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The recent bioterrorist attack causing an outbreak of anthrax in
several states, including New Jersey, has stressed the resources
of the public health care system. Part of that stress is a result
of some misconceptions on the part of health care providers and
the public that must be addressed to eliminate the inappropriate
use of tests and antibiotics that could lead to adverse effects
among patients. This memo addresses those issues and is directed
at health care providers to assist them in their efforts to manage
their patients in a medically sound approach, given our current
knowledge.
The
NJDHSS discourages the use of nasal swabs for assessing patients
concerned about exposure to anthrax as they are not a clinically
useful tool. The use of nasal swabs in recent investigations
in Florida, NYC, DC, and New Jersey has been for epidemiologic purposes,
in order to help determine where suspicious letters were handled
in the work area around a confirmed case. The results have been
used to guide further investigation and to determine the source
of exposure, and to make overall recommendations on prophylaxis
for persons involved at the site regardless of individual nasal
swab test results.
There
is no screening test available for the detection of anthrax infection
in an asymptomatic person. The sensitivity and specificity and
clinical value of nasal swab testing for an individual patient are
unknown. The presence of anthrax spores in the nose only indicates
recent exposure and has no predictive value regarding the number
of spores inhaled or infectious status of the individual. In addition,
nasal swab tests may be reported preliminarily as positive for Bacillus
species but may ultimately be negative for B. anthracis when
tested in the State Lab.
Serologic
tests are available at reference laboratories such as the CDC, but
are only performed in symptomatic individuals with a clinical picture
consistent with inhalational or cutaneous disease. Serology is not
used as a screening or preliminary test in individuals. Preliminary
tests in symptomatic individuals being evaluated for anthrax, should
instead focus on blood cultures (BEFORE antibiotic therapy).
The
New Jersey Department of Health and Senior Services (NJDHSS) continues
to strongly urge physicians NOT to prescribe post exposure prophylactic
antibiotics for persons who are not among the groups recommended
for this. At this time, those recommended for PEP are the following:
- Postal workers or business visitors to the work areas at the
Route 130 Mail Processing Facility in Hamilton
- Postal workers at the West Trenton Postal Facility in Ewing
Twsp.
Although
we recognize the heightened concern regarding the threat of bioterrorism
with the unfolding events of the past several weeks, antibiotic
therapy in asymptomatic individuals should be limited to persons
with a known risk exposure.
Prophylactic
antibiotics at this time should be limited to persons with a known
documented anthrax exposure, or if prophylaxis has been recommended
by local, state or federal public health authorities as part of
an ongoing investigation at a specific worksite. Clinicians seeing
patients who say they may have been exposed to anthrax should assess
the individual risk of exposure. If concerned that a high-risk exposure
has occurred, please call the NJDHSS at the Emergency Operations
Center at 609-538-6030 for medical consultation, BEFORE making treatment
recommendations.
Use
of prophylactic antibiotics is not without risk. Inappropriate use
of antibiotics may result in serious adverse effects (e.g., Clostridium
difficile colitis, allergic reactions, interactions with other
medications) and will lead to increased antibiotic resistance among
microorganisms causing common bacterial infections (e.g., otitis
media, pneumonia).
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