Anthrax

Learn all the key facts about anthrax, including its causes, different types of
anthrax, signs and symptoms, treatment, and nursing management in this
study guide.

● What is Anthrax?
● Pathophysiology
● Causes
● Types
● Statistics and Incidences
● Clinical Manifestations
● Assessment and Diagnostic Findings
● Medical Management
○ Pharmacologic Management
 ● Nursing Management
○ Nursing Assessment
○ Nursing Diagnosis
○ Nursing Care Planning and Goals
○ Nursing Interventions
○ Evaluation
○ Documentation Guidelines
● Summary
● Practice Quiz: Anthrax
● References

What is Anthrax?
Anthrax is an acute infectious disease caused by a spore-forming gram-
positive, rod-shaped bacteria known as Bacillus anthracis. Anthrax is a rare
and fatal zoonotic disease (animal to human transmission) that can be found
naturally in soil and usually affects wild and domestic animals around the
world.

● The term anthrakis means coal in Greek, and the disease is

named after the black appearance of its cutaneous form.
● Contact with anthrax can cause severe illness in both humans
and animals.

Pathophysiology
Anthrax is primarily a disease of herbivores (eg, cattle, sheep, goats, horses).

● Bacillus anthracis is a large, spore-forming, gram-positive rod.

● Persistence of spores is aided by nitrogen and organic soil
content, environmental pH greater than 6, and ambient
temperature greater than 15°C.
 ● Spores can exist indefinitely in the environment; optimal growth
conditions result in a vegetative phase and bacterial
multiplication.
● Drought or rainfall can trigger anthrax spore germination, while
flies and vultures spread the spores.
● Anthrax toxins are composed of 3 entities: a protective antigen, a
lethal factor, and an edema factor.
● The protective antigen is an 83-kd protein that binds to cell
receptors within a target tissue.
● The binding of edema factor at this site results in the formation of
edema toxin; the binding of lethal factor results in the formation
of lethal toxin.
● Humans are relatively resistant to cutaneous invasion by B
anthracis, but the organisms may gain access through
microscopic or gross breaks in the skin.
● The organisms multiply locally and may spread to the
bloodstream or other organs (eg, spleen) via the efferent
lymphatics.
● Primary intestinal anthrax predominantly affects the cecum and
produces a local lesion similar to the lesion produced in the
cutaneous form.
● Inhaled spores are ingested by pulmonary macrophages and
then carried to hilar and mediastinal lymph nodes.
● Anthrax in the lungs does not cause pneumonia, but it does
cause hemorrhagic mediastinitis and pulmonary edema.

Causes
Anthrax is caused by Bacillus anthracis, a gram-positive bacillus.

● Working with infected animals or animal products. Most

people who get sick from anthrax are exposed while working with
infected animals or animal products such as wool, hides, or hair.
● Eating raw or undercooked meat from infected animals.
People who eat raw or undercooked meat from infected animals
may get infected with gastrointestinal anthrax; this usually occurs
in countries where livestock are not routinely vaccinated against
anthrax and food animals are not inspected prior to slaughter.
● Injecting heroin. A newly discovered type of anthrax is injection
anthrax; this type of anthrax has been seen in northern Europe in
people injecting heroin.
Types
The type of illness a person develops depends on how anthrax enters the
body; typically, anthrax gets into the body through the skin, lungs, or
gastrointestinal system.

● Cutaneous anthrax. Cutaneous anthrax is the most common

form of anthrax infection, and it is also considered to be the least
dangerous; cutaneous anthrax is most common on the head,
neck, forearms, and hands; infection usually develops from 1 to 7
days after exposure.
● Inhalation anthrax. Inhalation anthrax is considered to be the
most deadly form of anthrax; infection usually develops within a
week after exposure, but it can take up to 2 months; without
treatment, only about 10-15% of patients with inhalation anthrax
survive.
● Gastrointestinal anthrax. Gastrointestinal anthrax has rarely
been reported in the United States; infection usually develops
from 1 to 7 days after exposure; once ingested, anthrax spores
can affect the upper gastrointestinal tract, stomach, and
intestines.
● Injection anthrax. Injection anthrax can spread throughout the
body faster and be harder to recognize and treat; symptoms may
be similar to those of cutaneous anthrax, but there may be
infection deep under the skin or in the muscle where the drug
was injected.

Statistics and Incidences

Natural incidence is rare, but infection is an occupational hazard among
veterinarians, farmers, and individuals who handle animal wool, hair, hides, or
bone meal products.

● From 1955–1994, US cases totaled 235, with 224 cases of

cutaneous anthrax, 11 cases of inhalational anthrax, and 20
fatalities.
● In October 2001, 22 confirmed or suspected cases of anthrax
infection were identified.
● Cases were reported from Florida, New York, New Jersey, the
District of Columbia, and Connecticut.
 ● There were 11 confirmed cases of inhalational anthrax (5 deaths)
and 7 confirmed and 4 suspected cases of cutaneous anthrax
(no deaths).
● Anthrax is uncommon in Western Europe, but the disease is not
uncommon in the Middle East, the Indian subcontinent, Africa,
Asia, and Latin America.
● Anthrax is endemic in Africa and Asia despite vaccination
programs.

Clinical Manifestations
The symptoms of anthrax depend on the type of infection and can take
anywhere from 1 day to more than 2 months to appear.

● Cutaneous symptoms. A group of small blisters or bumps that

may itch, swelling that occurs around the sore, and a painless
skin sore or ulcer with a black center that appears after the small
blisters or bumps.
● Inhalation symptoms. Inhalation anthrax symptoms can include
fever and chills, chest discomfort, shortness of breath, confusion
or dizziness, cough, nausea and vomiting or stomach pains,
headache, sweats, extreme tiredness, and body aches.
● Gastrointestinal symptoms. Gastrointestinal symptoms include
painful swallowing, hoarseness, nausea and bloody vomiting,
diarrhea, stomach pain, and swelling of abdomen.
● Injection symptoms. Injection anthrax symptoms include fever
and chills, a small group of blisters or bumps that may itch,
appearing where the drug was injected, a painless skin sore with
a black center, swelling around the sore, and abscesses deep
under the skin or in the muscle where the drug was injected.

Assessment and Diagnostic

Findings
Bacillus anthracis is present in high numbers in the ulcer/eschar of cutaneous
anthrax, in bloody pleural fluid in inhalational anthrax, in the cerebrospinal fluid
(CSF) in anthrax meningitis, and in the blood in septicemic anthrax.
 ● Gram stain and blood culture. The preferred diagnostic
procedure for cutaneous anthrax is staining the ulcer exudate
with methylene blue or Giemsa stain; B anthracis readily grows
on blood agar, and staining microbiologically differentiates the
organism from non–B anthracis bacilli.
● Enzyme-linked immunosorbent assay (ELISA). Enzyme-linked
immunosorbent assay (ELISA) serologic diagnosis is also
available; the ELISA for edema and lethal toxins is positive if a
single acute-phase titer is highly elevated or if a fourfold greater
rise in the titer is observed between acute and convalescent
specimens.
● Chest radiography and computed tomography. If inhalational
anthrax is suspected, obtain a chest radiograph or computed
tomography (CT) scan; the appearance on chest radiograph or
CT scan may suggest the diagnosis, especially if other
predisposing disorders that might result in a widening
mediastinum (eg, dissecting aortic aneurysm, bacterial
mediastinitis) are absent.
● Lumbar puncture. If anthrax meningitis is suspected, perform a
lumbar puncture to obtain CSF for stain and culture.
● Histologic findings. The characteristic finding in anthrax is the
presence of the organisms in the capillaries at the infection site;
therefore, if a patient is infected, expect B anthracis in the
capillaries of the skin, intestines, liver, spleen, lungs, or
leptomeninges.

Medical Management
There are several options to treat patients with anthrax; however, patients with
serious cases may require aggressive treatment.

● Treatment for cutaneous anthrax. Patients with isolated

cutaneous anthrax without systemic involvement (ie, without
edema, fever, cough, headache, etc) or complications may be
treated on an outpatient basis with antibiotic monotherapy.
● Prehospital care. Persons who are potentially contaminated
should wash with soap and water, not bleach solutions; clothing
and evidence/materials should be placed in plastic bags (triple); if
the contamination is confirmed, then a 1:10 dilution of household
beach may be used to decontaminate any materials and surfaces
not sufficiently cleaned by soap and water.
 ● Emergency department care. The emergency department
workup includes rapid initiation of intravenous antibiotic therapy;
patients can be admitted to a normal hospital room with barrier
nursing procedures (ie, gown, gloves, mask) and secretion
precautions (ie, special handing of potentially infectious
dressings, drainage, and excretions).
● Consultations. Anthrax is a reportable disease; notify local
health care authorities and the Centers for Disease Control and
Prevention of suspected cases; in addition, consultation with an
infectious disease specialist may be warranted, although
treatment of patients in whom anthrax is suspected is
straightforward.
● Deterrence and prevention. For PEP in adults, the CDC
recommends vaccination and the use of oral fluoroquinolones
(ciprofloxacin, 500 mg bid; levofloxacin, 500 mg qd; or ofloxacin,
400 mg bid); a vaccine exists but is not readily available;
preexposure vaccination is recommended only for populations at
high risk of exposure to aerosolized B anthracis spores,
according to the CDC’s Advisory Committee on Immunization
Practices (ACIP).

Pharmacologic Management

Pharmacologic treatment of Anthrax include:

● Other antibiotics. Empirical antimicrobial therapy must be

comprehensive and should cover all likely pathogens in the
context of the clinical setting.
● Corticosteroids. These agents are used for severe edema,
meningitis, or swelling in the head and neck region.
● Other antidotes. A monoclonal antibody (raxibacumab) and
human anthrax immune globulin have been approved by the FDA
using the animal efficacy rule for inhalational anthrax.
● Vaccines. The FDA approved a standard anthrax vaccine
designated “anthrax vaccine adsorbed” (AVA), which is a sterile
filtrate of cultures of an avirulent strain that elaborates protective
antigen; no human controlled trials are available; it is the first
vaccine approved utilizing the animal rule by the FDA; the
efficacy of this vaccine in inhalation (biowarfare) anthrax is
questionable.
Nursing Management
Nursing management for a patient with anthrax include the following:

Nursing Assessment

Nursing assessment for a patient with anthrax include:

● History. Anthrax is primarily zoonotic; no reports of direct

human-to-human transmission exist in the literature, but
laboratory personnel may contract the disease from specimens;
military personnel and civilians may become exposed in biologic
warfare situations; exposure may be through agriculture or
industry.
● Physical assessment. Physical findings are nonspecific; the
incubation period for all clinical manifestations is 1-6 days
following exposure; the prodrome includes fever, malaise, and
adenopathy.

Nursing Diagnosis
Based on the assessment data, the major nursing diagnosis for anthrax are:

● Ineffective airway clearance related to obstruction of the

airway.
● Ineffective breathing pattern related to a decrease in lung
expansion.
● Impaired swallowing related to mechanical obstruction
(oropharyngeal edema).
● Diarrhea related to increased motility of the GI.
● Impaired tissue integrity related to irritant toxin anthrax
bacteria.
● Hyperthermia related to an increase in metabolic demand.

Nursing Care Planning and Goals

The major nursing care planning goals for a patient with anthrax include:

● Improve patency of airway.

● Improve breathing pattern.
● Improve swallowing.
● Eliminate diarrhea.
● Improve tissue integrity.
● Improve temperature to normal range.

Nursing Interventions

The following are the nursing interventions for patients with anthrax:

● Improve airway patency. Auscultate chest for crackles,

indicating the need for better secretion mobilization; monitor
oxygen saturation and arterial blood gases periodically to
determine oxygenation status and acid-base balance; and
suction frequently and provide chest physiotherapy to clear
airways, prevent atelectasis, and maximize oxygen therapy.
● Improve breathing pattern. Position for maximum chest
expansion and reposition frequently to mobilize secretions; and
provide supplemental oxygen or mechanical ventilation, as
needed.
● Improve swallowing. Corticosteroids are used to decrease the
swelling in the head or neck region.
● Eliminate diarrhea. Cases of gastrointestinal anthrax can be
treated with ciprofloxacin or doxycycline for 60 days.
● Improve tissue integrity. Patients with isolated cutaneous
anthrax without systemic involvement (ie, without edema, fever,
cough, headache, etc) or complications may be treated on an
outpatient basis with antibiotic monotherapy.
● Diminish hyperthermia. Administer analgesics as prescribed.

Evaluation
Nursing goals are met for a patient with anthrax as evidenced by:

● Improved patency of airway.

 ● Improved breathing pattern.
● Improved swallowing.
● Elimination of diarrhea.
● Improved tissue integrity.
● Improved temperature to normal range.

Documentation Guidelines

Documentation in a patient with anthrax include:

● Individual findings, including factors affecting, interactions, nature

of social exchanges, specifics of individual behavior.
● Cultural and religious beliefs, and expectations.
● Plan of care.
● Teaching plan.
● Responses to interventions, teaching, and actions performed.
● Attainment or progress toward the desired outcome.

Summary
Here are some of the most important points about Anthrax:

● Anthrax is a serious infectious disease caused by gram-positive,

rod-shaped bacteria known as Bacillus anthracis.
● There are four types of anthrax: cutaneous, inhalation,
gastrointestinal, and injection anthrax.
● Anthrax is primarily a disease of herbivores (eg, cattle, sheep,
goats, horses).
● Anthrax is NOT contagious.
● The type of illness a person develops depends on how anthrax
enters the body; typically, anthrax gets into the body through the
skin, lungs, or gastrointestinal system.
● Natural incidence is rare, but infection is an occupational hazard
among veterinarians, farmers, and individuals who handle animal
wool, hair, hides, or bone meal products.
● Natural incidence is rare, but infection is an occupational hazard
among veterinarians, farmers, and individuals who handle animal
wool, hair, hides, or bone meal products.
 ● Bacillus anthracis is present in high numbers in the ulcer/eschar
of cutaneous anthrax, in bloody pleural fluid in inhalational
anthrax, in the cerebrospinal fluid (CSF) in anthrax meningitis,
and in the blood in septicemic anthrax.
● Patients with isolated cutaneous anthrax without systemic
involvement (ie, without edema, fever, cough, headache, etc) or
complications may be treated on an outpatient basis with
antibiotic monotherapy.
● The emergency department workup includes rapid initiation of
intravenous antibiotic therapy; patients can be admitted to a
normal hospital room with barrier nursing procedures (ie, gown,
gloves, mask) and secretion precautions (ie, special handing of
potentially infectious dressings, drainage, and excretions).

Practice Quiz: Anthrax

Nursing practice questions for Anthrax. For more practice questions, visit our
NCLEX practice questions page.

1. A client who states that he may have been contaminated by anthrax

arrives at the ED. The following actions are part of the ED protocol for
possible anthrax exposure or infection. Which action will you take first?

A. Escort the client to a decontamination room.

B. Assess the client for signs of infection.

C. Notify hospital security personnel about the client.

D. Administer ciprofloxacin (Cipro) 250 mg PO.

1. Answer: A. Escort the client to a decontamination room.

• Option A: To prevent contamination of staff or other clients by anthrax,
decontamination of the client by removal and disposal of clothing and
showering is the initial action in possible anthrax exposure.

• Option B: Assessment of the client for signs of infection should be before

decontamination.

• Option C: Notification of security personnel is necessary in the case of

possible bioterrorism, but this should occur before decontaminating and caring
for the client.

• Option D: According to the CDC guidelines, antibiotics should be

administered only if there are signs of infection or the contaminating
substance tests positive for anthrax.

2. A community health nurse is conducting a teaching session about

terrorism with members of the community and discussing information
regarding anthrax. The nurse tells those attending that anthrax can be
transmitted via which route(s)? Select all that apply.

A. Skin

B. Kissing

C. Inhalation

D. Gastrointestinal

E. Direct contact with an infected individual

F. Sexual contact with an infected individual

2. Answers: A, C, and D.

• Options A, C, D: Anthrax is caused by Bacillus anthracis, and it can be

contracted through the digestive system, abrasions in the skin, or inhalation. It
cannot be spread from person to person.
3. In the work setting, what is the primary responsibility of the nurse in
preparation for disaster management, that includes natural disasters
and bioterrorism incidents?

A. Being aware of the signs and symptoms of potential agents of bioterrorism.

B. Making ethical decisions regarding exposing self to potentially lethal

substances.

C. Being aware of the agency’s emergency response plan.

D. Being aware of what and how to report to the Centers for Disease Control
and Prevention.

3. Answer: C. Being aware of the agency’s emergency response plan.

• Option C: In disaster preparedness, the nurse should know the emergency

response plan. This gives guidance that includes the roles of the team
members, responsibilities, and mechanism of reporting.

4. A group of passengers enters the ED with complaints of cough,

tightness in the throat, and extreme periorbital swelling. There is a
strong odor exuding from their clothes. They report exposure to a “gas
bomb” that was placed in the bus terminal. What is the priority action?

A. Readily transfer clients and visitors from the area.

B. Check vital signs and auscultate lung sounds.

C. Assist clients in the decontamination area.

D. Direct clients to the cold or clean zone for immediate treatment.

4. Answer: C. Assist clients in the decontamination area.

• Option C: Prioritization. Decontamination in a specified area is the priority.4.

• Options A and B: Doing assessments and transferring others delay

decontamination and do not protect the total environment. Donning personal
protective equipment and measures is vital before assisting with
decontamination or assessing the clients.

• Option D: The clients must undergo decontamination before entering cold or

clean zones.

5. Which of the following is the FIRST priority in preventing infections

when providing care for a client?

A. Handwashing.

B. Wearing gloves.

C. Using a barrier between the client’s furniture and nurse’s bag.

D. Wearing gowns and goggles.

5. Answer: A. Handwashing.

• Option A: Handwashing remains the most effective way to avoid spreading

infection. However, too often nurses do not practice good handwashing
techniques and do not teach families to do so. Nurses need to wash their
hands before and after touching the client and before entering the nursing
bag.

References
Sources and references for this Anthrax study guide include:

• Centers for Disease Control and Prevention. (2017, Jan 31). Anthrax.
Retrieved from https://www.cdc.gov/anthrax/

• Cennimo, D.J.(2018, Sept 13). Anthrax. Retrieved from

https://emedicine.medscape.com/article/212127-overview