Anthrax Nursing Care Management & Care Plan

Anthrax is rare, but it is a reportable disease and the inhalation form kills. It does not spread person to person, so your job is barrier precautions, fast IV antibiotics, and airway support, not isolating the unit. Know the four routes of entry, because the route drives the presentation and the urgency.

What is Anthrax?

Anthrax is an acute infectious disease caused by the spore-forming, gram-positive, rod-shaped bacterium Bacillus anthracis. It is a rare, often fatal zoonotic disease (animal to human) found naturally in soil, and it mainly affects wild and domestic animals worldwide. The name comes from the Greek anthrakis (coal), after the black eschar of the cutaneous form.

Pathophysiology

Anthrax is primarily a disease of herbivores (cattle, sheep, goats, horses).

• Bacillus anthracis is a large, spore-forming, gram-positive rod.
• Spore persistence is aided by nitrogen and organic soil content, environmental pH greater than 6, and ambient temperature greater than 15°C.
• Spores can exist indefinitely in the environment; optimal conditions trigger a vegetative phase and bacterial multiplication. Drought or rainfall can trigger germination, and flies and vultures spread the spores.
• Anthrax toxins are composed of three entities: a protective antigen, a lethal factor, and an edema factor. The protective antigen is an 83-kd protein that binds cell receptors in target tissue. Edema factor binding forms edema toxin; lethal factor binding forms lethal toxin.
• Humans are relatively resistant to cutaneous invasion, but organisms enter through microscopic or gross skin breaks, multiply locally, and may spread to the bloodstream or other organs (such as the spleen) via the efferent lymphatics.
• Primary intestinal anthrax predominantly affects the cecum and produces a local lesion similar to the cutaneous lesion.
• Inhaled spores are ingested by pulmonary macrophages and carried to hilar and mediastinal lymph nodes. Anthrax in the lungs does not cause pneumonia; it causes hemorrhagic mediastinitis and pulmonary edema.

Causes

Anthrax is caused by Bacillus anthracis, a gram-positive bacillus. Exposure routes:

• Working with infected animals or animal products. Most cases occur from contact with infected animals or products such as wool, hides, or hair.
• Eating raw or undercooked meat from infected animals. This causes gastrointestinal anthrax, usually in countries where livestock are not routinely vaccinated and food animals are not inspected before slaughter.
• Injecting heroin. Injection anthrax has been seen in northern Europe in people injecting heroin.

Types

The type of illness depends on how anthrax enters the body, typically through the skin, lungs, or gastrointestinal tract.

• Cutaneous anthrax. The most common and least dangerous form, most often on the head, neck, forearms, and hands. Infection develops 1 to 7 days after exposure.
• Inhalation anthrax. The deadliest form. Infection usually develops within a week but can take up to 2 months. Without treatment, only about 10-15% of patients survive.
• Gastrointestinal anthrax. Rarely reported in the United States. Develops 1 to 7 days after exposure and affects the upper GI tract, stomach, and intestines.
• Injection anthrax. Spreads through the body faster and is harder to recognize and treat. Symptoms resemble cutaneous anthrax, with infection deep under the skin or in the muscle at the injection site.

Statistics and Incidences

Natural incidence is rare, but infection is an occupational hazard for veterinarians, farmers, and people who handle animal wool, hair, hides, or bone meal.

• From 1955 to 1994, US cases totaled 235: 224 cutaneous, 11 inhalational, and 20 fatalities.
• In October 2001, 22 confirmed or suspected cases were identified, reported from Florida, New York, New Jersey, the District of Columbia, and Connecticut. There were 11 confirmed inhalational cases (5 deaths) and 7 confirmed plus 4 suspected cutaneous cases (no deaths).
• Anthrax is uncommon in Western Europe but not uncommon in the Middle East, the Indian subcontinent, Africa, Asia, and Latin America. It is endemic in Africa and Asia despite vaccination programs.

Clinical Manifestations

Symptoms depend on the type of infection and take anywhere from 1 day to more than 2 months to appear.

• Cutaneous. A group of small blisters or bumps that may itch, swelling around the sore, and a painless skin sore or ulcer with a black center.
• Inhalation. Fever and chills, chest discomfort, shortness of breath, confusion or dizziness, cough, nausea and vomiting or stomach pain, headache, sweats, extreme tiredness, and body aches.
• Gastrointestinal. Painful swallowing, hoarseness, nausea and bloody vomiting, diarrhea, stomach pain, and abdominal swelling.
• Injection. Fever and chills, a small group of blisters or bumps that may itch at the injection site, a painless skin sore with a black center, swelling around the sore, and abscesses deep under the skin or in the muscle.

Assessment and Diagnostic Findings

Bacillus anthracis is present in high numbers in the ulcer/eschar of cutaneous anthrax, in bloody pleural fluid in inhalational anthrax, in the CSF in anthrax meningitis, and in the blood in septicemic anthrax.

• Gram stain and blood culture. The preferred procedure for cutaneous anthrax is staining the ulcer exudate with methylene blue or Giemsa stain. B anthracis readily grows on blood agar, and staining differentiates it from non-B anthracis bacilli.
• Enzyme-linked immunosorbent assay (ELISA). Serologic diagnosis is positive if a single acute-phase titer is highly elevated or if a fourfold rise is observed between acute and convalescent specimens.
• Chest radiography and CT. If inhalational anthrax is suspected, obtain a chest radiograph or CT. The appearance may suggest the diagnosis, especially when other causes of a widening mediastinum (dissecting aortic aneurysm, bacterial mediastinitis) are absent.
• Lumbar puncture. If anthrax meningitis is suspected, obtain CSF for stain and culture.
• Histologic findings. The characteristic finding is organisms in the capillaries at the infection site (skin, intestines, liver, spleen, lungs, or leptomeninges).

Medical Management

Treatment options vary; serious cases need aggressive treatment.

• Cutaneous anthrax. Isolated cutaneous anthrax without systemic involvement (no edema, fever, cough, headache) or complications can be treated outpatient with antibiotic monotherapy.
• Prehospital care. Wash potentially contaminated people with soap and water, not bleach. Place clothing and materials in triple plastic bags. If contamination is confirmed, use a 1:10 dilution of household bleach to decontaminate materials and surfaces not cleaned by soap and water.
• Emergency department care. Start IV antibiotic therapy rapidly. Patients can be admitted to a normal room with barrier nursing (gown, gloves, mask) and secretion precautions.
• Consultations. Anthrax is reportable. Notify local health authorities and the CDC of suspected cases, and consider an infectious disease consult.
• Deterrence and prevention. For postexposure prophylaxis in adults, the CDC recommends vaccination plus oral fluoroquinolones (ciprofloxacin, 500 mg bid; levofloxacin, 500 mg qd; or ofloxacin, 400 mg bid). Preexposure vaccination is recommended only for populations at high risk of exposure to aerosolized B anthracis spores, per the CDC's Advisory Committee on Immunization Practices (ACIP).

Pharmacologic Management

• Antibiotics. Empirical antimicrobial therapy must be comprehensive and cover all likely pathogens for the clinical setting.
• Corticosteroids. Used for severe edema, meningitis, or swelling in the head and neck.
• Antitoxins. A monoclonal antibody (raxibacumab) and human anthrax immune globulin are FDA-approved for inhalational anthrax under the animal efficacy rule.
• Vaccines. The FDA approved anthrax vaccine adsorbed (AVA), a sterile filtrate of cultures of an avirulent strain that produces protective antigen. No human controlled trials exist, and efficacy in inhalation (biowarfare) anthrax is questionable.

Nursing Management

Nursing Assessment

• History. Anthrax is primarily zoonotic with no documented human-to-human transmission, though lab personnel may contract it from specimens. Exposure may be occupational (agriculture, industry) or, for military and civilians, through biologic warfare.
• Physical assessment. Findings are nonspecific. The incubation period for all forms is 1-6 days; the prodrome includes fever, malaise, and adenopathy.

Nursing Diagnosis

• Ineffective airway clearance related to airway obstruction.
• Ineffective breathing pattern related to decreased lung expansion.
• Impaired swallowing related to mechanical obstruction (oropharyngeal edema).
• Diarrhea related to increased GI motility.
• Impaired tissue integrity related to anthrax toxin.
• Hyperthermia related to increased metabolic demand.

Nursing Care Planning and Goals

• Improve airway patency.
• Improve breathing pattern.
• Improve swallowing.
• Eliminate diarrhea.
• Improve tissue integrity.
• Return temperature to normal range.

Nursing Interventions

• Improve airway patency. Auscultate for crackles, monitor oxygen saturation and ABGs to track oxygenation and acid-base balance, and suction frequently with chest physiotherapy to clear airways, prevent atelectasis, and maximize oxygen therapy.
• Improve breathing pattern. Position for maximum chest expansion, reposition frequently to mobilize secretions, and provide supplemental oxygen or mechanical ventilation as needed.
• Improve swallowing. Corticosteroids decrease head and neck swelling.
• Eliminate diarrhea. Gastrointestinal anthrax can be treated with ciprofloxacin or doxycycline for 60 days.
• Improve tissue integrity. Isolated cutaneous anthrax without systemic involvement or complications can be treated outpatient with antibiotic monotherapy.
• Diminish hyperthermia. Administer analgesics as prescribed.

Evaluation

Goals are met when the patient shows improved airway patency and breathing pattern, improved swallowing, resolved diarrhea, improved tissue integrity, and temperature back in normal range.

Documentation Guidelines

• Individual findings, including factors affecting, interactions, nature of social exchanges, and specifics of individual behavior.
• Cultural and religious beliefs and expectations.
• Plan of care.
• Teaching plan.
• Responses to interventions, teaching, and actions performed.
• Attainment or progress toward the desired outcome.

Key Points

• Anthrax is caused by the gram-positive, rod-shaped bacterium Bacillus anthracis and is primarily a disease of herbivores (cattle, sheep, goats, horses).
• There are four types: cutaneous, inhalation, gastrointestinal, and injection. The type depends on how anthrax enters the body.
• Anthrax is NOT contagious person to person.
• Natural incidence is rare but is an occupational hazard for veterinarians, farmers, and animal-product handlers.
• Start rapid IV antibiotic therapy. Admit to a normal room with barrier nursing (gown, gloves, mask) and secretion precautions. Isolated cutaneous anthrax without systemic involvement can be treated outpatient with antibiotic monotherapy.