Bioterrorism and Emerging Infections

Bioterrorism and Emerging Infections is a topic covered in the Washington Manual of Medical Therapeutics.

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  • Changing patterns in human behavior and demographics, natural phenomena, and microbial evolution lead to new infections within a population or increased incidence or geographic range of known pathogens (emerging infections) (Table 14-14). Included in this category are several highly fatal and easily produced microorganisms, which have the potential to be used as agents of bioterrorism and produce substantial illness in large populations via an aerosol route of exposure. Most of these diseases are rare, so a high index of suspicion is necessary to identify the first few cases.
  • A bioterrorism-related outbreak should be considered if an unusually large number of patients present simultaneously with a respiratory, gastrointestinal, or febrile rash syndrome; if several otherwise healthy patients present with unusually severe disease; or if an unusual pathogen for the region is isolated.
Table 14-14: Emerging Infectious Diseases
PathogenEpidemiologyClinical Presentation and DiagnosisManagement
ESKAPE pathogens
Enterococcus faecium
Staphylococcus aureus
Klebsiella pneumoniae
Acinetobacter baumannii
Pseudomonas aeruginosa
Enterobacter species
Group of antibiotic-resistant bacteria that are the leading cause of nosocomial infections worldwide.
They are selected by inappropriate antimicrobial use. Most are MDROs via acquired plasmid-mediated resistance (e.g., colistin resistance by the mcr-1 gene).
Multiple clinical presentations, but most commonly cause nosocomial BSI, VAP, IAI, and hardware-associated infections.
Diagnosis is based on cultures with susceptibility testing and/or detection of β-lactamase, carbapenamase, PBP2A, or other mechanism or resistance via molecular or biochemical tests.
Treatment is organism-specific and should be based on antimicrobial susceptibility testing results.
An ID consultation should always be obtained as this has shown to decrease mortality in these infections.1
Candida aurisMultidrug-resistant Candida i.e., hard to identify in the laboratory.
Commonly misidentified as Candida haemulonii.
Health care–associated BSI, wound, and ear infections.
Fungal cultures with susceptibilities allow the diagnosis.
Pending susceptibilities and echinocandin should be used.
Consultation with an ID specialist is highly recommended.
Zoonotic influenza virusesEmergence of influenza A strains previously confined to avian/swine host via antigenic shifts, with the potential to cause a pandemic.
Acquired via exposure to infected live or dead poultry/pigs (e.g., live animal markets).
Ranges from a mild upper respiratory infection (fever and cough) to a rapid progression to severe pneumonia, ARDS, shock, and even death.
Nasopharyngeal swab for PCR is the most sensitive diagnostic test. If PCR is not available, a rapid antigen detection immunoassay should be done.
A neuraminidase inhibitor (oseltamivir) for a minimum of 5 d is the treatment of choice.
Infection control measures and close communication with public health authorities are critical.
Vaccine-preventable diseasesThe antivaxxer movement has contributed to the rise of preventable infections in countries with established vaccination programs.See “Lower Respiratory Tract Infections” section in this chapter for details about pertussis.
Measles presents with high fever, coryza, cough, conjunctivitis, and small white spots inside the cheeks (Koplik spots). After several days, a descending rash affecting palms and soles appears.
Specific serological and/or PCR testing establish the diagnosis.
Prevention through vaccination per recommended ACIP guidelines is key.
Patients with measles should be placed on respiratory isolation.
Close contacts of patients with Bordetella pertussis should receive antimicrobial prophylaxis with a macrolide.
Viral hemorrhagic fever
Filoviruses (Ebola and Marburg)
Flaviviruses (dengue, yellow fever)
Bunyaviruses (hantaviruses, Congo–Crimean hemorrhagic fever, Rift Valley fever)
Arenaviruses (South American hemorrhagic fever, Lassa fever)
Caused by many different RNA viruses in endemic areas.
Most are transmitted by aerosol or contact with infected body fluids.
Ebola has been shown to also have sexual transmission via semen.
Fever, headache, joint and muscle aches, diarrhea/vomiting, and unexplained bleeding or bruising are common to all of these infections.
Specific serological and/or molecular testing will establish the diagnosis.
There is currently no antiviral drug licensed by the FDA for any of these infections. CYD–TDV (Dengvaxia) vaccine has been approved for use in dengue-endemic territories, only in children of middle-school age, and with previous laboratory evidence of DENV infection. The vaccine is not approved for travelers. WHO endorses the use of the recombinant vesicular stomatitis virus vaccine for the Zaire Ebola virus, if an Ebola outbreak occurs.

ARDS, acute respiratory distress syndrome; BSI, bloodstream infection; FDA, Food and Drug Administration; IAI, intra-abdominal infections; ID, Infectious Diseases; MDRO, multidrug-resistant organism; PBP2A, penicillin-binding protein 2A; PCR, polymerase chain reaction; VAP, ventilator-associated pneumonia; WHO, World Health Organization.

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  • Changing patterns in human behavior and demographics, natural phenomena, and microbial evolution lead to new infections within a population or increased incidence or geographic range of known pathogens (emerging infections) (Table 14-14). Included in this category are several highly fatal and easily produced microorganisms, which have the potential to be used as agents of bioterrorism and produce substantial illness in large populations via an aerosol route of exposure. Most of these diseases are rare, so a high index of suspicion is necessary to identify the first few cases.
  • A bioterrorism-related outbreak should be considered if an unusually large number of patients present simultaneously with a respiratory, gastrointestinal, or febrile rash syndrome; if several otherwise healthy patients present with unusually severe disease; or if an unusual pathogen for the region is isolated.
Table 14-14: Emerging Infectious Diseases
PathogenEpidemiologyClinical Presentation and DiagnosisManagement
ESKAPE pathogens
Enterococcus faecium
Staphylococcus aureus
Klebsiella pneumoniae
Acinetobacter baumannii
Pseudomonas aeruginosa
Enterobacter species
Group of antibiotic-resistant bacteria that are the leading cause of nosocomial infections worldwide.
They are selected by inappropriate antimicrobial use. Most are MDROs via acquired plasmid-mediated resistance (e.g., colistin resistance by the mcr-1 gene).
Multiple clinical presentations, but most commonly cause nosocomial BSI, VAP, IAI, and hardware-associated infections.
Diagnosis is based on cultures with susceptibility testing and/or detection of β-lactamase, carbapenamase, PBP2A, or other mechanism or resistance via molecular or biochemical tests.
Treatment is organism-specific and should be based on antimicrobial susceptibility testing results.
An ID consultation should always be obtained as this has shown to decrease mortality in these infections.1
Candida aurisMultidrug-resistant Candida i.e., hard to identify in the laboratory.
Commonly misidentified as Candida haemulonii.
Health care–associated BSI, wound, and ear infections.
Fungal cultures with susceptibilities allow the diagnosis.
Pending susceptibilities and echinocandin should be used.
Consultation with an ID specialist is highly recommended.
Zoonotic influenza virusesEmergence of influenza A strains previously confined to avian/swine host via antigenic shifts, with the potential to cause a pandemic.
Acquired via exposure to infected live or dead poultry/pigs (e.g., live animal markets).
Ranges from a mild upper respiratory infection (fever and cough) to a rapid progression to severe pneumonia, ARDS, shock, and even death.
Nasopharyngeal swab for PCR is the most sensitive diagnostic test. If PCR is not available, a rapid antigen detection immunoassay should be done.
A neuraminidase inhibitor (oseltamivir) for a minimum of 5 d is the treatment of choice.
Infection control measures and close communication with public health authorities are critical.
Vaccine-preventable diseasesThe antivaxxer movement has contributed to the rise of preventable infections in countries with established vaccination programs.See “Lower Respiratory Tract Infections” section in this chapter for details about pertussis.
Measles presents with high fever, coryza, cough, conjunctivitis, and small white spots inside the cheeks (Koplik spots). After several days, a descending rash affecting palms and soles appears.
Specific serological and/or PCR testing establish the diagnosis.
Prevention through vaccination per recommended ACIP guidelines is key.
Patients with measles should be placed on respiratory isolation.
Close contacts of patients with Bordetella pertussis should receive antimicrobial prophylaxis with a macrolide.
Viral hemorrhagic fever
Filoviruses (Ebola and Marburg)
Flaviviruses (dengue, yellow fever)
Bunyaviruses (hantaviruses, Congo–Crimean hemorrhagic fever, Rift Valley fever)
Arenaviruses (South American hemorrhagic fever, Lassa fever)
Caused by many different RNA viruses in endemic areas.
Most are transmitted by aerosol or contact with infected body fluids.
Ebola has been shown to also have sexual transmission via semen.
Fever, headache, joint and muscle aches, diarrhea/vomiting, and unexplained bleeding or bruising are common to all of these infections.
Specific serological and/or molecular testing will establish the diagnosis.
There is currently no antiviral drug licensed by the FDA for any of these infections. CYD–TDV (Dengvaxia) vaccine has been approved for use in dengue-endemic territories, only in children of middle-school age, and with previous laboratory evidence of DENV infection. The vaccine is not approved for travelers. WHO endorses the use of the recombinant vesicular stomatitis virus vaccine for the Zaire Ebola virus, if an Ebola outbreak occurs.

ARDS, acute respiratory distress syndrome; BSI, bloodstream infection; FDA, Food and Drug Administration; IAI, intra-abdominal infections; ID, Infectious Diseases; MDRO, multidrug-resistant organism; PBP2A, penicillin-binding protein 2A; PCR, polymerase chain reaction; VAP, ventilator-associated pneumonia; WHO, World Health Organization.

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