Guidelines for Testing for Anthrax

Purpose

The purpose of these policy guidelines is to recommend procedures for handling potential biological threats of Anthrax exposure.

I. Testing of Symptomatic Patients for Anthrax

Suspected anthrax cases should be reported immediately to the local health department. The health department will provide assistance with testing decisions and facilitate communication with ODH and CDC. Antigen detection may be available through a reference laboratory or CDC. Nasal swabs are not currently recommended for diagnosis of symptomatic patients.

II. Testing of Asymptomatic Patients for Anthrax

There is no reliable clinical test for detection of anthrax exposure in asymptomatic individuals. The use of nasal cultures (swabs) is NOT recommended and should be discouraged. Nasal swabs will ONLY be done under the direction of government agencies. A negative nasal culture does not rule out anthrax infection or exposure. The hospital cannot process nasal swabs to rule out anthrax.

Ill. Testing Suspicious Items/Substances

The local law enforcement authorities and local health departments handle all suspicious substances/items. The ODH laboratory processes all suspicious substances/items. The hospital will not test or accept these items in their laboratory.

	DIAGNOSTIC STUDIES	CULTURES*
INHALATION ANTHRAX	chest X-ray and/or chest CT peripheral blood smear gram stain of CSF** gram stain pleural/ascitic fluid	blood CSF** pleural/ascitic fluid
CUTANEOUS ANTHRAX	gram stain of skin lesion gram stain of skin biopsy peripheral blood smear	blood vesicular fluid sterile punch biopsy
GASTROINTESTINAL ANTHRAX		blood stool

* sputum cultures and gram stains unlikely to be diagnostic

** if meningeal signs present

Lab

Due to potential risks associated with handling infectious materials, laboratory testing should be the minimum necessary for diagnostic evaluation and patient care. Laboratory specimens should be placed in plastic bags that are sealed, and then transported in clearly labeled, durable, leak-proof containers directly to the specimen handling area of the laboratory. Care should be taken not to contaminate the external surfaces of the container. Lab personnel should be notified of what they are handling. Bio-Safety Level 2 should be used for handling specimens.

SEND ALL SPECIMENS TO MICROBIOLOGY LAB; DO NOT USE TUBE SYSTEM

Anthrax	Blood Cultures: two separate sets from different sites (one set is 2 bottles – 10 ml each bottle)	Lavender Tube (EDTA) (for inpatients only) (or direct gram stain)	2 red-top or gold-top tubes (for PCR and acute serology)	Sputum	Pleural fluid (if present)	CSF (if meningeal signs present)	Cutaneous Lesions: swabs X 2 and punch biopsies X 3 (see notes below)	Stool (not in transport medium)	Anterior Nares Swab	ID Consult	Note under comments on microbiology requisition
Possible B. Anthracis	No	No	No	No	No	No	No	No	No	No	Not applicable
Anthrax – inhalational	Yes	Yes	Yes	Yes	Yes	Yes	No	No	No	Yes	R/O Anthrax
Anthrax cutaneous – vesicular stage	Yes	Yes	Yes	No	No	No	See notes below	No	No	Yes	R/O Anthrax
Anthrax cutaneous – eschar stage	Yes	Yes	Yes	No	No	No	See notes below	No	No	Yes	R/O Anthrax
Anthrax – GI	Yes	Yes	Yes	No		No	No	Yes	No	Yes	R/O Anthrax

Notes regarding cutaneous Lesions:

1. Swabs

a. Vesicular lesions – soak 2 swabs (1 culture swab) in previously unopened vesicle fluid and send to micro lab

b. Eschar lesions – rotate 2 swabs (1 culture swab) beneath edge of eschar without removing eschar and send to micro lab

2. Punch biopsies

a. Send one is sterile saline for culture

b. Send one in 10% formaline to be sent to CDC for histopathology and immunohistochemical staining

c. Send one in a sterile cup to be frozen and sent to CDC for culture and PCR

References:

CDC Website

http://www.bt.cdc.gov/agent/anthrax/index.asp

Note: These are guidelines that have been developed with data available as of 1/21/02.

Initially Prepared by

The Akron Regional Hospital Association

Emergency Preparedness Subcommittee

August 20, 2002