Clinical condition Treatment

Postexposure prophylaxis

Inhalational
anthrax

Prophylaxis for 60 days c :
Ciprofloxacin 10–15 mg/kg
PO q12h OR
Levofloxacin 8 mg/kg PO
q12h OR
Doxycycline 2.2 mg/kg PO
q12h

Pneumonic plague
d

Ricin
Tularemia
(pneumonic)
Smallpox

Ciprofloxacin 10–15 mg/kg
IV q12h OR
Levofloxacin 8 mg/kg PO
q12h OR
Doxycycline 2.2 mg/kg IV
q12h
AND
Clindamycin a 10–15 mg/kg

IV q8h
AND
Penicillin G b 400–600k
U/kg/d IV ÷ q4h
AND consider:
Raxibacumab
(>50 kg: 40 mg/kg IV; 15–
50 kg: 60 mg/kg IV; <15
kg: 80 mg/kg IV) OR
Obiltoxaximab
(>40 kg: 16 mg/kg IV)
Gentamicin 2.5 mg/kg IV
q8h OR
Doxycycline 2.2 mg/kg IV
q12h OR
Ciprofloxacin 15 mg/kg IV
q12h OR
Levofloxacin 8 mg/kg
IV/PO q12h
Supportive therapy
Same as for Plague e

Doxycycline 2.2 mg/kg PO
q12h OR Ciprofloxacin
20 mg/kg PO q12h OR
Levofloxacin 8 mg/kg PO
q12h

Supportive therapy
Same as for Plague e


Tecoviramat 200 mg PO
Vaccination may be
q12h (for children 13–25
effective if given within
kg); 400 mg PO q12h (for
96 hours after exposure
children 25–40 kg); 600


Viral hemorrhagic
fever (e.g.,
Ebola)
Botulism

mg PO q12h (for children
>40 kg)
Supportive therapy; consider Supportive therapy
ribavirin in select cases
Supportive therapy; an
antitoxin may prevent
disease progression

Supportive therapy

a Rifampin

or clarithromycin also targets bacterial protein synthesis may thus be acceptable alternatives to
clindamycin. If ciprofloxacin or another quinolone is employed, doxycycline may be used as a second agent,
as it also targets protein synthesis.

b Ampicillin, imipenem, meropenem, or chloramphenicol penetrates the CSF well and may thus be
acceptable alternatives to penicillin.
c Treatment for cutaneous anthrax would be the same as for postexposure prophylaxis. Sixty days of
treatment is indicated if concern for concomitant inhalation exposure.
d If signs/symptoms of sepsis, treatment of patient with bubonic plague is same as for pneumonic plague.
e Levofloxacin and moxifloxacin are licensed by the Food and Drug Administration for the prophylaxis and
treatment of plague in the setting of a bioterror attack, but not tularemia.

GOALS OF TREATMENT
The goals of emergency therapy include early recognition of a potential biologic
agent attack, efficient and accurate triage of victims, rapid institution of proper
isolation and infection control precautions to protect healthcare workers and other
patients, and administration of proper antibiotics or antitoxins, when appropriate.

CLINICAL CONSIDERATIONS
Clinical Recognition
Recognition of a biologic agent exposure may be difficult because pediatricians
and emergency department (ED) physicians rarely encounter victims of such
attacks. Considering three critical epidemiologic characteristics of such an attack
might enhance early recognition: an epidemic number of patients, a common
exposure history, and exotic disease presentations. A large number of patients, out
of proportion to time of year and expected clinical syndromes, might trigger
suspicion. Although some variations in the incubation period may occur after a
biologic agent attack, most persons would initially be exposed at the same time,
and thus become ill and present in a relatively compressed time frame. In
contrast, most natural epidemics evolve with a gradual rise in disease incidence


because persons are progressively exposed to increased numbers of infectious
patients, fomites, or vectors that spread the organism.

A history of geographic connection among patients, or some observation of an
unusual source of exposure such as a powder in an envelope, might also trigger
suspicion. By exotic diseases, it is suggested that many infections caused by
biologic weapons, particularly with advanced disease, are relatively unusual and
unique. Diseases that are rare, not endemic in the area of exposure, or that are
normally spread by vectors that are not indigenous to the relevant geographic area
would also be suspected, especially if numerous cases developed simultaneously.

FIGURE 132.1 Approach to the early recognition and diagnosis of an attack with an unknown
biologic agent. VEE, Venezuelan equine encephalitis; JE, Japanese encephalitis; Rx, treatment;
CXR, chest x-ray; VHF, viral hemorrhagic fever. (Reprinted from Henretig FM, Cieslak TJ,
Kortepeter MG, et al. Medical management of the suspected victim of bioterrorism: an
algorithmic approach to the undifferentiated patient. Emerg Med Clin N Amer 2002;20:351–
364. Copyright © 2002 Elsevier Science (USA). With permission.)

Additional clues to a biologic agent attack might include especially high
infection or intoxication rates among exposed persons, high numbers of patients
with atypical pneumonia, unusually high morbidity or mortality, simultaneous
epidemics caused by different pathogens, attack rates lower in persons sheltered


from the suspected route of exposure, presence of infected or dying animals, and
the discovery of suspicious actions or potential delivery systems.
Most of the primary biologic threat agents can be categorized as causing the
subacute onset of effects (e.g., days after exposure); those effects can be divided
into predominantly respiratory, neurologic, or dermatologic syndromes. Thus,
with a careful medical and epidemiologic history, physical examination, and
limited, routine laboratory evaluation, an early suspicion of a biologic attack
might be raised, and initial diagnostic impression considered, as outlined in
Figure 132.1 . This in turn could trigger appropriate requests for infectious

disease consultation and more definitive laboratory testing, as well as early
empiric therapy. A similar approach, applied in the setting of unusual increases in
patient volume or illness presentations, might also help practitioners to participate
in the early recognition of a new or reemerging natural infectious disease (e.g.,
West Nile disease, severe acute respiratory syndrome [SARS], Middle East
Respiratory Syndrome [MERS], monkeypox, Ebola, and pneumonic tularemia, to
name some recent examples). If a pediatrician or emergency medicine physician
recognizes, or even suspects, any such natural or intentional outbreak, immediate
reporting to local and regional public health authorities is appropriate, even
before a specific diagnosis can be confirmed.

Triage Considerations: Minimizing Spread of Infection
As soon as ED staff suspect that a patient may be the victim of biologic terrorism,
appropriate steps must take place to prevent or minimize exposure to limit the
spread of disease. The level of ED mitigation and preparedness activities will
largely depend on the level of awareness of the disease outbreak. For example,
faced with a known release of smallpox by terrorists, EDs would need to take
dramatic steps to protect staff and patients. Such steps might include setting up
screening stations outside of the hospital, staffed by clinicians wearing gowns,
gloves, N-95 respirators, and eye protection. If a child suspected to have smallpox
were encountered at the screening station, he or she would need to be covered
with a sheet, provided a mask, and escorted directly to a negative-pressure room
for further evaluation and treatment. Infection Prevention and Control specialists
would need to provide guidance on specimen collection, handling, and testing.
Patients suspected to have smallpox should be moved to a specialized
biocontainment facility as soon as possible. In the event of a large outbreak, when
the supply of scarce biocontainment beds is likely to be exhausted, airborne
infection isolation rooms might be an acceptable alternative. Should these also
prove inadequate for the number of affected patients, the cohorting of patients in
designated “smallpox wards” might be necessary.