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EDITORIALS: C Anthony Hart and Nicholas J Beeching Prophylactic treatment of anthrax with antibiotics BMJ 2001; 323: 1017-1018 [Full text]

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The anthrax issue underlines the need for infection specialists trained at the bedside.

Stephen T Green   (4 November 2001)

Am I missing something?

Chris Butler   (19 November 2001)

The anthrax issue underlines the need for infection specialists trained at the bedside. 4 November 2001
Stephen T Green, Consultant Physician in Infectious Diseases and Tropical Medicine Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Trust, Sheffield S10 2JF. Send response to journal: Re: The anthrax issue underlines the need for infection specialists trained at the bedside.	I suspect that it never entered the minds of most people, whether doctors or not, that biological weapons would ever pose a credible threat in the developed world. Now the US public exhibit unprecedented levels of interest in anthrax (1), and the recent crisis in that country and possibly also in Pakistan (2) have lent an urgency to assessing how well the United Kingdom might respond to such a challenge. There is no doubt that healthcare services need to retain the confidence of the public in their ability to respond to such crises. Hart and Beeching's editorial (3rd November 2001) is therefore timely, and they not only discuss at length how best to manage anthrax once a potential case has been recognised, but they also allude to the clinical presentation of this infectious disease. This latter issue exposes a crucial point at which it can all break down. When it comes to a potential case of anthrax, or for that matter diagnosing any patient who has been afflicted by any of the other pathogens possessing potential as "weapons of war" (and there are many, such as smallpox, tularaemia and plague), being diagnosed appropriately, how are doctors going to recognise such cases for what they are if and when they should encounter them ? After all, if a medical practitioner fails to interpret the symptoms and signs in front of him or her correctly and ask the right questions of the patient and relevant others, then it is more than possible that that patient might as well not have bothered asking for their help in the first place. Furthermore, when it comes to the contagious options, such as the smallpox virus (thankfully, human to human spread of anthrax is not an issue), a chance to limit the spread of such pathogens to other human beings might be lost. The answer lies in the availability of appropriate expertise. At present in the United Kingdom, physicians with "bedside" training and accumulated experience in the recognition and management of Infectious Diseases and Tropical Conditions are relatively few and far between - indeed, they are an especially rarified species outside of teaching centres (and also, for that matter, in some teaching centres and medical schools !). Our microbiology colleagues will depend heavily upon the accurate recognition and assessment of candidate patients by physicians possessing a knowledge base appropriate and adequate to the needs of such a situation, and who will subsequently approach the microbiologist and public health authroties to discuss the case and arrange for the appropriate confirmatory tests to be performed. However, access in many parts of the UK to physicians with an interest and expertise in infection comparable to, say, cardiologists with a special interest in transplantation or neurologists specialising in demyelinating disease, is at present simply not there. Telephone consultations may not be the best way to conduct business. I appreciate that every speciality claims that its consultant numbers are too low and can make a convincing case. However, there is a way forward in the UK. When one looks at the USA and Canada, Infectious Diseases is a large and thriving speciality which combines elements of laboratory microbiology and bedside clinical work. In the UK, there has been a slow movement towards creating a similar sort of doctor, with Specialist Registrar training leading towards a CCST encompassing both Infectious Diseases and Microbiology or Virology (3). The current heightened awareness of the potential for a biological weapon-based Armegeddon (a possibility that might not recede for a very long time, if ever) is yet another compelling reason to add to the others (e.g. ever-increasing international travel, multi-drug resistant tuberculosis, new and re-emerging infectious diseases) for accelerating and reinforcing the trend in the UK towards more doctors trained in the bedside aspects of Infection Diseases. Competing interests: None. References: 1. Leader. How anthrax caninfect and kill. International Herald Tribune. Thursday, 25th October 2001. P.1. 2. Buncombe A. Anthrax found in letter sent to Pakistani paper. Independent. 3rd November, 2001. P. 1. 3. http://www.phls.co.uk/whoweare/Training/
Am I missing something? 19 November 2001
Chris Butler, Associate Professor in Family Medicine McMaster University Medical Centre, 1200 Main Street West, Hamilton, ON, Canada, L8N 3Z5 Send response to journal: Re: Am I missing something?	Hart and Beeching (1) explain why ciprofloxacin should be used with caution, but do not explain why it is chosen in the first place for prophylaxis after possible exposure to bio terrorist anthrax attacks. They do mention that anthrax is sensitive to penicillin. Have any of the anthrax isolates associated with bio terrorism exhibited penicillin resistance? What is the evidence, animal or human, to favor use of newer, expensive broad spectrum antibiotics in this setting? (1) Hart CA, Beeching NJ. Prophylactic treatment of anthrax with antibiotics. BMJ 2001:323:1017-8.