Guidance for patients with suspected plague (Yersinia pestis infection): RHC ED

Bubonic plague

• Sudden onset of fever, headache, chills, and weakness and one or more swollen, tender, and painful lymph nodes (buboes).
• Buboes are typically non-fluctuant and may be associated with erythema and oedema of the surrounding skin. The inguinal lymph nodes are most commonly affected, but buboes may be found elsewhere e.g. axillary or cervical regions

Pneumonic plague

• Patients develop fever, headache, weakness, and a rapidly developing pneumonia with shortness of breath, chest pain, and cough.
• Sputum may be watery or purulent and is often blood stained. Pulmonary haemorrhage may occur.

Septicaemic plague

• Patients develop fever, chills, extreme weakness, gastrointestinal disturbance (abdominal pain, nausea, vomiting, diarrhoea), and shock. There may be bleeding into the skin (purpuric lesions) and other organs. Peripheral gangrene, multi-organ dysfunction and disseminated intravascular coagulation may develop later in the course of illness.

Meningeal plague

• Meningeal plague is uncommon. It may occur in conjunction with other forms of plague, or it may occur as a primary manifestation of infection. Symptoms and signs are similar to those seen in meningitis caused by other, more common bacteria.

Pharyngeal plague

• Pharyngeal plague presents as pharyngitis and/or tonsillitis, with associated anterior cervical lymphadenitis. It is rare and may occur as a primary phenomenon or in conjunction with other forms of plague.

Atypical presentations

• Atypical and non-specific presentations of plague have been described, including patients who have presented with influenza-like illness or non-specific febrile illnesses, and patients who presented with symptoms and signs suggestive or urinary tract infection, gastrointestinal infection, and upper respiratory tract infection.

• Personal protective equipment (PPE), including respiratory protective equipment (RPE) should be used for the assessment of possible plague cases and treatment of confirmed cases.
• It should be worn at all times when in the isolation room.
• This comprises:
  • FFP3 respirator (EN149:2001), fit tested to the wearer
  • Single-use fluid-repellent gown
  • Single-use gloves
  • Eye protection e.g. goggles or full face visor, preferably single-use

• Reception staff to ask patients if they have been to Madagascar in the past 8 days
• If there is a positive travel history Madagascar in that time frame, reception staff to ask patient to wait in the breast feeding room across from the reception desk for the triage nurse.
• Reception staff to inform triage nurse and ED nurse coordinator immediately.
• Reception staff to take screen shot identifying list of patients in the ED waiting room and in triage queue.
• Breast feeding room to be source cleaned.

• Triage nurse to go to the breast feeding room to confirm that child has a travel history to Madagascar and has been unwell in keeping with symptoms above.
• Give the patient and relative/s a FFP3 face mask and take patient/s directly through to CDU Room 17/18 to gather further information.
• Information gathering should not be done in the breast feeding room or in triage to minimize contamination of rooms and to allow more time to gather the information in a safe and private room.
• If child appears unwell, take the child straight through to the resuscitation room.
• Triage nurse to wear appropriate PPE (FFP3/Goggles/gloves/theatre gown) to assess child.

• Initial medical assessment should be done by an ED doctor and ED nurse.
• Medical staff assessing patient wears appropriate PPE and carries a radio walkie talkie when assessing patient to allow communication with staff outside the room.
• Those in PPE should be in communication with a member of staff outside at all times.
• Medical staff to contact Infectious Diseases (ID) and Infection Control (IC) team as soon as possible for advice.
• If the child is unwell, move the child through to the resuscitation room.
• If the child requires admission, the ED doctor will refer the patient to the CDU doctor for further management.
• Initial samples for testing – Contact virology lab for baseline sample testing.

• Close each door after patient goes through into room 17/18.
• Supplies/equipment are available in store room in CDU (right side across from reception desk) including:
  • Supplies of FFP3 respirators
  • Gloves - disposable and latex-free alternatives, e.g. nitrile
  • Gowns/Aprons - disposable fluid-resistant full-sleeve gowns and single-use plastic aprons
  • Eye protection e.g. tight-fitting goggles or face shield - disposable, or if non-disposable, with a wipe able surface - not with elastic straps
  • Leak-proof, clinical waste disposal bags and yellow waste bin
  • Hand hygiene supplies
  • General-purpose detergent and disinfectant solutions
• Move supply/equipment trolley from store room into the negative pressure room (Between the inner and outer door)
• 2 large yellow waste bins are required - One should be placed in the negative pressure room (inside room through both doors) and another between inner and outer doors for contaminated PPE.
• De-robing should take place between inner and outer doors of negative pressure room and contaminated PPE should be placed in the yellow waste bin.
• Medical equipment – Dedicated stethoscope and other medical equipment should be cleaned and left in the de-robing area.

• Parents of patients should be advised of the risk to them and if well should be given PPE.
• Unwell adult/parent should be assessed for symptoms and remain in CDU pressure room. (Adult ED have no negative pressure rooms)
• ED doctor to contact Adult ED to discuss management of unwell adult.

After discussion with infectious diseases consultant

Treatment

• Gentamicin 5mg/kg intravenously once a day
  OR
  
• Doxycycline 100mg orally twice daily (NB: >12 yrs and >45kg)
  OR
  
• Ciprofloxacin 10mg/kg intravenously twice daily (maximum 400mg - not to exceed 800mg per day) or for milder cases only, 15mg/kg orally twice daily (not to exceed 1g per day)
  OR
  
• If meningeal plague suspected: Chloramphenicol 25mg/kg (maximum 500mg) orally or intravenously four times daily

Antibiotic prophylaxis

• Ciprofloxacin 15mg/kg orally twice daily -not to exceed 1g per day
  OR
• Persons who have experienced other high-risk exposures such as bites from fleas in an epidemic area or direct and unprotected contact with bodily fluids or tissues of infected animal or humans prophylaxis for 7 days
• Persons who have had close (<2 meters) and unprotected contact with pneumonic plague cases
• Ciprofloxacin twice daily doses by age:
  • newborn - 6 months 100mg/day
  • 1 year - less than 3 years 200mg/day
  • 3 years – less than 5 years 300mg/day
  • 5 years - less than 7 years 400mg/day
  • 7 years - less than 12 years 500mg/day
  • 12 years and over (adult dose) 1000mg/day
    
    OR
    
    
• Doxycycline (only if no alternative options)>12years of age and >45kg: 100mg orally twice daily