S. F Dept. Public Health – Infectious Disease Emergencies ANTHRAX, July 2008 Page 10/14
Anthrax meningitis can be treated using the inhalational anthrax guidelines; however, IV treatment
with a fluoroquinolone plus 1-2 antimicrobials with good central nervous system (CNS) penetration
ANTHRAX: TREATMENT AND POST-EXPOSURE PROPHYLAXIS RECOMMENDATIONS
A
I
NITIAL IV THERAPY
B,C
FOR
INHALATIONAL, GI ANTHRAX, OR
CUTANEOUS ANTHRAX WITH
COMPLICATIONS
D
I
NITIAL THERAPY FOR CUTANEOUS
ANTHRAX
B,D
T
HERAPY FOR ANTHRAX IN THE MASS
CASUALTY SETTING, OR POSTEXPOSURE
PROPHYLAXIS, OR AFTER CLINICAL
IMPROVEMENT ON IV THERAPY
E,F
Adult
Ciprofloxacin, 400 mg IV q12 hr or
Doxycycline
G
, 100 mg IV q12 hr
AND
One or two additional antimicrobials
(agents with in vitro activity include
rifampin, vancomycin, penicillin, ampicillin,
chloramphenicol, imipenem, clindamycin,
and clarithromycin)
H
Ciprofloxacin, 500 mg orally q12 hrs
for 60 days or
Doxycycline, 100 mg orally q12 hrs for
60 days
Ciprofloxacin
I
, 500 mg orally twice
daily for 60 days or
Doxycycline
J
, 100 mg orally twice daily
for 60 days
Children
Ciprofloxacin
K,L
, 10 mg/kg IV q12 hrs
(max 400 g/dose) or
Doxycycline:
G,L,M
>
45 kg, 100 mg IV q12 hr
<45 kg, give 2.2 mg/kg IV q12 hrs
(max 200 mg/day)
AND
One or two additional antimicrobials
(agents with in vitro activity include
rifampin, vancomycin, penicillin, ampicillin,
chloramphenicol, imipenem, clindamycin,
and clarithromycin)
H
Ciprofloxacin, 15 mg/kg orally q12 hrs
(max 500 mg/dose) for 60 days or
Doxycycline:
G,L,M
>45 kg, give 100 mg orally q12 hrs
for 60 days
<45 kg, give 2.2 mg/kg orally q12 hrs
(max 200 mg/day) for 60 days
Ciprofloxacin
I
, 15 mg/kg orally twice
daily (max 500 mg/dose) for 60 days or
Doxycycline
J
:
>
45 kg, give 100 mg orally twice daily
for 60 days
<45 kg, give 2.2 mg/kg orally twice
daily (max 200 mg/day) for 60 days
or
Amoxicillin
N
>20 kg: 500 mg orally three times
daily for 60 days
<20 kg: 80 mg/kg/day orally in
three divided doses every 8 hrs for
60 days
Pregnant
women
Same as for non-pregnant adults
O
Same as for non-pregnant adults
O
Same as for non-pregnant adults or
Amoxicillin
N
500 mg orally three times
daily for 60 days
Immuno-
compromised
Persons
Same as for non-immunocompromised
persons and children
Same as for non-immunocompromised
persons and children
Same as for non-immunocompromised
persons and children
A
The treatment recommendations included in this table are adapted from guidance developed during the 2001 anthrax outbreaks. Therapy
recommendations in other situations should be guided by antimicrobial susceptibility results.
1, 2, 6, 17
B
Ciprofloxacin or doxycycline should be considered an essential part of first-line therapy for inhalational anthrax.
C
Steroids may be considered an adjunct therapy for patients with severe edema and for meningitis based on experience with bacterial meningitis of
other etiologies.
D
Cutaneous anthrax cases with signs of systemic involvement, extensive edema, or lesions on the head or neck require intravenous therapy, and a
multidrug approach is recommended.
E
Initial therapy may be altered based on clinical course of patient; one or two antimicrobial agents (eg, ciprofloxacin or doxycycline) may be adequate as
patient improves.
F
If pharmaceutical resources permit in a mass casualty setting, therapy with at least two agents is recommended over monotherapy.
G
If meningitis is suspected, doxycycline may be less optimal because of poor central nervous system penetration.
H
Because of concerns of constitutive and inducible beta-lactamases in Bacillus anthracis isolates, penicillin and ampicillin should not be used alone.
Consultation with an infectious disease specialist is advised.
I
In vitro studies suggest that ofloxacin (400 mg orally every 12 hours) or levafloxacin, (500 mg orally every 24 hours) could be used in place of
ciprofloxacin – if supplies were limited in a mass casualty or post-exposure prophylaxis situation. FDA has approved levafloxacin for PEP in adults and
children.
J
In vitro studies suggest that 500 mg of tetracycline orally every 6 hours could be used in place of doxycycline – if supplies were limited in a mass
casualty or post-exposure prophylaxis situation.
K
If intravenous ciprofloxacin is not available, oral ciprofloxacin may be acceptable because it is rapidly and well absorbed from the gastrointestinal tract
with no substantial loss by first-pass metabolism. Maximum serum concentrations are attained 1-2 hours after oral dosing but may not be achieved if
vomiting or ileus is present.
L
Tetracycline and quinolone antibiotics are generally not recommended during pregnancy or childhood; however their use may be indicated for life-
threatening illness. Ciprofloxacin may be preferred in pregnant women and children up to 8 years of age because of the known adverse event profile of
doxycycline (e.g., tooth discoloration). Doxycycline may be preferred in children 8 years and older because of the adverse event profile of ciprofloxacin
(e.g., arthropathies).
M
American Academy of Pediatrics recommends treatment of young children with tetracyclines for serious infections (eg, Rocky Mountain spotted fever).
N
Amoxicillin is not approved by the FDA for post-exposure prophylaxis or treatment of anthrax. However, CDC has indicated that if the isolate is
determined to be susceptible to amoxicillin, it could be used for pregnant women and children for post-exposure prophylaxis or for completion of 60 days
antibiotic therapy after initial treatment with ciprofloxacin or doxycycline. Amoxicillin resistance to anthrax is of greater concern than that of doxycycline
or ciprofloxacin, and amoxicillin is not recommended as a first-line agent unless the isolate is proven to be susceptible.
O
Although tetracyclines are not recommended for pregnant women, their use may be indicated for life-threatening illness. Adverse effects on developing
teeth and bones are dose-related; therefore, doxycycline might be used for a short time (7-14 days) before 6 months of gestation.
