospitalized with anthrax (cutaneous, inhalation, ingestion, injection [from contaminated heroin], primary meningitis) abstracted from published case reports, case series, and line lists in English from 1880 through 2018, assessing treatment impact by type and severity of disease. We analyzed geographic distribution, route of infection, exposure to anthrax, and incubation period. RESULTS Data on 764 adults and 167 children were reviewed. Most cases reported for 1880 through 1915 were from Europe; those for 1916 through 1950 were from North America; and from 1951 on, cases were from Asia. Cutaneous was the most common form of anthrax for all populations. Since 1960, adult anthrax mortality has ranged from 31% for cutaneous to 90% for primary meningitis. Median incubation periods ranged from 1 day (interquartile range [IQR], 0-4) for injection to 7 days (IQR, 4-9) for inhalation anthrax. Most patients with inhalation anthrax developed pleural effusions and more than half with ingestion anthrax developed ascites. Treatment and critical care advances have improved survival for those with systemic symptoms, from approximately 30% in those untreated to approximately 70% in those receiving antimicrobials or antiserum/antitoxin. CONCLUSIONS This review provides an improved evidence base for both clinical care of individual anthrax patients and public health planning for wide-area aerosol releases of B. anthracis spores.
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Affiliation(s)
- Katherine Hendricks
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Marissa K Person
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - John S Bradley
- Division of Infectious Diseases, Rady Children’s Hospital San Diego and the University of California San Diego School of Medicine, San Diego, California, USA
| | - Thitipong Mongkolrattanothai
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA,Oak Ridge Institute for Science and Education, CDC Fellowship Program, Oak Ridge, Tennessee, USA
| | - Nathaniel Hupert
- Departments of Population Health Sciences and of Medicine, Weill Cornell Medicine, Cornell University, and New York-Presbyterian Hospital, New York, New York, USA
| | - Peter Eichacker
- Department of Critical Care Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Arthur M Friedlander
- US Army Medical Research Institute of Infectious Diseases, Frederick, Maryland, USA,Department of Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
| | - William A Bower
- Correspondence: W. A. Bower, Centers for Disease Control and Prevention, 1600 Clifton Rd, NE, MS H24-12, Atlanta, GA 30329, USA ()
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Person MK, Cook R, Bradley JS, Hupert N, Bower WA, Hendricks K. Systematic Review of Hospital Treatment Outcomes for Naturally Acquired and Bioterrorism-Related Anthrax, 1880-2018. Clin Infect Dis 2022; 75:S392-S401. [PMID: 36251553 PMCID: PMC9649424 DOI: 10.1093/cid/ciac536] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Bacillus anthracis can cause anthrax and is a potential bioterrorism agent. The 2014 Centers for Disease Control and Prevention recommendations for medical countermeasures against anthrax were based on in vitro data and expert opinion. However, a century of previously uncompiled observational human data that often includes treatment and outcomes is available in the literature for analysis. METHODS We reviewed treatment outcomes for patients hospitalized with anthrax. We stratified patients by meningitis status, route of infection, and systemic criteria, then analyzed survival by treatment type, including antimicrobials, antitoxin/antiserum, and steroids. Using logistic regression, we calculated odds ratios and 95% confidence intervals to compare survival between treatments. We also calculated hospital length of stay. Finally, we evaluated antimicrobial postexposure prophylaxis (PEPAbx) using data from a 1970 Russian-language article. RESULTS We identified 965 anthrax patients reported from 1880 through 2018. After exclusions, 605 remained: 430 adults, 145 children, and 30 missing age. Survival was low for untreated patients and meningitis patients, regardless of treatment. Most patients with localized cutaneous or nonmeningitis systemic anthrax survived with 1 or more antimicrobials; patients with inhalation anthrax without meningitis fared better with at least 2. Bactericidal antimicrobials were effective for systemic anthrax; addition of a protein synthesis inhibitor(s) (PSI) to a bactericidal antimicrobial(s) did not improve survival. Likewise, addition of antitoxin/antiserum to antimicrobials did not improve survival. Mannitol improved survival for meningitis patients, but steroids did not. PEPAbx reduced risk of anthrax following exposure to B. anthracis. CONCLUSIONS Combination therapy appeared to be superior to monotherapy for inhalation anthrax without meningitis. For anthrax meningitis, neither monotherapy nor combination therapy were particularly effective; however, numbers were small. For localized cutaneous anthrax, monotherapy was sufficient. For B. anthracis exposures, PEPAbx was effective.
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Affiliation(s)
- Marissa K Person
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Rachel Cook
- Oak Ridge Institute for Science and Education, CDC Fellowship Program, Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, USA
| | - John S Bradley
- Division of Infectious Diseases, Rady Children’s Hospital San Diego and the University of California San Diego School of Medicine, San Diego, California, USA
| | - Nathaniel Hupert
- Departments of Population Health Sciences and of Medicine, Weill Cornell Medicine (Cornell University) and New York-Presbyterian Hospital, New York, New York, USA
| | - William A Bower
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Katherine Hendricks
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Chen X, Bahl P, de Silva C, Heslop D, Doolan C, Lim S, MacIntyre CR. Systematic Review and Evaluation of Mathematical Attack Models of Human Inhalational Anthrax for Supporting Public Health Decision Making and Response. Prehosp Disaster Med 2020; 35:412-9. [PMID: 32495728 DOI: 10.1017/S1049023X20000734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Anthrax is a potential biological weapon and can be used in an air-borne or mail attack, such as in the attack in the United States in 2001. Planning for such an event requires the best available science. Since large-scale experiments are not feasible, mathematical modelling is a crucial tool to inform planning. The aim of this study is to systematically review and evaluate the approaches to mathematical modelling of inhalational anthrax attack to support public health decision making and response. METHODS A systematic review of inhalational anthrax attack models was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. The models were reviewed based on a set of defined criteria, including the inclusion of atmospheric dispersion component and capacity for real-time decision support. RESULTS Of 13 mathematical modelling studies of human inhalational anthrax attacks, there were six studies that took atmospheric dispersion of anthrax spores into account. Further, only two modelling studies had potential utility for real-time decision support, and only one model was validated using real data. CONCLUSION The limited modelling studies available use widely varying methods, assumptions, and data. Estimation of attack size using different models may be quite different, and is likely to be under-estimated by models which do not consider weather conditions. Validation with available data is crucial and may improve models. Further, there is a need for both complex models that can provide accurate atmospheric dispersion modelling, as well as for simpler modelling tools that provide real-time decision support for epidemic response.
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Abstract
Health officials lack field-implementable tools for forecasting the effects that
a large-scale release of Bacillus anthracis spores would have
on public health and hospitals. We created a modeling tool (combining
inhalational anthrax caseload projections based on initial case reports, effects
of variable postexposure prophylaxis campaigns, and healthcare facility surge
capacity requirements) to project hospitalizations and casualties from a newly
detected inhalation anthrax event, and we examined the consequences of
intervention choices. With only 3 days of case counts, the model can predict
final attack sizes for simulated Sverdlovsk-like events (1979 USSR) with
sufficient accuracy for decision making and confirms the value of early
postexposure prophylaxis initiation. According to a baseline scenario, hospital
treatment volume peaks 15 days after exposure, deaths peak earlier (day 5), and
recovery peaks later (day 23). This tool gives public health, hospital, and
emergency planners scenario-specific information for developing quantitative
response plans for this threat.
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Gutting BW, Rukhin A, Marchette D, Mackie RS, Thran B. Dose-Response Modeling for Inhalational Anthrax in Rabbits Following Single or Multiple Exposures. Risk Anal 2016; 36:2031-2038. [PMID: 26889937 DOI: 10.1111/risa.12564] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
There is a need to advance our ability to characterize the risk of inhalational anthrax following a low-dose exposure. The exposure scenario most often considered is a single exposure that occurs during an attack. However, long-term daily low-dose exposures also represent a realistic exposure scenario, such as what may be encountered by people occupying areas for longer periods. Given this, the objective of the current work was to model two rabbit inhalational anthrax dose-response data sets. One data set was from single exposures to aerosolized Bacillus anthracis Ames spores. The second data set exposed rabbits repeatedly to aerosols of B. anthracis Ames spores. For the multiple exposure data the cumulative dose (i.e., the sum of the individual daily doses) was used for the model. Lethality was the response for both. Modeling was performed using Benchmark Dose Software evaluating six models: logprobit, loglogistic, Weibull, exponential, gamma, and dichotomous-Hill. All models produced acceptable fits to either data set. The exponential model was identified as the best fitting model for both data sets. Statistical tests suggested there was no significant difference between the single exposure exponential model results and the multiple exposure exponential model results, which suggests the risk of disease is similar between the two data sets. The dose expected to cause 10% lethality was 15,600 inhaled spores and 18,200 inhaled spores for the single exposure and multiple exposure exponential dose-response model, respectively, and the 95% lower confidence intervals were 9,800 inhaled spores and 9,200 inhaled spores, respectively.
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Affiliation(s)
- Bradford W Gutting
- CBR Concepts and Experimentation Branch (B21), Naval Surface Warfare Center, Dahlgren Division, Dahlgren, VA, USA
| | - Andrey Rukhin
- Sensor Fusion Branch (A43), Naval Surface Warfare Center, Dahlgren Division, Dahlgren, VA, USA
| | - David Marchette
- Sensor Fusion Branch (A43), Naval Surface Warfare Center, Dahlgren Division, Dahlgren, VA, USA
| | - Ryan S Mackie
- CBR Concepts and Experimentation Branch (B21), Naval Surface Warfare Center, Dahlgren Division, Dahlgren, VA, USA
| | - Brandolyn Thran
- Army Public Health Center (Provisional), Aberdeen Proving Ground, MD, USA
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Palmer J, Bell M, Darko C, Barnewall R, Keane-Myers A. Protein- and DNA-based anthrax toxin vaccines confer protection in guinea pigs against inhalational challenge with Bacillus cereus G9241. Pathog Dis 2014; 72:138-42. [PMID: 25044336 DOI: 10.1111/2049-632x.12204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 06/12/2014] [Accepted: 06/28/2014] [Indexed: 11/29/2022] Open
Abstract
In the past decade, several Bacillus cereus strains have been isolated from otherwise healthy individuals who succumbed to bacterial pneumonia presenting symptoms resembling inhalational anthrax. One strain was indistinguishable from B. cereus G9241, previously cultured from an individual who survived a similar pneumonia-like illness and which was shown to possess a complete set of plasmid-borne anthrax toxin-encoding homologs. The finding that B. cereus G9241 pathogenesis in mice is dependent on pagA1-derived protective antigen (PA) synthesis suggests that an anthrax toxin-based vaccine may be effective against this toxin-encoding B. cereus strain. Dunkin Hartley guinea pigs were immunized with protein- and DNA-based anthrax toxin-based vaccines, immune responses were evaluated and survival rates were calculated after lethal aerosol exposure with B. cereus G9241 spores. Each vaccine induced seroconversion with the protein immunization regimen eliciting significantly higher serum levels of antigen-specific antibodies at the prechallenge time-point compared with the DNA-protein prime-boost immunization schedule. Complete protection against lethal challenge was observed in all groups with a detectable prechallenge serum titer of toxin neutralizing antibodies. For the first time, we demonstrated that the efficacy of fully defined anthrax toxin-based vaccines was protective against lethal B. cereus G9241 aerosol challenge in the guinea pig animal model.
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Affiliation(s)
- John Palmer
- Vaccines and Medical Countermeasures, Biological Defense Research Directorate, Navy Medical Research Center, NMRC-Frederick, Fort Detrick, MD, USA
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