Case Study One

NY, a 30-year-old woman, isbrought to the local acutecare center by her roommate.Her roommateexplains that NY hasbeen feeling ill for 4 to 5days. As of this morning,NY appears confused and ishaving difficulty breathing.

According to her roommate, NY's illnessbegan with typical flu symptoms. She complained of fever andchills. Her symptoms worsened, and she experienced soakingsweats, along with nausea and vomiting. She also developeda mild cough. Her roommate did not think anything of NY's illnessuntil this morning, when she noticed that NY was confusedand appeared to be short of breath.

NY has no known significant medical history. She does nottake any medications, and she exercises 5 days per week. Sheis currently employed in the local legislative office building.

Physical examination shows that she is a well-nourishedwoman in respiratory distress. Her vital signs are reported asfollows: blood pressure 110/65, heart rate 140 bpm, respiratoryrate 20. A neurological evaluation shows that she is not orientedto place or time. On her chest exam, she is found to haverales in the right base with diffuse wheezing.

NY's chest x-ray shows mediastinal widening with fullness ofright hilar and peritracheal soft tissue. It also shows right pleuraleffusion and right, middle, and lower lobe infiltrates.

Laboratory results are reported as WBC 10,000/mm³, 85%neutrophils, 5% bands, 7% lymphocytes, and 8% monocytes;sodium 134 meq/L, potassium 5.5 meq/L, chloride100 meq/L, serum creatinine 1.5 mg/dL; arterial pH 7.43,PaCO² 25, PaO² 65. Blood and CSF cultures grew Bacillusanthracis.

The physician has never treated anthrax before and isunsure what antibiotics are approved by the FDA for the treatmentof inhalation anthrax infections. He calls the pharmacy toask what antibiotics to prescribe.

What antibiotics are approved for the treatment of inhalationanthrax?

Dr. Schlesselman is a clinical pharmacist based in Niantic, Conn.

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Although numerous medications are effective in the treatment of anthrax, penicillin, doxycycline, and ciprofloxacin areapproved by the FDA for the treatment of inhalation anthrax infection. Other medications that have been shown to have in vitro activity include rifampin, clindamycin,aminoglycosides, imipenem, vancomycin, chloramphenicol, macrolides, tetracycline, cefazolin, and linezolid. The Working Group on CivilianBiodefense recommends 60 days of antibiotics.

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