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| Emergency Medical Services ● Health Alert Network ● Health Hotline ● Emergency Preparedness & Response |
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Children & Anthrax: A Fact Sheet for Clinicians Description Anthrax is an acute infectious disease
caused by the bacterium Bacillus anthracis. Children, like
adults, may be affected by three clinical forms:
cutaneous,
inhalational, or gastrointestinal. Symptoms The symptoms and signs of anthrax
infection in children older than 2 months of age are similar to those in
adults. The clinical presentation of anthrax in young infants is not
well defined. When children
become ill and present for treatment, making a diagnosis may be more
difficult than in adults because young children have difficulty
reporting what has happened to them or telling a doctor exactly how they
feel. Because respiratory
illnesses are much more common in children than adults, the examining
clinician should have an understanding of disease manifestations in
children. The following are clinical descriptions (based on experience
with adults) of the three forms of anthrax (MMWR
2001;50(41):889-893). Inhalational. Inhalational anthrax begins with a brief prodrome
resembling an influenza-like viral respiratory illness followed by
development of dyspnea, systemic symptoms, and shock, with radiographic
evidence of mediastinal widening and pleural effusion. Inhalational
anthrax is the most lethal form of anthrax. The incubation period of
inhalational anthrax among humans typically ranges from 1 to 7 days but
may be up to 60 days. Host factors, dose of exposure, and
chemoprophylaxis may affect the duration of the incubation period.
Patients frequently develop meningitis. Case-fatality estimates for
inhalational anthrax are extremely high; the risk for death is high even
if patients are provided with supportive care, including appropriate
antimicrobial treatment. Cutaneous.
Cutaneous anthrax is characterized by a skin lesion evolving from a
papule, through a vesicular stage, to a depressed black eschar. The
incubation period ranges from 1 to 12 days. The lesion is usually
painless, but patients also may have fever, malaise, headache, and
regional lymphadenopathy. The case fatality rate for cutaneous anthrax
is 20% without, and <1% with, antimicrobial treatment. Gastrointestinal.
Gastrointestinal anthrax is characterized by severe abdominal pain
followed by fever and signs of septicemia. This form of anthrax usually
results from eating raw or undercooked meat containing B. anthracis, and
the incubation period is usually 1 to 7 days. An oropharyngeal and an
abdominal form of the disease have been described. Involvement of the
pharynx is usually characterized by lesions at the base of the tongue,
dysphagia, fever, and regional lymphadenopathy. Lower bowel inflammation
typically causes nausea, loss of appetite, and fever followed by
abdominal pain, hematemesis, and bloody diarrhea. The case-fatality rate
is estimated to be between 25% and 60%. The effect of early antibiotic
treatment on the case-fatality rate has not been established.
Neither CDC nor the American Academy of Pediatrics (AAP) recommend
dispensing antibiotics for parents to have on hand in case of a possible
exposure to Bacillus anthracis. CDC and its partner organizations will
dispense antibiotics through the National Pharmaceutical Stockpile (NPS)
program if exposure occurs. The NPS was designed to ensure the
availability of lifesaving pharmaceuticals; antimicrobials; chemical
interventions; and medical, surgical, and patient-support supplies, as
well as equipment for prompt delivery to disaster sites. Disasters
include a possible biological or chemical terrorist event anywhere in
the United States. For more detailed information about the NPS, see
CDC’s Web site at www.bt.cdc.gov.
Vaccination At this time, anthrax vaccine is not recommended for people younger
than 18 years of age. Military personnel and civilians at high risk for
repeated exposure (e.g., laboratory workers handling powders containing
Bacillus anthracis may benefit from the vaccine. Prophylaxis Post-exposure prophylaxis is indicated to prevent inhalational
anthrax after a confirmed or suspected aerosol exposure to Bacillus
anthracis. Consultation
with public health authorities is strongly encouraged to identify people
who should receive prophylaxis. When no information is available about
the antimicrobial susceptibility of the implicated strain of Bacillus
anthracis, CDC recommends initial therapy with either ciprofloxacin
or doxycycline for children, as follows: · Ciprofloxacin:
10-15
mg/kg/dose po Q12 hours (not to exceed 1 gram per day) for 60 days. · Doxycycline:
Reference: CDC. Update: Investigation of anthrax associated with
intentional exposure and interim public health guidelines, October, 2001.
MMWR 2001;50 (41):889-893. The National Pharmaceutical Stockpile
(NSP) contains oral and liquid types of both drugs for use by children
who are too small to tolerate pills. Both tetracyclines and
fluoroquinolones can cause adverse health effects in children. These
risks must be weighed carefully against the risk of developing a
life-threatening disease due to Bacillus anthracis. As soon as
the penicillin susceptibility of the organism has been confirmed,
prophylactic therapy for children should be changed to oral amoxicillin
80 mg/kg of body mass per day divided every 8 hours (not to exceed 500
mg three times daily). The NSP also includes amoxicillin suspension for
children. Bacillus anthracis is not susceptible to cephalosporins
or to trimethoprim/sulfamethoxazole, and these agents should not be used
for prophylaxis. Drug Recommendations For Pediatric Anthrax Cases Some antibiotics and other
treatments that have proven effective against anthrax in adults have not
been studied as extensively in children. Therefore, CDC provides the
following recommendations for treating anthrax in children: For inhalational anthrax:
Antimicrobial
therapy should be continued for 60 days because of the potential
persistence of spores after an aerosol exposure. Initial therapy may be
altered on the basis of the clinical course of the patient; one or two
antimicrobial agents (e.g., ciprofloxacin or doxycycline) may be
adequate as the patient improves. *If
intravenous ciprofloxacin is not available, oral ciprofloxacin may be
acceptable because it is rapidly and well absorbed from the
gastrointestinal tract with no substantial loss by first-pass
metabolism. Maximum serum concentrations are attained 1 to 2 hours after
oral dosing but may not be achieved if vomiting or ileus is present. In
children, ciprofloxacin dosage should not exceed 1 g/day. ¶
The
AAP recommends treatment of young children with tetracyclines for
serious infections (e.g., Rocky Mountain spotted fever). If meningitis
is suspected, doxycycline may be less optimal because of poor central
nervous system penetration. §
Other agents with in vitro activity include rifampin, vancomycin,
penicillin, ampicillin, chloramphenicol, imipenem, clindamycin, and
clarithromycin. Because of concerns of constitutive and inducible
beta-lactamases in Bacillus anthracis isolates involved in the
current bioterrorist attack, penicillin and ampicillin should not
be used alone. Consultation with an infectious disease specialist is
advised. For
cutaneous anthrax, CDC recommends the following treatment:
Cutaneous
anthrax with signs of systemic involvement, extensive edema, or lesions
on the head or neck requires intravenous therapy, and a multidrug
approach is recommended. Ciprofloxacin or doxycycline should be
considered first-line therapy. Amoxicillin 80 mg/kg/day divided every 8
hours is an option for completion of therapy after clinical improvement,
if the organism is susceptible. Previous
guidelines have suggested treating cutaneous anthrax for 7 to 10 days,
but 60 days is recommended in the setting of this attack, given the
likelihood of exposure to aerosolized Bacillus anthracis. For
gastrointestinal and oropharyngeal anthrax, use regimens recommended
for inhalational anthrax. Children
are more likely than adults to suffer side affects from some antibiotics
used to prevent or treat the disease. If a child does develop side
effects, testing should be done to determine whether the bacteria to
which the child was exposed are susceptible to other drugs with fewer
side effects, such as amoxicillin.
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