Suspected Glanders exposure
Purpose
The purpose of these policy guidelines is to recommend
procedures for handling biological threats of Glanders exposure.
Description of Agent/Syndrome
Burkholderia
(Pseudomonas, Actinobacillus, Malleomyces) mallei - A
gram-negative bacillus. This is primarily a disease of horses, mules and
donkeys. It has disappeared from the western hemisphere, but may be found in
Asia and some eastern Mediterranean countries. Human infection has occurred
almost exclusively in occupations with contact with animals or work in
laboratories (i.e. veterinarians, equine butchers, and pathologists).
Transmission
1. Naturally
acquired
Glanders is generally
transmitted from animal to humans via invasion of nasal, oral and conjunctival
mucous membranes, by inhalation into the lungs or through lacerated or abraded
skin.
2. Inhalation
Dissemination
The infection rate in those
exposed to aerosol is 46%.
3. Intentional (possible terrorist
action)
Incubation
Incubation is 10-14 days after inhalation.
Signs and Symptoms
There are three primary sites of infections, nasal membranes
and upper respiratory tract, the lungs, and the skin. The bacterium causes
lumps or nodules to form in the affected area. The nodules enlarge and form
ulcers. In the cutaneous form, craterlike ulcers form on the skin along the
course of the lymph vessels of the extremities; this form of Glanders is
commonly called farcy.
Symptoms:
Fever, rigors, night
sweats, myalgia, headache, pleuritic chest pain, photophobia, lacrimation,
diarrhea
Clinical
Presentation:
A. Acute
(localized, pulmonary, fulminant sepsis)
Fever, cervical adenopathy, splenomegaly, rash with generalized papular or pustular eruptions
B. Chronic
Rash, with cutaneous and intramuscular abscess, nasal discharge and ulceration (50%)
Diagnosis
·
Miliary nodules (0.5-1.0 cm)
·
Small multiple lung abscesses
·
Bronchopneumonia
·
Lobar pneumonia
·
Necrotizing nodular lesion
·
Scant small bacilli with Methylene blue stain
·
Sputum culture on meat nutrient mediums
C. Hematology
·
Mild leukocytosis with left shift
Treatment
The following oral regimens have been suggested for
localized disease: Amoxicillin/clavulanate
60 mg/kg/day in three divided doses; Tetracycline 40
mg/kg/day in three divided doses; or Trimethoprim/sulfa (TMP 4 mg/kg/day-sulfa
20 mg/kg/day) in two divided doses. The duration of treatment should be for 60
—150 days.
If the patient has localized disease with signs of
mild toxicity, then a combination of two of the oral regimens is recommended
for a duration of 30 days, followed by monotherapy with either
amoxicillin/clavulanate or TMP/sulfa for 60-150 days. If extrapulmonary
suppurative disease is present, then therapy should continue for 6-12 months.
Surgical drainage of abscesses may be required.
For severe disease, parental therapy with Ceftazidime
120 mg/kg/day in three divided doses combined with TMP/sulfa (TMP 8 mg/kg/day —
sulfa 40 mg/kg/day) in four divided doses for 2 weeks, followed by oral therapy
of 6 months.
Prophylaxis
1. No
vaccine currently available.
2. Post exposure prophylaxis with
Trimethoprim / Sulfamethoxazole has been tried. Efficacy unknown.
Control Measures and Decontamination
1. Standard Precautions
2. CDC report - human to human
transmission is possible
3. In the event of a bioterrorist
incident involving this organism, specific diagnostic and treatment guidelines
should be forthcoming from the federal health authorities
Notification
Internal: At hospital
notify______________________________
External: All suspected cases of suspected Glanders
exposure should be reported immediately to the Local Health Department who will
then contact the State Health Department and/or CDC.
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 (with a biohazard label) 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. Bio-Safety
Level 2 should be used for handling specimens.
References
Control of Communicable Diseases Manual; CDC division
of Bacterial and Mycotic Diseases, Family Practice Notebook.com
CDC Website
http://www.cdc.gov/ncidod/dbmd/diseaseinfo/glanders_g.htm
Initially Prepared by
The Akron Regional Hospital
Association
Emergency Preparedness
Subcommittee
August 20, 2002