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Anthracis

  • Bacillus anthracis treatment
  • 1. Treatment for cutaneous anthrax, without systemic involvement[1]
  • Preferred regimen (regardless of penicillin susceptibility or if susceptibility is unknown) (1): Ciprofloxacin 500 mg PO bid for 7-10 days
  • Preferred regimen (regardless of penicillin susceptibility or if susceptibility is unknown) (2): Doxycycline 100 mg PO bid for 7-10 days
  • Preferred regimen (regardless of penicillin susceptibility or if susceptibility is unknown) (3): Levofloxacin 750 mg PO qd for 7-10 days
  • Preferred regimen (regardless of penicillin susceptibility or if susceptibility is unknown) (4): Moxifloxacin 400 mg PO qd for 7-10 days
  • Alternative regimen (1): Clindamycin 600 mg PO tid for 7-10 days
  • Alternative regimen (2): Amoxicillin 1 g PO tid (for penicillin-susceptible strains) for 7-10 days
  • Alternative regimen (3): Penicillin VK 500 mg PO qid (for penicillin-susceptible strains) for 7-10 days
  • Note: Duration of treatment is 60 days for bioterrorism-related cases and 7-10 days for naturally acquired cases.
  • 2. Treatment for systemic anthrax including anthrax meningitis, inhalational anthrax, injectional anthrax, and gastrointestinal anthrax; and cutaneous anthrax with systemic involvement, extensive edema, or lesions of the head or neck[1]
  • 2.1 Systemic anthrax with possible/confirmed meningitis
  • 2.1.1 Bactericidal agent (fluoroquinolone)
  • Preferred regimen (2): Levofloxacin 750 mg IV q24h for 2-3 weeks
  • Preferred regimen (3): Moxifloxacin 400 mg IV q24h for 2-3 weeks AND
  • 2.1.2 Bactericidal agent (ß-lactam) for all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • Preferred regimen (1): Meropenem 2 g IV q8h for 2-3 weeks
  • Preferred regimen (2): Imipenem 1 g IV q6h for 2-3 weeks
  • Preferred regimen (3): Doripenem 500 mg IV q8h for 2-3 weeks
  • Preferred regimen (4): Penicillin G 4 MU IV q4h (for penicillin-susceptible strains) for 2-3 weeks
  • Preferred regimen (5): Ampicillin 3 g IV q6h (for penicillin-susceptible strains) for 2-3 weeks AND
  • 2.1.3 Protein synthesis inhibitor
  • Preferred regimen (1): Linezolid 600 mg IV q12h for 2-3 weeks
  • Preferred regimen (2): Clindamycin 900 mg IV q8h for 2-3 weeks
  • Preferred regimen (3): Rifampin 600 mg IV q12h for 2-3 weeks
  • Note (1): Patients exposed to aerosolized spores will require prophylaxis to complete an antimicrobial drug course of 60 days from onset of illness.
  • Note (3): Linezolid should be used with caution in patients with thrombocytopenia because it might exacerbate it. Linezolid use for > 14 days has additional hematopoietic toxicity.
  • Note (4): Rifampin is not a protein synthesis inhibitor. However, it may be used in combination with other antimicrobial drugs on the basis of its in vitro synergy.
  • 2.2 Systemic anthrax when meningitis has been excluded
  • 2.2.1 Bactericidal agent
  • Preferred regimen (2): Levofloxacin 750 mg IV q24h for 2 weeks
  • Preferred regimen (4): Meropenem 2 g IV q8h for 2 weeks
  • Preferred regimen (5): Imipenem 1 g IV q6h for 2 weeks
  • Preferred regimen (6): Doripenem 500 mg IV q8h for 2 weeks
  • Preferred regimen (7): Vancomycin 20 mg/kg IV q8h (maintain serum trough concentrations of 15-20 µg/mL) for 2 weeks
  • Preferred regimen (8): Penicillin G 4 MU IV q4h (penicillin-susceptible strains) for 2 weeks
  • Preferred regimen (9): Ampicillin 3 g IV q6h (penicillin-susceptible strains) for 2 weeks AND
  • 2.2.2 Protein synthesis inhibitor
  • Preferred regimen (1): Clindamycin 900 mg IV q8h for 2 weeks
  • Preferred regimen (2): Linezolid 600 mg IV q12h for 2 weeks
  • Preferred regimen (3): Doxycycline 200 mg IV initially, then 100 mg IV q12h for 2 weeks
  • Preferred regimen (4): Rifampin 600 mg IV q12h for 2 weeks
  • Note: Patients exposed to aerosolized spores will require prophylaxis to complete an antimicrobial drug course of 60 days from onset of illness.
  • 3. Specific considerations
  • 3.1 Treatment of anthrax for pregnant Women
  • 3.1.1 Intravenous antimicrobial treatment for systemic anthrax with possible/confirmed meningitis [2]
  • 3.1.1.1 A Bactericidal Agent (Fluoroquinolone)
  • Preferred regimen (1): Ciprofloxacin 400 mg IV q8h for 2–3 weeks OR
  • Preferred regimen (2): Levofloxacin 750 mg IV q24h for 2–3 weeksOR
  • 3.1.1.2 A Bactericidal Agent (ß-lactam)
  • 3.1.1.2.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • Preferred regimen: Meropenem 2 g q8h for 2–3 weeks
  • 3.1.1.2.2 Alternatives for penicillin-susceptible strains
  • Alternative regimen (1): Ampicillin 3 g IV q6h for 2–3 weeks
  • Alternative regimen (2): Penicillin G 4 MU IV q4h for 2–3 weeks OR
  • 3.1.1.3 A Protein Synthesis Inhibitor
  • Preferred regimen (1): Clindamycin 900 IV mg q8h for 2–3 weeks
  • Preferred regimen (2): Rifampin 600 IV mg q12h for 2–3 weeks
  • Note: At least one antibiotic with transplacental passage is recommended.
  • 3.1.2 Intravenous antimicrobial treatment for systemic anthrax when meningitis has been excluded
  • 3.1.2.1 A Bactericidal Antimicrobial
  • Preferred regimen (2): Levofloxacin 750 mg IV q24h for 2 weeks OR
  • 3.1.2.2 A Bactericidal Agent (ß-lactam)
  • 3.1.2.2.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • Preferred regimen: Meropenem 2 g q8h for 2 weeks OR
  • 3.1.2.2.2 Alternatives for penicillin-susceptible strains
  • Alternative regimen (1): Ampicillin 3 g IV q6h for 2 weeks
  • Alternative regimen (2): Penicillin G 4 MU IV q4h for 2 weeks OR
  • 3.1.2.3 A Protein Synthesis Inhibitor
  • Preferred regimen (1): Clindamycin 900 IV mg q8h for 2 weeks
  • Preferred regimen (2): Rifampin 600 IV mg q12h for 2 weeks
  • 3.1.3 Oral antimicrobial treatment for cutaneous anthrax without systemic involvement
  • 3.1.3.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • Note: Duration of treatment is 60 days
  • 3.2 Treatment for anthrax in childern [3]
  • 3.2.1 Treatment of cutaneous anthrax without systemic involvement (for children 1 month of age and older)
  • 3.2.1.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • Preferred regimen (1): Ciprofloxacin 30 mg/kg/day PO bid (not to exceed 500 mg/dose) for 7-10 days
  • Preferred regimen (2):
  • If patients body weight is < 45 kg: Doxycycline 4.4 mg/kg/day PO bid (not to exceed 100 mg/dose) for 7-10 days
  • If patients body weight is = 45 kg: Doxycycline 100 mg/dose PO bid for 7-10 days
  • Preferred regimen (3): Clindamycin 30 mg/kg/day PO tid (not to exceed 600 mg/dose) for 7-10 days
  • Preferred regimen (4):
  • If patients body weight is < 50 kg: Levofloxacin 16 mg/kg/day PO bid (not to exceed 250 mg/dose) for 7-10 days
  • If patients body weight is > 50 kg: Levofloxacin 500 mg PO qd for 7-10 days
  • 3.2.1.2 Alternatives for penicillin-susceptible strains
  • Alternative regimen (1):Amoxicillin 75 mg/kg/day PO tid (not to exceed 1 g/dose) for 7-10 days
  • Alternative regimen (2): Penicillin VK 50-75 mg/kg/day PO tid or qid for 7-10 days
  • 3.2.2 Combination therapy for systemic anthrax when meningitis can be ruled out (for children 1 month of age and older)
  • 3.2.2.1 A bactericidal antimicrobial
  • 3.2.2.1.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • Preferred regimen (1): Ciprofloxacin 30 mg/kg/day IV divided q8h (not to exceed 400 mg/dose) for 14 days
  • Preferred regimen (2): Meropenem 60 mg/kg/day IV divided q8h (not to exceed 2 g/dose) for 14 days
  • Preferred regimen (3):
  • If patients body weight is < 50 kg: Levofloxacin 20 mg/kg/day IV divided q12h (not to exceed 250 mg/dose) for 14 days
  • If patients body weight is > 50 kg: Levofloxacin 500 mg IV q24h for 14 days
  • Preferred regimen (4): Imipenem/Cilastatin 100 mg/kg/day IV divided q6h (not to exceed 1 g/dose) for 14 days
  • Preferred regimen (5): Vancomycin 60 mg/kg/day IV divided q8h (follow serum concentrations) for 14 days
  • 3.2.2.1.2 Alternatives for penicillin-susceptible strains
  • Alternative regimen (1): Penicillin G 400 000 U/kg/day IV divided q4h (not to exceed 4 MU/dose) for 14 days
  • Alternative regimen (2): Ampicillin 200 mg/kg/day IV divided q6h (not to exceed 3 g/dose) for 14 days AND
  • 3.2.2.2 A Protein Synthesis Inhibitor
  • Preferred regimen (1): Clindamycin, 40 mg/kg/day IV divided q8h (not to exceed 900 mg/dose) for 14 days
  • Preferred regimen (2): (non-CNS infection dose)
  • If patient is < 12 y old: Linezolid 30 mg/kg/day IV divided q8h for 14 days
  • If patient is = 12 y old: Linezolid 30 mg/kg/day IV divided q12h (not to exceed 600 mg/dose) for 14 days
  • Preferred regimen (3):
  • If patients body weight is < 45 kg: Doxycycline 4.4 mg/kg/day IV loading dose (not to exceed 200 mg) THEN Doxycycline 4.4 mg/kg/day IV divided q12h (not to exceed 100 mg/dose) for 14 days
  • If patients body weight is =45 kg: Doxycycline 200 mg IV loading dose THEN Doxycycline 100 mg IV given q12h for 14 days
  • Preferred regimen (4): Rifampin 20 mg/kg/day IV divided q12h (not to exceed 300 mg/dose) for 14 days
  • Note: Duration of therapy for 14 days or longer until clinical criteria for stability are met.Will require prophylaxis to complete an antimicrobial course of up to 60 days from onset of illness.
  • 3.2.3 Triple therapy for systemic anthrax (anthrax meningitis or disseminated infection and meningitis cannot be ruled out) for Children 1 Month of Age and Older
  • 3.2.3.1 A bactericidal antimicrobial (fluoroquinolone)
  • Preferred regimen (1): Ciprofloxacin 30 mg/kg/day IV divided q8h (not to exceed 400 mg/dose) for 2–3 wks
  • Preferred regimen (2):
  • If patients body weight is < 50 kg: Levofloxacin 16 mg/kg/day IV divided q12h (not to exceed 250 mg/dose) for 2–3 wks
  • If patients body weight is > 50 kg: Levofloxacin 500 mg IV q24h for 2–3 wks
  • Preferred regimen (3):
  • If patients age is 3 months to < 2 years: Moxifloxacin 12 mg/kg/day IV, divided q12h (not to exceed 200 mg/dose) for 2–3 wks
  • If patients age is 2-5 years: Moxifloxacin 10 mg/kg/day IV divided q1h (not to exceed 200 mg/dose) for 2–3 wks
  • If patients age is 6–11 years: Moxifloxacin 8 mg/kg/day IV divided q12h (not to exceed 200 mg/dose) for 2–3 wks
  • If patients age is 12–17 years, = 45 kg body weight: Moxifloxacin 400 mg IV q24h for 2–3 wks
  • If patients age is 12–17 years, < 45 kg body weight: Moxifloxacin 8 mg/kg/day IV divided q12h (not to exceed 200 mg/dose) for 2–3 wks AND
  • 3.2.3.2 A bactericidal antimicrobial (ß-lactam or glycopeptide)
  • 3.2.3.2.1 For all strains, regardless of penicillin susceptibility testing or if susceptibility is unknown:
  • Preferred regimen (1): Meropenem 120 mg/kg/day IV divided q8h (not to exceed 2 g/dose) for 2–3 wks
  • Preferred regimen (2): Imipenem/Cilastatin 100 mg/kg/day IV divided q6h (not to exceed 1 g/dose) for 2–3 wks
  • Preferred regimen (3): Doripenem 120 mg/kg/day IV divided q8h (not to exceed 1 g/dose) for 2–3 wks
  • Preferred regimen (4): Vancomycin 60 mg/kg/day IV divided q8h for 2–3 wks
  • 3.2.3.2.2 Alternatives for penicillin-susceptible strains
  • Alternative regimen (1): Penicillin G 400 000 U/kg/day IV divided q4h (not to exceed 4 MU/dose) for 2–3 wks
  • Alternative regimen (2): Ampicillin 400 mg/kg/day IV divided q6h (not to exceed 3 g/dose) for 2–3 wks AND
  • 3.2.3.3 A Protein Synthesis Inhibitor
  • Preferred regimen (1):
  • If patients age is < 12 y old: Linezolid 30 mg/kg/day IV divided q8h for 2–3 wk
  • If patients age is = 12 y old: Linezolid 30 mg/kg/day,IV divided q12h (not to exceed 600 mg/dose) for 2–3 wk
  • Preferred regimen (2): Clindamycin 40 mg/kg/day IV divided q8h (not to exceed 900 mg/dose) for 2–3 wk
  • Preferred regimen (3): Rifampin 20 mg/kg/day IV divided q12h (not to exceed 300 mg/dose) for 2–3 wk
  • Preferred regimen (4): Chloramphenicol 100 mg/kg/day IV divided q6h for 2–3 wk
Note (1): Duration of therapy for 2–3 wk or greater, until clinical criteria for stability are met.Will require prophylaxis to complete an antimicrobial course of up to 60 days from onset of illness.
Note (2): A 400-mg dose of Ciprofloxacin IV, provides an equivalent exposure to that of a 500-mg ciprofloxacin oral tablet.
  • 3.2.4 Oral follow-up combination therapy for severe anthrax (for Children 1 Month of Age and Older)
  • 3.2.4.1 A bactericidal antimicrobial
  • 3.2.4.1.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • Preferred regimen (1): Ciprofloxacin 30 mg/kg/day PO bid (not to exceed 500 mg/dose)
  • Preferred regimen (2):
  • If patients body weight is < 50 kg: Levofloxacin 16 mg/kg/day PO bid (not to exceed 250 mg/dose)
  • If patients body weight is = 50 kg: Levofloxacin 500 mg PO qd
  • 3.2.4.1.2 Alternatives for penicillin-susceptible strains
  • Alternative regimen (1): Amoxicillin 75 mg/kg/day PO tid (not to exceed 1 g/dose)
  • Alternative regimen (2): Penicillin VK 50–75 mg/kg/day PO tid or qds AND
  • 3.2.4.2 A protein synthesis inhibitor:
  • Preferred regimen (1):Clindamycin 30 mg/kg/day PO tid (not to exceed 600 mg/dose)
  • Preferred regimen (2):
  • If the patients body weight is < 45 kg: Doxycycline 4.4 mg/kg/day PO bid (not exceed 100 mg/dose)
  • If the patients body weight is = 45 kg: Doxycycline 100 mg PO bid
  • Preferred regimen (3): (non-CNS infection dose):
  • If the patients age is < 12 yrs old: Linezolid 30 mg/kg/day PO tid
  • If the patients age is = 12 yrs old: Linezolid 30 mg/kg/day PO bid (not to exceed 600 mg/dose)
  • Note: Duration of therapy to complete a treatment course of 14 days or greater. May require prophylaxis to complete an antimicrobial course of up to 60 days from onset of illness.
  • 3.2.5 Dosing in preterm and term neonates 32 to 44 Weeks postmenstrual Age (Gestational Age Plus Chronologic Age)
  • 3.2.5.1 Triple therapy for severe anthrax(anthrax meningitis or disseminated infection and meningitis cannot be ruled out)
  • 3.2.5.1.1 Bactericidal antimicrobial (fluoroquinolone) therapy
  • 3.2.5.1.1.1 For 32–34 weeks gestational age
  • For 0–1 week of age
  • Preferred regimen (1): Ciprofloxacin 20 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (2): Moxifloxacin 5 mg/kg/day IV q24h for 2–3 weeks
  • For 1–4 weeks of age
  • Preferred regimen (1): Ciprofloxacin 20 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (2): Moxifloxacin 5 mg/kg/day IV q24h for 2–3 weeks
  • 3.2.5.1.1.2 For 34–37 week gestational age
  • For 0–1 wk of age
  • Preferred regimen (1): Ciprofloxacin 20 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (2):Moxifloxacin 5 mg/kg/day IV q24h for 2–3 weeks
  • For 1–4 wk of age
  • Preferred regimen (1): Ciprofloxacin 20 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (2): Moxifloxacin 5 mg/kg/day IV q24h for 2–3 weeks
  • 3.2.5.1.1.3 Term newborn infant
  • For 0–1 week of age
  • Preferred regimen (1): Ciprofloxacin 30 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (2): Moxifloxacin 10 mg/kg/day IV q24h for 2–3 weeks
  • For 1–4 weeks of age
  • Preferred regimen (1): Ciprofloxacin 30 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (2): Moxifloxacin 10 mg/kg/day IV q24h for 2–3 weeks AND
  • 3.2.5.1.2 A bactericidal antimicrobial (ß-lactam)
  • 3.2.5.1.2.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown:
  • 3.2.5.1.2.1.1 For 32–34 weeks gestational age
  • For 0–1 week of Age :
  • Preferred regimen (1): Meropenem 60 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (2): Imipenem 50 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (3): Doripenem 20 mg/kg/day IV divided q12h for 2–3 weeks
  • For 1–4 wk of Age :
  • Preferred regimen (1): Meropenem 90 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (2): Imipenem 75 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (3): Doripenem 30 mg/kg/day IV divided q8h for 2–3 weeks
  • 3.2.5.1.2.1.2 For 34–37 week gestational age
  • For 0–1 week of Age :
  • Preferred regimen (1): Meropenem 60 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (2): Imipenem 50 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (3): Doripenem 20 mg/kg/day IV divided q12h for 2–3 weeks
  • For 1–4 week of Age :
  • Preferred regimen (1): Meropenem 90 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (2): Imipenem 75 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (3): Doripenem 30 mg/kg/day IV divided q8h for 2–3 weeks
  • 3.2.5.1.2.1.3 Term newborn infant
  • For < 1 week of age
  • Preferred regimen (1): Meropenem 60 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (2): Imipenem 50 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (3): Doripenem 20 mg/kg/day IV divided q12h for 2–3 weeks
  • For 1–4 week of age
  • Preferred regimen (1): Meropenem 90 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (2): Imipenem 75 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (3): Doripenem 30 mg/kg/day IV divided q8h for 2–3 weeks
  • 3.2.5.1.2.2 Alternatives for penicillin-susceptible strains
  • 3.2.5.1.2.2.1 For 32–34 weeks gestational age
  • For 0–1 week of age
  • Alternative regimen (1): Penicillin G 200000 Units/kg/day IV divided q12h for 2–3 weeks
  • Alternative regimen (2): Ampicillin 100 mg/kg/day IV divided q12h for 2–3 weeks
  • For 1–4 week of age :
  • Alternative regimen (1): Penicillin G 300000 Units/kg/day IV divided q12h for 2–3 weeks
  • Alternative regimen (2): Ampicillin 150 mg/kg/day divided IV q12h for 2–3 weeks
  • 3.2.5.1.2.2.2 For 34–37 week gestational age
  • For < 1 week of age
  • Alternative regimen (1): Penicillin G 300000 Units/kg/day IV divided q12h for 2–3 weeks
  • Alternative regimen (2): Ampicillin 150 mg/kg/day IV divided q12h for 2–3 weeks
  • For 1–4 week of age
  • Alternative regimen (1): Penicillin G 400000 Units/kg/day IV divided q12h for 2–3 weeks
  • Alternative regimen (2): Ampicillin 200 mg/kg/day IV divided q12h for 2–3 weeks
  • 3.2.5.1.2.2.3 Term newborn infant
  • For 0–1 week of age
  • Alternative regimen (1): Penicillin G 300000 Units/kg/day IV divided q12h for 2–3 weeks
  • Alternative regimen (2): Ampicillin 150 mg/kg/day IV divided q12h for 2–3 weeks
  • For 1–4 week of age
  • Alternative regimen (1): Penicillin G 400000 Units/kg/day IV divided q12h for 2–3 weeks
  • Alternative regimen (2): Ampicillin 200 mg/kg/day IV divided q12h for 2–3 weeks AND
  • 3.2.5.1.3 A protein synthesis inhibitor
  • 3.2.5.1.3.1 For 32–34 weeks gestational age
  • For < 1 week of age
  • Preferred regimen (1): Linezolid 20 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (2): Clindamycin 10 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (3): Rifampin 10 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (4): Chloramphenicol 25 mg/kg/day IV q24h for 2–3 weeks
  • For 1–4 week of age
  • Preferred regimen (1): Linezolid 30 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (2): Clindamycin 15 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (3): Rifampin 10 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (4): Chloramphenicol 50 mg/kg/day IV q12h for 2–3 weeks
  • 3.2.5.1.3.2 For 34–37 week gestational age
  • For < 1 week of age
  • Preferred regimen (1): Linezolid 30 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (2): Clindamycin 15 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (3): Rifampin 10 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (4): Chloramphenicol 25 mg/kg/day IV q24h for 2–3 weeks
  • For 1–4 week of age
  • Preferred regimen (1): Linezolid 30 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (2): Clindamycin 20 mg/kg/day IV divided q6h for 2–3 weeks
  • Preferred regimen (3): Rifampin 10 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (4): Chloramphenicol 50 mg/kg/day IV q12h for 2–3 weeks
  • 3.2.5.1.3.3 Term newborn infant
  • For < 1 week of age
  • Preferred regimen (1): Linezolid 30 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (2): Clindamycin 15 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (3): Rifampin 10 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (4): Chloramphenicol 25 mg/kg/day IV q24h for 2–3 weeks
  • For 1–4 week of age
  • Preferred regimen (1): Linezolid 30 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (2): Clindamycin 20 mg/kg/day IV divided q6h for 2–3 weeks
  • Preferred regimen (3): Rifampin 20 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (4): Chloramphenicol 50 mg/kg/day IV q12h for 2–3 weeks
  • Note :Duration of therapy for 2–3 weeks, until clinical criteria for stability are met. Will require prophylaxis to complete an antibiotic course of upto 60 days from onset of illness.
  • 3.2.5.2 Therapy for severe anthrax when meningitis can be ruled out
  • 3.2.5.2.1 A bactericidal antimicrobial
  • 3.2.5.2.1.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • 3.2.5.2.1.1.1 For 32–34 weeks gestational age
  • For < 1 week of age
  • Preferred regimen (1): Ciprofloxacin 20 mg/kg/day IV divided q12h for 2-3 weeks
  • Preferred regimen (2): Meropenem 40 mg/kg/day IV divided q8h for 2-3 weeks
  • Preferred regimen (3): Imipenem 40 mg/kg/day IV divided q12h for 2-3 weeks
  • For 1–4 week of age
  • Preferred regimen (1): Ciprofloxacin 20 mg/kg/day IV divided q12h for 2-3 weeks
  • Preferred regimen (2): Meropenem 60 mg/kg/day IV divided q8h for 2-3 weeks
  • Preferred regimen (3): Imipenem 50 mg/kg/day IV divided q12h for 2-3 weeks
  • 3.2.5.2.1.1.2 For 34–37 week gestational age
  • For < 1 week of age
  • Preferred regimen (1): Ciprofloxacin 20 mg/kg/day IV divided q12h for 2-3 weeks
  • Preferred regimen (2): Meropenem 60 mg/kg/day IV divided q8h for 2-3 weeks
  • Preferred regimen (3): Imipenem 50 mg/kg/day IV divided q12h for 2-3 weeks
  • For 1–4 week of age
  • Preferred regimen (1): Ciprofloxacin 20 mg/kg/day IV divided q12h for 2-3 weeks
  • Preferred regimen (2): Meropenem 60 mg/kg/day IV divided q8h for 2-3 weeks
  • Preferred regimen (3): Imipenem 75 mg/kg/day IV divided q8h for 2-3 weeks
  • 3.2.5.2.1.1.3 Term Newborn Infant
  • For < 1 week of age
  • Preferred regimen (1): Ciprofloxacin 30 mg/kg/day IV divided q12h for 2-3 weeks
  • Preferred regimen (2): Meropenem 60 mg/kg/day IV divided q8h for 2-3 weeks
  • Preferred regimen (3): Imipenem 50 mg/kg/day IV divided q12h for 2-3 weeks
  • For 1–4 week of age
  • Preferred regimen (1): Ciprofloxacin 30 mg/kg/day IV divided q12h for 2-3 weeks
  • Preferred regimen (2): Meropenem 60 mg/kg/day IV divided q8h for 2-3 weeks
  • Preferred regimen (3): Imipenem 75 mg/kg/day IV divided q8h for 2-3 weeks
  • Vancomycin IV (dosing based on serum creatinine for infants of 32 wk gestational age). Follow vancomycin serum concentrations to modify dose.
  • If Serum creatinine < 0.7 then Vancomycin 15 mg/kg/dose IV q12h for 2-3 weeks
  • If Serum creatinine 0.7 -0.9 then Vancomycin 20 mg/kg/dose IV q24h for 2-3 weeks
  • If Serum creatinine 1–1.2 then Vancomycin 15 mg/kg/dose IV q24h for 2-3 weeks
  • If Serum creatinine 1.3–1.6 then Vancomycin 10 mg/kg/dose IV q24h for 2-3 weeks
  • If Serum creatinine > 1.6 then Vancomycin mg/kg/dose IV q48h for 2-3 weeks
  • Note: Begin treatment with a 20 mg/kg loading dose OR
  • 3.2.5.2.1.2 Alternatives for penicillin-susceptible strains
  • 3.2.5.2.1.2.1 For 32–34 weeks gestational age
  • For < 1 week of age
  • Alternative regimen (1): Penicillin G 200000 U/kg/day IV divided q12h for 2-3 weeks
  • Alternative regimen (2): Ampicillin 100 mg/kg/day IV divided q12h for 2-3 weeks
  • For 1–4 week of age
  • Alternative regimen (1): Penicillin G 300000 U/kg/day IV divided q8h for 2-3 weeks
  • Alternative regimen (2): Ampicillin 150 mg/kg/day IV divided q8h for 2-3 weeks
  • 3.2.5.2.1.2.2 For 34–37 week gestational age
  • For < 1 week of age
  • Alternative regimen (1): Penicillin G 300000 U/kg/day IV divided q8h for 2-3 weeks
  • Alternative regimen (2): Ampicillin 150 mg/kg/day IV divided q8h for 2-3 weeks
  • For 1–4 week of age
  • Alternative regimen (1): Penicillin G 400000 U/kg/day IV divided q6h for 2-3 weeks
  • Alternative regimen (2): Ampicillin 200 mg/kg/day IV divided q6h for 2-3 weeks
  • 3.2.5.2.1.2.3 Term newborn infant
  • For < 1 week of age
  • Alternative regimen (1): Penicillin G 300000 U/kg/day IV divided q8h for 2-3 weeks
  • Alternative regimen (2): Ampicillin 150 mg/kg/day IV divided q8h for 2-3 weeks
  • For 1–4 week of age
  • Alternative regimen (1): Penicillin G 400000 U/kg/day IV divided q6h for 2-3 weeks
  • Alternative regimen (2):Ampicillin 200 mg/kg/day IV divided q6h for 2-3 weeks
  • 3.2.5.2.2 A protein synthesis inhibitor
  • 3.2.5.2.2.1 For 32–34 weeks gestational age
  • For < 1 week of age
  • Preferred regimen (1): Clindamycin 10 mg/kg/day IV divided q12h for 2–3 wks
  • Preferred regimen (2): Linezolid 20 mg/kg/day IV divided q12h for 2–3 wks
  • Preferred regimen (3): Rifampin 10 mg/kg/day IV q24h for 2–3 wks
  • For 1–4 week of age
  • Preferred regimen (1): Clindamycin 15 mg/kg/day IV divided q8h for 2–3 wks
  • Preferred regimen (2): Linezolid 30 mg/kg/day IV divided q8h for 2–3 wks
  • Preferred regimen (3): Rifampin 10 mg/kg/day IV q24h for 2–3 wks
  • 3.2.5.2.2.2 For 34–37 week gestational age
  • For < 1 week of age
  • Preferred regimen (1): Clindamycin 15 mg/kg/day IV divided q8h for 2–3 wks
  • Preferred regimen (2): Linezolid 30 mg/kg/day IV divided q8h for 2–3 wks
  • Preferred regimen (3): Rifampin 10 mg/kg/day IV q24h for 2–3 wks
  • For 1–4 week of age
  • Preferred regimen (1): Clindamycin 20 mg/kg/day IV divided q6h for 2–3 wks
  • Preferred regimen (2): Linezolid 30 mg/kg/day IV divided q8h for 2–3 wks
  • Preferred regimen (3): Rifampin 10 mg/kg/day IV q24h for 2–3 wks
  • 3.2.5.2.2.3 Term newborn infant
  • For 0–1 week of age :
  • Preferred regimen (1): Clindamycin 15 mg/kg/day IV divided q8h for 2–3 wks
  • Preferred regimen (2): Linezolid 30 mg/kg/day IV divided q8h for 2–3 wks
  • Preferred regimen (3): Doxycycline 4.4 mg/kg/day IV divided q12h, (loading dose 4.4 mg/kg) for 2–3 wks
  • Preferred regimen (4): Rifampin 10 mg/kg/day IV q24h for 2–3 wks
  • For 1–4 week of age :
  • Preferred regimen (1): Clindamycin 20 mg/kg/day IV divided q6h for 2–3 wks
  • Preferred regimen (2): Linezolid 30 mg/kg/day IV divided q8h for 2–3 wks
  • Preferred regimen (3): Doxycycline 4.4 mg/kg/day IV divided q12h, (loading dose 4.4 mg/kg) for 2–3 wks
  • Preferred regimen (4): Rifampin 10 mg/kg/day IV q24h for 2–3 wks
  • Note: Duration of therapy for 2–3 wks, until clinical criteria for stability are met (see text). Will require prophylaxis to complete an antimicrobial course of upto 60 days from onset of illness
  • 3.2.5.3 Oral follow-up combination therapy for severe anthrax
  • 3.2.5.3.1 A bactericidal antimicrobial
  • 3.2.5.3.1.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • 3.2.5.3.1.1.1 For 32–34 weeks gestational age
  • For < 1 week of age
  • For 1–4 week of age
  • 3.2.5.3.1.1.2 For 34–37 week gestational age
  • For < 1 week of age
  • For 1–4 week of age
  • 3.2.5.3.1.1.3 Term newborn infant
  • For < 1 week of age
  • For 1–4 week of age
  • 3.2.5.3.1.2 Alternatives for penicillin-susceptible strains
  • 3.2.5.3.1.2.1 For 32–34 weeks gestational age
  • For < 1 week of age
  • Alternative regimen (1): Amoxicillin 50 mg/kg/day PO bid
  • Alternative regimen (2): Penicillin VK 50 mg/kg/day PO bid
  • For 1–4 week of age
  • Alternative regimen (1): Amoxicillin 75 mg/kg/day PO bid
  • Alternative regimen (2): Penicillin VK 75 mg/kg/day PO bid
  • 3.2.5.3.1.2.2 For 34–37 week gestational age
  • For < 1 week of age
  • Alternative regimen (1): Amoxicillin 50 mg/kg/day PO bid
  • Alternative regimen (2): Penicillin VK 50 mg/kg/day PO bid
  • For 1–4 week of age
  • Alternative regimen (1): Amoxicillin 75 mg/kg/day PO bid
  • Alternative regimen (2): Penicillin VK 75 mg/kg/day PO tid
  • 3.2.5.3.1.2.3 Term newborn infant
  • For < 1 week of age
  • Alternative regimen (1): [Amoxicillin]] 75 mg/kg/day PO tid
  • Alternative regimen (2): Penicillin VK 75 mg/kg/day PO tid
  • For 1–4 week of age
  • Alternative regimen (1): Amoxicillin 75 mg/kg/day PO tid
  • Alternative regimen (2): Penicillin VK 75 mg/kg/day PO tid or qid
  • 3.2.5.3.2 A protein synthesis inhibitor
  • 3.2.5.3.2.1 For 32–34 weeks gestational age
  • For < 1 week of age
  • Preferred regimen (2): Linezolid 20 mg/kg/day PO bid
  • For 1–4 week of age
  • Preferred regimen (2): Linezolid 30 mg/kg/day PO bid
  • 3.2.5.3.2.2 For 34–37 week gestational age
  • For < 1 week of age
  • Preferred regimen (2): Linezolid 30 mg/kg/day PO tid
  • For 1–4 week of age
  • Preferred regimen (2): Linezolid 30 mg/kg/day PO tid
  • 3.2.5.3.2.3 Term newborn infant
  • For < 1 week of age
  • Preferred regimen (2): Doxycycline 4.4 mg/kg/day PO bid (loading dose 4.4 mg/kg)
  • Preferred regimen (3): Linezolid 30 mg/kg/day PO tid
  • For 1–4 week of age
  • Preferred regimen (1): Clindamycin 20 mg/kg/day PO qid
  • Preferred regimen (2): Doxycycline 4.4 mg/kg/day PO bid (loading dose 4.4 mg/kg)
  • Preferred regimen (3): Linezolid 30 mg/kg/day PO tid
  • Note: Duration of therapy to complete a treatment course of 10–14 days or greater. May require prophylaxis to complete an antimicrobial course of upto 60 days from onset of illness.
  • 3.2.5.4 Treatment of cutaneous anthrax without systemic involvement
  • 3.2.5.4.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • 3.2.5.4.1.1 For 32–34 weeks gestational age
  • For < 1 week of age
  • For 1–4 week of age
  • 3.2.5.4.1.2 For 34–37 week gestational age
  • For < 1 week of age
  • For 1–4 week of age
  • 3.2.5.4.1.3 Term newborn infant
  • For < 1 week of age
  • Preferred regimen (2): Doxycycline 4.4 mg/kg/day PO bid (Loading dose 4.4 mg/kg)
  • For 1–4 week of age
  • Preferred regimen (2): Doxycycline 4.4 mg/kg/day PO bid (Loading dose 4.4 mg/kg)
  • 3.2.5.4.2 Alternatives for penicillin-susceptible strains
  • 3.2.5.4.2.1 For 32–34 weeks gestational age
  • For < 1 week of age
  • Alternative regimen (1): Amoxicillin 50 mg/kg/day PO bid
  • Alternative regimen (2): Penicillin Vk 50 mg/kg/day PO bid
  • For 1–4 week of age
  • Alternative regimen (1): Amoxicillin 75 mg/kg/day PO tid
  • Alternative regimen (2): Penicillin Vk 75 mg/kg/day PO tid
  • 3.2.5.4.2.2 For 34–37 week gestational age
  • For < 1 week of age
  • Alternative regimen (1): Amoxicillin 50 mg/kg/day PO bid
  • Alternative regimen (2): Penicillin Vk 50 mg/kg/day PO bid
  • For 1–4 week of age
  • Alternative regimen (1): Amoxicillin 75 mg/kg/day PO bid
  • Alternative regimen (2): Penicillin Vk 75 mg/kg/day PO bid
  • 3.2.5.4.2.3 Term newborn infant
  • For < 1 week of age
  • Alternative regimen (1): Amoxicillin 75 mg/kg/day PO tid
  • Alternative regimen (2): Penicillin Vk 75 mg/kg/day PO tid
  • For 1–4 week of age
  • Alternative regimen (1): Amoxicillin 75 mg/kg/day PO tid
  • Alternative regimen (2): Penicillin Vk 75 mg/kg/day PO tid or qid
  • Note : Duration of therapy for naturally acquired infection is 7–10 days and for a biological weapon–related event,may require additional prophylaxis for inhaled spores to complete an antimicrobial course of up to 60 days from onset of illness.
  • Bacillus anthracis, postexposure prophylaxis
  • 1. For adults[1]
  • 1.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • 1.2 Alternatives for penicillin-susceptible strain
  • Preferred regimen (2): Penicillin VK 500 mg IV q6h
  • 2. For children = 1 month[3]
  • 2.1 For penicillin-resistant strains or prior to susceptibility testing
  • Preferred regimen (1): Ciprofloxacin 30 mg/kg/day, PO, bid (not to exceed 500 mg/dose)
  • Preferred regimen (2):
  • If patients body weight < 45 kg: Doxycycline 4.4 mg/kg/day, PO, bid (not to exceed 100 mg/dose)
  • If patients body weight > 45 kg: Doxycycline 100 mg/dose, PO, bid
  • Preferred regimen (3): Clindamycin 30 mg/kg/day, PO, tid (not to exceed 900 mg/dose)
  • Preferred regimen (4):
  • If patients body weight < 50 kg: Levofloxacin 16 mg/kg/day, PO, bid (not to exceed 250 mg/dose)
  • If patients body weight > 50 kg: Levofloxacin 500 mg, PO, qd
  • 2.2 For penicillin-susceptible strains
  • Preferred regimen (1): Amoxicillin 75 mg/kg/day, PO, tid (not to exceed 1 g/dose)
  • Preferred regimen (2): Penicillin VK 50-75 mg/kg/day, PO, id or tid
  • Note: Duration of Therapy is 60 days after exposure
  • 3. For children < 1 month
  • 3.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • 3.1.1 For 32–34 weeks gestational age
  • 3.1.1.1 For < 1 week of Age
  • Preferred regimen (2): Clindamycin 10 mg/kg/day, PO, bid
  • 3.1.1.2 For 1–4 week of age
  • Preferred regimen (2): Clindamycin 15 mg/kg/day, PO, tid
  • 3.1.2 For 34–37 week gestational age
  • 3.1.2.1 For < 1 week of age
  • Preferred regimen (2): Clindamycin 15 mg/kg/day, PO, tid
  • 3.1.2.2 For 1–4 week of age
  • Preferred regimen (2): Clindamycin 20 mg/kg/day, PO, id
  • 3.1.3 Term newborn infant
  • 3.1.3.1 For < 1 week of age
  • Preferred regimen (2): Doxycycline 4.4 mg/kg/day, PO, bid (Loading dose 4.4 mg/kg)
  • Preferred regimen (3): Clindamycin 15 mg/kg/day, PO, tid
  • 3.1.3.2 For 1–4 week of Age
  • Preferred regimen (2): Doxycycline 4.4 mg/kg/day, PO, bid (Loading dose 4.4 mg/kg)
  • Preferred regimen (3): Clindamycin 20 mg/kg/day, PO, qid
  • 3.2 Alternatives for penicillin-susceptible strains
  • 3.2.1 For 32–34 weeks gestational age
  • 3.2.1.1 For < 1 week of age
  • Alternative regimen (1): Amoxicillin 50 mg/kg/day, PO, bid
  • Alternative regimen (2): Penicillin Vk 50 mg/kg/day, PO, bid
  • 3.2.1.2 For 1–4 week of age
  • Alternative regimen (1): Amoxicillin 75 mg/kg/day, PO, tid
  • Alternative regimen (2): Penicillin Vk 75 mg/kg/day, PO, tid
  • 3.2.2 For 34–37 week gestational age
  • 3.2.2.1 For < 1 week of age
  • Alternative regimen (1): Amoxicillin 50 mg/kg/day, PO, bid
  • Alternative regimen (2): Penicillin Vk 50 mg/kg/day, PO, bid
  • 3.2.2.2 For 1–4 week of age
  • Alternative regimen (1): Amoxicillin 75 mg/kg/day, PO, tid
  • Alternative regimen (2): Penicillin Vk 75 mg/kg/day, PO, tid
  • 3.2.3 Term newborn infant
  • 3.2.3.1 For < 1 week of age
  • Alternative regimen (1): Amoxicillin 75 mg/kg/day, PO, tid
  • Alternative regimen (2): Penicillin Vk 75 mg/kg/day, PO, tid
  • 3.2.3.2 For 1–4 week of age
  • Alternative regimen (1): Amoxicillin 75 mg/kg/day, PO, tid
  • Alternative regimen (2): Penicillin Vk 75 mg/kg/day, PO, id or tid
  • Note: Duration of therapy is 60 days from exposure



Antimicrobial Prophylaxis for Surgery

  • Ántimicrobial Prophylaxis'[4][5]


Procedure Causative etiologies Recommended antimicrobials Usual adult dosage Comments
Cardiovascular
Staphylococcus aureus, Staphylococcus epidermidis Cefazolin 1-2 g IV Antibiotic prophylaxis has been proved beneficial in the following patients: reconstruction of abdominal aorta, procedures on the leg that involve a groin incision, any vascular procedure that inserts prosthesis/foreign body, lower extremity amputation for ischemia, cardiac surgery, permanent pacemakers, heart transplant. The recommended dose of Cefazolin is 1 g for patients who weigh <80 kg and 2 g for those ~80 kg. Morbidly obese patients may need higher doses. Some experts recommend an additional dose when patients are removed from bypass during open-heart surgery.
Cefuroxime 1.5 g IV Some experts recommend an additional dose when patients are removed from bypass during open-heart surgery.
Vancomycin 1 g IV Vancomycin is preferable in hospitals with high frequency of MRSA, high risk patients, those colonized with MRSA or for pen-allergic patients. Clindamycin 900 mg IV is another alternative for pen-allergic or vanco-allergic patients. Vancomycin can be used in hospitals in which methicillin-resistant S. aureus and S. epidermidis are a frequent cause of postoperative wound infection, in patients previously colonized with MRSA, or for those who are allergic to penicillins or cephalosporins. Rapid IV administration may cause hypotension, which could be especially dangerous during induction of anesthesia. Even when the drug is given over 60 minutes, hypotension may occur; treatment with Diphenhydramine (Benadryl, and others) and further slowing of the infusion rate may be helpful. Some experts would give 15 mg/kg of Vancomycin to patients weighing more than 751<g, up to a maximum of 1.5 g, with a slower infusion rate (90 minutes for 1.5 g). For procedures in which enteric gram-negative bacilli are common pathogens, many experts would add another drug such as an aminoglycoside (Gentamicin, Tobramycin or Amikacin), Aztreonam or a fluoroquinolone.
Mupirocine Consider intranasal Mupirocine evening before, day of surgery and bid for 5 days post-op in patients with positive nasal culture for S. aureus. Mupirocine resistance has been encountered.
Gastrointestinal
Esophageal, gastroduodenal (includes percutaneous endoscopic gastrostomy - high risk only) Enteric gram-negative bacilli, gram-positive cocci High-risk only: Cefazolin, Cefoxitin, Ceftriaxone Single-dose: 2 g IV The recommended dose of Cefazolin is 1 g for patients who weigh <80 kg and 2 g for those ~80 kg. Morbidly obese patients may need higher doses. PEG placement: high-risk is marked obesity, obstruction, reduced gastric acid or reduced motility.
Biliary tract Enteric gram-negative bacilli, enterococci, clostridia High-risk only: Cefazolin, Cefoxitin or Cefotetan 1-2 g IV High risk: age >70, acute cholecystitis, non-functioning gallbladder, obstructive jaundice or common duct stones. With cholangitis, treat as infection, not prophylaxis. The recommended dose of Cefazolin is 1 g for patients who weigh <80 kg and 2 g for those ~80 kg. Morbidly obese patients may need higher doses. Low-risk, laparoscopic: no prophylaxis.
OR Ampicillin/Sulbactam 3 g IV
Endoscopic retrograde cholangiopancreatography Ciprofloxacin 500 - 750 mg PO OR 400 mg IV 2 hours before procedure Only needed if there is obstruction. Greatest benefit of prophylaxis occurs when complete drainage cannot be achieved.
OR Piperaciline-Tazobactam 4.5 g IV 1 hour before procedure Only needed if there is obstruction.
Colorectal Enteric gram-negative bacilli, anaerobes, enterococci Oral: Neomycin PLUS Erythromycin bases OR Metronidazole In addition to mechanical bowel preparation, 1 g of Neomycin PLUS 1 g of Erythromycin at 1 PM, 2 PM and 11 PM or 2 g of Neomycin PLUS 2 g of Metronidazole at 7 PM and 11 PM the day before an 8 AM operation.
Parenteral: Cefoxitin or Cefotetan 1-2 g IV
OR Cefazolin 1-2 g IV The recommended dose of Cefazolin is 1 g for patients who weigh <80 kg and 2 g for those ~80 kg. Morbidly obese patients may need higher doses.
PLUS Metronidazole 0.5 g IV
Ampicillin/Sulbactam 3 g IV
Ertapenem 1 g IV Ertapenem can be used if there is beta-lactam allergy. Other regimens include: Clindamycin 900 mg IV PLUS Gentamycin 5mg/kg OR Aztreonam 2 g IV OR Ciprofloxacin 400 mg IV.
Appendectomy, non-perforated Same as for colorectal Cefoxitin OR Cefotetan 1-2 g IV For patients allergic to penicillins and cephalosporins, Clindamycin OR Vancomycin with either Gentamicin, Ciprofloxacin, Levofloxacin or Aztreonam is a reasonable alternative. Fluoroquinolones should not be used for prophylaxis in cesarean section.
OR Cefazolin 1-2 g IV
PLUS Metronidazole 0.5 g IV
Genitourinary
Cystoscopy alone Enteric gram-negative bacilli, enterococci High-risk only: Ciprofloxacin 500 mg PO OR 400 mg IV Due to increasing resistance of E. coli to fluoroquinolones and Ampicillin/Sulbactam, local sensitivity profiles should be reviewed prior to use. AUA recommends prophylaxis for those with several potentially adverse host factors (e.g. advanced age, immunocompromised state, anatomic abnormalities, etc.).
OR Trimethoprim-Sulfamethoxazole 1 DS tablet
Cystoscopy with manipulation or upper tract instrumentation Enteric gram-negative bacilli, enterococci Ciprofloxacin 500 mg PO OR 400 mg IV Due to increasing resistance of E. coli to fluoroquinolones and Ampicillin/Sulbactam, local sensitivity profiles should be reviewed prior to use.
OR Trimethoprim-Sulfamethoxazole 1 DS tablet Viable alternative in populations with low rates of resistance.
Transrectal prostate biopsy Enteric gram-negative bacilli, enterococci Ciprofloxacin 500 mg PO 12 hours before biopsy and 12 hours after first dose.
Open or laparoscopic surgery Enteric gram-negative bacilli, enterococci Cefazolin 1-2 g IV The recommended dose of Cefazolin is 1 g for patients who weigh <80 kg and 2 g for those ~80 kg. Morbidly obese patients may need higher doses.
Gynecologic and Obstetric
Vaginal, abdominal or laparoscopic hysterectomy Enteric gram-negative bacilli, anaerobes, Gp B strep, enterococci Cefazolin OR Cefoxitin OR Cefotetan 1-2 g IV The recommended dose of Cefazolin is 1 g for patients who weigh <80 kg and 2 g for those ~80 kg. Morbidly obese patients may need higher doses. For patients allergic to penicillins and cephalosporins, Clindamycin OR Vancomycin with either Gentamicin, Ciprofloxacin, Levofloxacin or Aztreonam is a reasonable alternative. Fluoroquinolones should not be used for prophylaxis in cesarean section. Due to increasing resistance of E. coli to fluoroquinolones and Ampicillin/Sulbactam, local sensitivity profiles should be reviewed prior to use.
OR Ampicillin/Sulbactam 3 g IV For patients allergic to penicillins and cephalosporins, Clindamycin OR Vancomycin with either Gentamicin, Ciprofloxacin, Levofloxacin or Aztreonam is a reasonable alternative. Fluoroquinolones should not be used for prophylaxis in cesarean section. Due to increasing resistance of E. coli to fluoroquinolones and Ampicillin/Sulbactam, local sensitivity profiles should be reviewed prior to use.
Cesarean section Same as for hysterectomy Cefazolin 1-2 g IV The recommended dose of Cefazolin is 1 g for patients who weigh <80 kg and 2 g for those ~80 kg. Morbidly obese patients may need higher doses. For patients allergic to penicillins and cephalosporins, Clindamycin OR Vancomycin with either Gentamicin, Ciprofloxacin, Levofloxacin or Aztreonam is a reasonable alternative. Fluoroquinolones should not be used for prophylaxis in cesarean section. Due to increasing resistance of E. coli to fluoroquinolones and Ampicillin/Sulbactam, local sensitivity profiles should be reviewed prior to use.
Clindamycin 900 mg IV Use as alternative method to Cefazolin and associated with Gentamicin 5 mg/kg IV OR Tobramycin 5 mg/kg IV single dose.
Abortion, surgical Same as for hysterectomy Doxycycline 300 mg PO Divided into 100 mg before the procedure and 200 mg after.
Head and Neck Surgery
Incisions through oral or pharyngeal mucosa Anaerobes, enteric gram-negative bacilli, S. aureus Clindamycin 600 mg - 900 mg IV Clean, uncontaminated head and neck surgery does not require prophylaxis. If using Clindamycin, consider associating Gentamicin 5 mg/kg IV single dose.
OR Cefazolin 2 g IV The recommended dose of Cefazolin is 1 g for patients who weigh <80 kg and 2 g for those ~80 kg. Morbidly obese patients may need higher doses.
PLUS Metronidazole 0.5 g IV
OR Ampicillin/Sulbactam 3 g IV
Neurosurgery
S. aureus, S. epidermidis Cefazolin 1-2 g IV The recommended dose of Cefazolin is 1 g for patients who weigh <80 kg and 2 g for those ~80 kg. Morbidly obese patients may need higher doses.
OR Vancomycin 1 g IV Vancomycin can be used in hospitals in which methicillin-resistant S. aureus and S. epidermidis are a frequent cause of postoperative wound infection, in patients previously colonized with MRSA, or for those who are allergic to penicillins or cephalosporins. Rapid IV administration may cause hypotension, which could be especially dangerous during induction of anesthesia. Even when the drug is given over 60 minutes, hypotension may occur; treatment with Diphenhydramine (Benadryl, and others) and further slowing of the infusion rate may be helpful. Some experts would give 15 mg/kg of Vancomycin to patients weighing more than 751<g, up to a maximum of 1.5 g, with a slower infusion rate (90 minutes for 1.5 g). For procedures in which enteric gram-negative bacilli are common pathogens, many experts would add another drug such as an aminoglycoside (Gentamicin, Tobramycin or Amikacin), Aztreonam or a fluoroquinolone.
Clindamycin 900 mg IV Clindamycin can be used in clean, contaminated surgeries (cross sinuses, or naso/oropharynx). British recommend Amoxicilin-clavulanate 1.2 g IV OR Cefuroxime 1.5 g IV PLUS Metronidazole 0.5 mg g IV.
Ophthalmic
S. aureus, S. epidermidis, streptococci, enteric gram-negative bacilli, Pseudomonas spp. Gentamicin, Tobramycin, Ciprofloxacin, Gatifloxacin, Levofloxacin, Moxifloxacin, Ofloxacin OR Neomycin-gramicidin-polymyxin B Multiple drops topically over 2 to 24 hours
OR Cefazolin 100 mg subconjunctivally
Orthopedic
Hip arthroplasty, spinal fusion S. aureus, S. epidermidis Same as cardiac surgery
Total joint replacement (other than hip) S. aureus, S. epidermidis Cefazolin 1-2 g IV The recommended dose of Cefazolin is 1 g for patients who weigh <80 kg and 2 g for those ~80 kg. Morbidly obese patients may need higher doses.
OR Vancomycin 1 g IV Vancomycin can be used in hospitals in which methicillin-resistant S. aureus and S. epidermidis are a frequent cause of postoperative wound infection, in patients previously colonized with MRSA, or for those who are allergic to penicillins or cephalosporins. Rapid IV administration may cause hypotension, which could be especially dangerous during induction of anesthesia. Even when the drug is given over 60 minutes, hypotension may occur; treatment with Diphenhydramine (Benadryl, and others) and further slowing of the infusion rate may be helpful. Some experts would give 15 mg/kg of Vancomycin to patients weighing more than 751<g, up to a maximum of 1.5 g, with a slower infusion rate (90 minutes for 1.5 g). For procedures in which enteric gram-negative bacilli are common pathogens, many experts would add another drug such as an aminoglycoside (Gentamicin, Tobramycin or Amikacin), Aztreonam or a fluoroquinolone. If a tourniquet is to be used in the procedure, the entire dose of antibiotic must be infused prior to its inflation. For patients weighing >90 kg use Vancomycin 1.5 g IV as single dose OR Clindamycin 900 mg IV.
Open reduction of closed fracture with internal fixation S. aureus, S. epidermidis Ceftriaxone 2 g IV single dose
Thoracic (non-cardiac)
S. aureus, S. epidermidis, enteric gram-negative bacilli, streptococci Cefazolin 1-2 g IV The recommended dose of Cefazolin is 1 g for patients who weigh <80 kg and 2 g for those ~80 kg. Morbidly obese patients may need higher doses.
OR Vancomycin 1 g IV Vancomycin can be used in hospitals in which methicillin-resistant S. aureus and S. epidermidis are a frequent cause of postoperative wound infection, in patients previously colonized with MRSA, or for those who are allergic to penicillins or cephalosporins. Rapid IV administration may cause hypotension, which could be especially dangerous during induction of anesthesia. Even when the drug is given over 60 minutes, hypotension may occur; treatment with Diphenhydramine (Benadryl, and others) and further slowing of the infusion rate may be helpful. Some experts would give 15 mg/kg of Vancomycin to patients weighing more than 751<g, up to a maximum of 1.5 g, with a slower infusion rate (90 minutes for 1.5 g). For procedures in which enteric gram-negative bacilli are common pathogens, many experts would add another drug such as an aminoglycoside (Gentamicin, Tobramycin or Amikacin), Aztreonam or a fluoroquinolone.
OR Ampicillin/Sulbactam 3 g IV Due to increasing resistance of E. coli to fluoroquinolones and Ampicillin/Sulbactam, local sensitivity profiles should be reviewed prior to use.
Vascular
Arterial surgery involving· a prosthesis, the abdominal aorta, or a groin incision S. aureus, S. epidermidis, enteric gram-negative bacilli Cefazolin 1-2 g IV The recommended dose of Cefazolin is 1 g for patients who weigh <80 kg and 2 g for those ~80 kg. Morbidly obese patients may need higher doses.
OR Vancomycin 1 g IV Vancomycin can be used in hospitals in which methicillin-resistant S. aureus and S. epidermidis are a frequent cause of postoperative wound infection, in patients previously colonized with MRSA, or for those who are allergic to penicillins or cephalosporins. Rapid IV administration may cause hypotension, which could be especially dangerous during induction of anesthesia. Even when the drug is given over 60 minutes, hypotension may occur; treatment with Diphenhydramine (Benadryl, and others) and further slowing of the infusion rate may be helpful. Some experts would give 15 mg/kg of Vancomycin to patients weighing more than 751<g, up to a maximum of 1.5 g, with a slower infusion rate (90 minutes for 1.5 g). For procedures in which enteric gram-negative bacilli are common pathogens, many experts would add another drug such as an aminoglycoside (Gentamicin, Tobramycin or Amikacin), Aztreonam or a fluoroquinolone.
Lower extremity amputation for ischemia S. aureus, S. epidermidis, enteric gram-negative bacilli, clostridia Cefazolin 1-2 g IV The recommended dose of Cefazolin is 1 g for patients who weigh <80 kg and 2 g for those ~80 kg. Morbidly obese patients may need higher doses.
OR Vancomycin 1 g IV Vancomycin can be used in hospitals in which methicillin-resistant S. aureus and S. epidermidis are a frequent cause of postoperative wound infection, in patients previously colonized with MRSA, or for those who are allergic to penicillins or cephalosporins. Rapid IV administration may cause hypotension, which could be especially dangerous during induction of anesthesia. Even when the drug is given over 60 minutes, hypotension may occur; treatment with Diphenhydramine (Benadryl, and others) and further slowing of the infusion rate may be helpful. Some experts would give 15 mg/kg of Vancomycin to patients weighing more than 751<g, up to a maximum of 1.5 g, with a slower infusion rate (90 minutes for 1.5 g). For procedures in which enteric gram-negative bacilli are common pathogens, many experts would add another drug such as an aminoglycoside (Gentamicin, Tobramycin or Amikacin), Aztreonam or a fluoroquinolone.

References

  1. ↑ 1.0 1.1 1.2 Hendricks KA, Wright ME, Shadomy SV, Bradley JS, Morrow MG, Pavia AT; et al. (2014). "Centers for disease control and prevention expert panel meetings on prevention and treatment of anthrax in adults". Emerg Infect Dis. 20 (2). doi:10.3201/eid2002.130687. PMC 3901462. PMID 24447897.
  2. ↑ Meaney-Delman D, Zotti ME, Creanga AA, Misegades LK, Wako E, Treadwell TA; et al. (2014). "Special considerations for prophylaxis for and treatment of anthrax in pregnant and postpartum women". Emerg Infect Dis. 20 (2). doi:10.3201/eid2002.130611. PMC 3901460. PMID 24457117.
  3. ↑ 3.0 3.1 Bradley JS, Peacock G, Krug SE, Bower WA, Cohn AC, Meaney-Delman D; et al. (2014). "Pediatric anthrax clinical management". Pediatrics. 133 (5): e1411–36. doi:10.1542/peds.2014-0563. PMID 24777226.
  4. ↑ Treatment Guidelines from The Medical Letter • Vol. 10 (Issue 122) • October 2012
  5. ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
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