Master in Medicina NBC - 2010
Tularemia polmonare
Pasquale Urbano
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
F. Urbano per il Master in Medicina NBC – 2010
Outbrea
k
Taglio dei prati e dei cespugli
identificati
come fattori
di rischio, in
Grosso
allarme
zona endozootica
F. Urbano per il Master in Medicina NBC – 2010
F. Urbano per il Master in Medicina NBC – 2010
F. Urbano per il Master in Medicina NBC – 2010
Batterioscopia
F. Urbano per il Master in Medicina NBC – 2010
Isolamento
•Richiede BSL 3
•Infezioni di
laboratorio
F. Urbano per il Master in Medicina NBC – 2010
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
F. Urbano per il Master in Medicina NBC – 2010
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
F. Urbano per il Master in Medicina NBC – 2010
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.
F. Urbano per il Master in Medicina NBC – 2010
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
F. Urbano per il Master in Medicina NBC – 2010
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
F. Urbano per il Master in Medicina NBC – 2010
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
F. Urbano per il Master in Medicina NBC – 2010
Working Group Consensus
Mass 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
F. Urbano per il Master in Medicina NBC – 2010
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
F. Urbano per il Master in Medicina NBC – 2010
Master in Medicina NBC - 2010
Grazie dell’attenzione
Domande?