Tularemia polmonare

1. Tularemia polmonare Pasquale Urbano

2. Tularemia • Incubazione: 2-10 gg • Prodromi: • Febbre, cefalea, brividi, mialgie, tosse, nausea, vomito, diarrea • Può presentarsi come polmonite • Diagnosi • Laboratorio: Coltura/Batterioscopia (Gram) da sangue, escreato, linfonodo • La coltura è esigente, e comporta rischi di Tularemia per il personale di laboratorio

3. Outbreak Taglio dei prati e dei cespugli identificati come fattori di rischio, in zona endozootica Grosso allarme

6. Batterioscopia

7. Isolamento • Richiede BSL 3 • Infezioni di laboratorio

8. Cautela! • When F. tularensis is presumptively identified in a routine BSL-2 clinical laboratory (level A), specimens should be forwarded to a BSL-3 laboratory (level B) (eg, a state public health laboratory) for confirmation of agent and other studies, such as antimicrobial susceptibility testing Vedi: incidente di laboratorio

9. Tularemia polmonare Isolamento Standard; non contagiosa Non trasmissione interumana Trattamento Streptomicina, gentamicina, o doxiciclina Se esposti: osservazione per 7 gg,; trattare se viene la febbre Vaccino: sperimentale Letalità 30% senza trattamento; < 10% nei trattati

10. Vaccino per tularemia F. tularensis is designated as a category A bioterrorism agent. At present, no licensed tularemia vaccine is available in the USA. However, the LVS vaccine (live vaccine strain) is available to military personnel under an investigational new drug protocol held by the US Army Medical Research Institute of Infectious Diseases (4). It is administered via scarification using multiple punctures of a bifurcated needle. LVS is derived from strain 15 developed in the former USSR and was obtained by the US military in 1956 (5). It is not well-standardized and contains 2 phenotypes of F. tularensis, only one of which seems to be immunogenic (6). However, in studies published in 1977, the vaccine was shown to significantly reduce the incidence of typhoidal tularemia in US government laboratory workers from 5.7 to 0.27 cases per at-risk employee years (7). It did not reduce the incidence of the ulceroglandular form, but the disease in vaccinees was reported to be milder. I am not aware whether the vaccine is effective if given postexposure.

11. Working Group Consensus Contained Casualty Recommended Therapy • Adults • Preferred choices • Streptomycin, 1 g IM twice daily • Gentamicin, 5 mg/kg IM or IV once daily • Alternative choices • Doxycycline, 100 mg IV twice daily • Chloramphenicol, 15 mg/kg IV 4 times daily • Ciprofloxacin, 400 mg IV twice daily

12. Working Group Consensus Contained Casualty Recommended Therapy • Children • Preferred choices • Streptomycin, 15 mg/kg IM twice daily (should not exceed 2 g/d) • Gentamicin, 2.5 mg/kg IM or IV 3 times daily • Alternative choices • Doxycycline; if weight >45 kg, 100 mg IV twice daily; if weight <45 kg, give 2.2 mg/kg IV twice daily • Chloramphenicol, 15 mg/kg IV 4 times daily • Ciprofloxacin, 15 mg/kg IV twice daily

13. Working Group Consensus Contained Casualty Recommended Therapy • Pregnant Women • Preferred choices • Gentamicin, 5 mg/kg IM or IV once daily • Streptomycin, 1 g IM twice daily • Alternative choices • Doxycycline, 100 mg IV twice daily • Ciprofloxacin, 400 mg IV twice daily

14. Working Group ConsensusMass Casualty Recommended Therapy Adults • Preferred choices • Doxycycline, 100 mg orally twice daily • Ciprofloxacin, 500 mg orally twice daily • Children • Preferred choices • Doxycycline; if <45 kg, give 100 mg orally twice daily; if >45 kg, give 2.2 mg/kg orally twice daily • Ciprofloxacin, 15 mg/kg orally twice daily • Pregnant Women • Preferred choices • Ciprofloxacin, 500 mg orally twice daily • Doxycycline, 100 mg orally twice daily

15. Incognite Non essendo da escludere che per usi aggressivi siano impiegati ceppi manipolati geneticamente, magari resistenti ai comuni antibiotici, è importante ottenere presto gli antibiogrammi, e valutare attentamente la risposta terapeutica, per eventualmente cambiare regime di trattamento

16. Grazie dell’attenzione Domande?