Bacillus anthracis: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
Line 37: Line 37:
{{main|Anthrax}}
{{main|Anthrax}}
Infections with ''B. anthracis'' can be treated with [[Beta-lactam|β-lactam]] [[antibiotic]]s such as [[penicillin]], and others which are active against Gram-positive bacteria.<ref>{{cite journal |author = Barnes JM |title=Penicillin and ''B. anthracis''. |journal= J Path Bacteriol |volume=194|year=1947|pages=113}}</ref>
Infections with ''B. anthracis'' can be treated with [[Beta-lactam|β-lactam]] [[antibiotic]]s such as [[penicillin]], and others which are active against Gram-positive bacteria.<ref>{{cite journal |author = Barnes JM |title=Penicillin and ''B. anthracis''. |journal= J Path Bacteriol |volume=194|year=1947|pages=113}}</ref>
==Treatment==
===Antimicrobial therapy===
:* [[Bacillus anthracis]], treatment
::* (A) '''Treatment for cutaneous anthrax, without systemic involvement'''<ref name="pmid24447897">{{cite journal| author=Hendricks KA, Wright ME, Shadomy SV, Bradley JS, Morrow MG, Pavia AT et al.| title=Centers for disease control and prevention expert panel meetings on prevention and treatment of anthrax in adults. | journal=Emerg Infect Dis | year= 2014 | volume= 20 | issue= 2 | pages=  | pmid=24447897 | doi=10.3201/eid2002.130687 | pmc=PMC3901462 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24447897  }} </ref>
:::* Preferred regimen (regardless of penicillin susceptibility or if susceptibility is unknown): [[Ciprofloxacin]] 500 mg PO q12h {{or}} [[Doxycycline]] 100 mg PO q12h {{or}} [[Levofloxacin]] 750 mg PO q24h {{or}} [[Moxifloxacin]] 400 mg PO q24h
:::* Alternative regimen: [[Clindamycin]] 600 mg PO q8h {{or}} [[Amoxicillin]] 1 g PO q8h (for penicillin-susceptible strains) {{or}} [[Penicillin VK]] 500 mg PO q6h (for penicillin-susceptible strains)
:::: Note: Duration of treatment is 60 days for bioterrorism-related cases and 7-10 days for naturally acquired cases.
::* (B) '''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'''<ref name="pmid24447897">{{cite journal| author=Hendricks KA, Wright ME, Shadomy SV, Bradley JS, Morrow MG, Pavia AT et al.| title=Centers for disease control and prevention expert panel meetings on prevention and treatment of anthrax in adults. | journal=Emerg Infect Dis | year= 2014 | volume= 20 | issue= 2 | pages=  | pmid=24447897 | doi=10.3201/eid2002.130687 | pmc=PMC3901462 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24447897  }} </ref>
:::* (B-1) '''Systemic anthrax with possible/confirmed meningitis'''
::::* (1) Bactericidal agent (fluoroquinolone): '''[[Ciprofloxacin]] 400 mg IV q8h''' ({{or}} [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h) {{and}}
::::* (2) Bactericidal agent (β-lactam) for all strains, regardless of penicillin susceptibility or if susceptibility is unknown: '''[[Meropenem]] 2 g IV q8h''' {{or}} [[Imipenem]] 1 g IV q6h {{or}} [[Doripenem]] 500 mg IV q8h {{or}} [[Penicillin G]] 4 MU IV q4h (for penicillin-susceptible strains) {{or}} [[Ampicillin]] 3 g IV q6h (for penicillin-susceptible strains) {{and}}
::::* (3) Protein synthesis inhibitor: '''[[Linezolid]] 600 mg IV q12h''' {{or}} [[Clindamycin]] 900 mg IV q8h {{or}} [[Rifampin]] 600 mg IV q12h {{or}} [[Chloramphenicol]] 1 g IV q6-8h
::::: Note (1): Duration of treatment: ≥ 2-3 weeks until clinical criteria for stability are met (Preferred drugs are indicated in boldface).
::::: Note (2): Patients exposed to aerosolized spores will require prophylaxis to complete an antimicrobial drug course of 60 days from onset of illness.
::::: Note (3): Alternative drugs are listed in order of preference for treatment for patients who cannot take first-line treatment, or if first-line treatment is unavailable.
::::: Note (4): Increased risk for seizures associated with [[Imipenem]]/[[Cilastatin]] treatment.
::::: Note (5): [[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 (6): [[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.
::::: Note (7): [[Chloramphenicol]] should only be used if other options are not available because of toxicity concerns.
:::* (B-2) '''Systemic anthrax when meningitis has been excluded'''
::::* (1) Bactericidal agent: '''[[Ciprofloxacin]] 400 mg IV q8h''' {{or}} [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg q24h {{or}} [[Meropenem]] 2 g IV q8h {{or}} [[Imipenem]] 1 g IV q6h {{or}} [[Doripenem]] 500 mg IV q8h {{or}} [[Vancomycin]] 20 mg/kg IV q8h (maintain serum trough concentrations of 15-20 µg/mL) {{or}} [[Penicillin G]] 4 MU IV q4h (penicillin-susceptible strains) {{or}} [[Ampicillin]] 3 g IV q6h (penicillin-susceptible strains) {{and}}
::::* (2) Protein synthesis inhibitor: '''[[Clindamycin]] 900 mg IV q8h''' {{or}} '''[[Linezolid]] 600 mg IV q12h''' {{or}} [[Doxycycline]] 200 mg IV initially, then 100 mg IV q12h {{or}} [[Rifampin]] 600 mg IV q12h
::::: Note (1): Duration of treatment: for 2 weeks until clinical criteria for stability are met (Preferred drugs are indicated in boldface).
::::: Note (2): Patients exposed to aerosolized spores will require prophylaxis to complete an antimicrobial drug course of 60 days from onset of illness.
::::: Note (3): Alternative drugs are listed in order of preference for treatment for patients who cannot take first-line treatment, or if first-line treatment is unavailable.
::::: Note (4): Increased risk for seizures associated with [[Imipenem]]/[[Cilastatin]] treatment.
::::: Note (5): [[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 (6): [[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.
::::: Note (7): A single 10-14 days course of [[Doxycycline]] is not routinely associated with tooth staining.
::* Specific considerations
:::* '''Treatment of anthrax for pregnant Women''' 
::::* (A) Intravenous antimicrobial treatment for systemic anthrax with possible/confirmed meningitis <ref name="pmid24457117">{{cite journal| author=Meaney-Delman D, Zotti ME, Creanga AA, Misegades LK, Wako E, Treadwell TA et al.| title=Special considerations for prophylaxis for and treatment of anthrax in pregnant and postpartum women. | journal=Emerg Infect Dis | year= 2014 | volume= 20 | issue= 2 | pages=  | pmid=24457117 | doi=10.3201/eid2002.130611 | pmc=PMC3901460 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24457117  }} </ref>
:::::* (1)''' A Bactericidal Agent (Fluoroquinolone)''': '''[[Ciprofloxacin]]''' 400 mg IV q8h is preferred, {{or}}  [[Levofloxacin]] 750 mg IV q24h, {{or}}
:::::* (2).''' A Bactericidal Agent (β-lactam)'''
::::::* (a). For all strains, regardless of penicillin susceptibility or if susceptibility is unknown : '''[[Meropenem]] 2 g q8h''',{{or}}
::::::* (b). Alternatives for penicillin-susceptible strains: [[Ampicillin]] 3 g IV q6h,{{or}} [[Penicillin G]] 4 million units IV q4h, {{or}}
:::::* (3).''' A Protein Synthesis Inhibitor''': '''[[Clindamycin]] 900 IV mg q8h''',{{or}}  [[Rifampin]] 600 IV mg q12h
:::::: Note (1): At least one antibiotic with transplacental passage is recommended.
:::::: Note (2): Duration of treatment is for ≥2–3 weeks until clinical criteria for stability are met. Patients exposed to aerosolized spores will require prophylaxis to complete an antimicrobial drug course of 60 days from onset of illness.
::::* (B) Intravenous antimicrobial treatment for systemic anthrax when meningitis has been excluded
:::::* (1).''' A Bactericidal Antimicrobial''': '''[[Ciprofloxacin]] 400 mg IV q8h''' is preferred, {{or}}  [[Levofloxacin]] 750 mg IV q24h, {{or}}
:::::* (2).''' A Bactericidal Agent (β-lactam)'''
::::::* (a). For all strains, regardless of penicillin susceptibility or if susceptibility is unknown : '''[[Meropenem]] 2 g q8h''',{{or}}
::::::* (b). Alternatives for penicillin-susceptible strains:[[Ampicillin]] 3 g IV q6h,{{or}} [[Penicillin G]] 4 million units IV q4h, {{or}}
:::::* (3).''' A Protein Synthesis Inhibitor''':[[Clindamycin]] 900 IV mg q8h,{{or}}  [[Rifampin]] 600 IV mg q12h
::::::Note (1): At least one antibiotic with transplacental passage is recommended.
::::::Note (2):Duration of treatment: for ≥2 weeks until clinical criteria for stability are met. Patients exposed to aerosolized spores will require prophylaxis to complete an antimicrobial drug course of 60 days from onset of illness
::::*(C) Oral antimicrobial treatment for cutaneous anthrax without systemic involvement
:::::* (a).For all strains, regardless of penicillin susceptibility or if susceptibility is unknown: '''[[Ciprofloxacin]] 400 mg IV q8h''' is preferred.
::::::Note (1): duration of treatment is 60 days
::::::Note (2): Recommendations are specific to cutaneous anthrax in the setting of bioterrorism.
:::* '''Treatment for anthrax in childern''' <ref name="pmid24777226">{{cite journal| author=Bradley JS, Peacock G, Krug SE, Bower WA, Cohn AC, Meaney-Delman D et al.| title=Pediatric anthrax clinical management. | journal=Pediatrics | year= 2014 | volume= 133 | issue= 5 | pages= e1411-36 | pmid=24777226 | doi=10.1542/peds.2014-0563 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24777226  }} </ref>
::::* '''(1). Treatment of cutaneous anthrax without systemic involvement (for children 1 month of age and older)'''
:::::* (A). For all strains, regardless of penicillin susceptibility or if susceptibility is unknown : '''[[Ciprofloxacin]], 30 mg/kg/day, by mouth (PO), divided q12h (not to exceed 500 mg/dose)''' {{or}} [[Doxycycline]], <45 kg: 4.4 mg/kg/day, PO, divided q12h (not to exceed 100 mg/dose) ≥45 kg: 100 mg/dose, PO, given q12h {{or}} [[Clindamycin]], 30 mg/kg/day, PO, divided q8h (not to exceed 600 mg/dose) {{or}} [[Levofloxacin]] <50 kg: 16 mg/kg/day, PO, divided q12h (not to exceed 250 mg/dose) >50 kg: 500 mg, PO, given q24h {{or}}
:::::* (B). Alternatives for penicillin-susceptible strains: '''[[Amoxicillin]], 75 mg/kg/day, PO, divided q8h (not to exceed 1 g/dose)''' {{or}} [[Penicillin VK]], 50-75 mg/kg/day, PO, divided q6h to q8h
:::::: Note (1): Duration of therapy for naturally acquired infection: 7-10 days and for a biological weapon-related event: will require additional prophylaxis for inhaled spores, to complete an antimicrobial course of up to 60 days from onset of illness.
:::::: Note (2): Bold font for preferred antimicrobial agent.
:::::: Note (3): Normal font for alternative selections are listed in order of preference for therapy for patients who cannot take first-line therapy or first-line therapy is unavailable.
:::::: Note (4): Doses are provided for children with normal renal and hepatic function. Doses may vary for those with some degree of organ failure.
:::::: Note (5): Italicized font indicates FDA approval for the indication in the pediatric population.
:::::: Note (6): A single 10- to 14-day course of doxycycline is not routinely associated with tooth staining.
:::::: Note (7): Be aware of the possibility of emergence of penicillin-resistance during monotherapy with amoxicillin or penicillin.
::::* '''(2). Combination therapy for systemic anthrax when meningitis can be ruled out (for children 1 month of age and older)'''
:::::* (A). A bactericidal antimicrobial
::::::* (a). For all strains, regardless of penicillin susceptibility or if susceptibility is unknown: '''[[Ciprofloxacin]], 30 mg/kg/day, intravenously (IV), divided q8h (not to exceed 400 mg/dose)''' {{or}} [[Meropenem]], 60 mg/kg/day, IV, divided q8h (not to exceed 2 g/dose) {{or}} [[Levofloxacin]] <50 kg: 20 mg/kg/day, IV, divided q12h (not to exceed 250 mg/dose >50 kg: 500 mg, IV, q24h {{or}} [[Imipenem]]/[[Cilastatin]],a 100 mg/kg/day, IV, divided q6h (not to exceed 1 g/dose) {{or}} [[Vancomycin]], 60 mg/kg/day, IV, divided q8h (follow serum concentrations)
::::::* (b). Alternatives for penicillin-susceptible strains: '''[[Penicillin G]], 400 000 U/kg/day, IV, divided q4h (not to exceed 4 MU/dose)''' {{or}} [[Ampicillin]], 200 mg/kg/day, IV, divided q6h (not to exceed 3 g/dose) {{and}}
:::::* (B). A Protein Synthesis Inhibitor: '''[[Clindamycin]], 40 mg/kg/day, IV, divided q8h (not to exceed 900 mg/dose)''' {{or}} [[Linezolid]] (non-CNS infection dose): <12 y old: 30 mg/kg/day, IV, divided q8h ≥12 y old: 30 mg/kg/day, IV, divided q12h (not to exceed 600 mg/dose) {{or}} [[Doxycycline]] <45 kg: 4.4 mg/kg/day, IV, loading dose (not to exceed 200 mg); ≥45 kg: 200 mg, IV, loading dose then <45 kg: 4.4 mg/kg/day, IV, divided q12h  (not to exceed 100 mg/dose); ≥45 kg: 100 mg, IV, given q12h {{or}} Rifampin,d 20 mg/kg/day, IV, divided q12h (not to exceed 300 mg/dose)
:::::: Note (1): 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.
:::::: Note (2): Systemic anthrax includes inhalation anthrax; injection, gastrointestinal, or cutaneous anthrax with systemic involvement, extensive edema, or lesions of the head or neck.
:::::: Note (3): Children with altered mental status, signs of meningeal inflammation, or focal neurologic deficits should be considered to have CNS infection if CSF examination is not possible. A normal CSF may not completely exclude deep brain hemorrhage/abscess.
:::::: Note (4): Bold font for preferred antimicrobial agent.
:::::: Note (5): Normal font for  alternative selections are listed in order of preference for therapy for patients who cannot tolerate first-line therapy or if first-line therapy is unavailable.
:::::: Note (6): Doses are provided for children with normal renal and hepatic function. Doses may vary for those with some degree of organ failure.
:::::: Note (7): Increased risk of seizures associated with [[Imipenem]]/[[Cilastatin]] therapy.
:::::: Note (8): [[Linezolid]] should be used with caution in patients with thrombocytopenia, as it may exacerbate it.[[Linezolid]] use for >14 days carries additional hematopoietic toxicity.
:::::: Note (9): A single 14-day course of [[Doxycycline]] is not routinely associated with tooth staining.
:::::: Note (10): [[Rifampin]] is not a protein synthesis inhibitor; it may also be used in combination therapy based on in vitro synergy
::::* '''(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'''
:::::* (A). A bactericidal antimicrobial (fluoroquinolone): [[Ciprofloxacin]], 30 mg/kg/day, intravenously (IV), divided q8h (not to exceed 400 mg/dose){{or}} [[Levofloxacin]] <50 kg: 16 mg/kg/day, IV, divided q12h (not to exceed 250 mg/dose); >50 kg: 500 mg, IV, q24h {{or}} [[Moxifloxacin]] 3 months to <2 years: 12 mg/kg/day, IV, divided q12h (not to exceed 200 mg/dose)
:::::: 2-5 years: 10 mg/kg/day, IV, divided q12h (not to exceed 200 mg/dose)
::::::6–11 years: 8 mg/kg/day, IV, divided q12h (not to exceed 200 mg/dose)
:::::: 12–17 years, ≥45 kg body weight: 400 mg, IV, once daily
:::::: 12–17 years, <45 kg body weight: 8 mg/kg/day, IV, divided q12h (not to exceed 200 mg/dose) {{and}}
:::::* (B). A bactericidal antimicrobial (β-lactam or glycopeptide)
::::::* (a). For all strains, regardless of penicillin susceptibility testing or if susceptibility is unknown : [[Meropenem]], 120 mg/kg/day, IV, divided q8h (not to exceed 2 g/dose) {{or}} [[Imipenem]]/[[Cilastatin]], 100 mg/kg/day, IV, divided q6h (not to exceed 1 g/dose) {{or}} [[Doripenem]], 120 mg/kg/day, IV, divided q8h (not to exceed 1 g/dose) {{or}} [[Vancomycin]], 60 mg/kg/day, IV, divided q8h
::::::* (b). Alternatives for penicillin-susceptible strains: [[Penicillin G]], 400 000 U/kg/day, IV, divided q4h (not to exceed 4 MU/dose) {{or}} [[Ampicillin]], 400 mg/kg/day, IV, divided q6h (not to exceed 3 g/dose) {{and}}
::::::* (C). A Protein Synthesis Inhibitor: [[Linezolid]] <12 y old: 30 mg/kg/day, IV, divided every 8 h≥12 y old: 30 mg/kg/day, IV, divided q12h (not to exceed 600 mg/dose) {{or}} [[Clindamycin]], 40 mg/kg/day, IV, divided q8h (not to exceed 900 mg/dose)  {{or}} [[Rifampin]], 20 mg/kg/day, IV, divided q12h (not to exceed 300 mg/dose)  {{or}} [[Chloramphenicol]], 100 mg/kg/day, IV, divided q6h
::::::: 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): Systemic anthrax includes anthrax meningitis; inhalation anthrax; or injection, gastrointestinal, and cutaneous anthrax with systemic involvement, extensive edema, or lesions of the head or neck.
::::::: Note (3): Children with altered mental status, signs of meningeal inflammation, or focal neurologic deficits should be considered to have CNS infection if CSF examination is not possible. Normal CSF may not completely exclude deep brain hemorrhage/abscess.
::::::: Note (4): Bold font for preferred antimicrobial agent.
::::::: Note (5): Normal font for alternative selections are listed in order of preference for therapy for patients who cannot tolerate first-line therapy or if first-line therapy is unavailable.
::::::: Note (6): Doses are provided for children with normal renal and hepatic function. Doses may vary for those with some degree of organ failure.
::::::: Note (7):  A 400-mg dose of [[Ciprofloxacin]], IV, provides an equivalent exposure to that of a 500-mg ciprofloxacin oral tablet.
::::::: Note (8): Increased risk of seizures associated with [[Imipenem]]/[[Cilastatin]] therapy.
::::::: Note (9): [[Doripenem]] is approved in Japan at this dose for the treatment of community-acquired bacterial meningitis.
::::::: Note (10): [[Linezolid]] should be used with caution in patients with thrombocytopenia, as it may exacerbate it. Linezolid use for >14 days carries additional hematopoietic toxicity.
::::::: Note (11): [[Rifampin]] is not a protein synthesis inhibitor; it may also be used in combination therapy based on in vitro synergy for some strains of staphylococci. Not evaluated for Bacillus anthracis.
::::::: Note (12) : [[Chloramphenicol]] Should be used only if other options are not available, because of toxicity concerns.
::::* (4).'''Oral follow-up combination therapy for severe anthrax (for Children 1 Month of Age and Older)'''
:::::* (A). A bactericidal antimicrobial
:::::: (a). For all strains, regardless of penicillin susceptibility or if susceptibility is unknown: [[Ciprofloxacin]], 30 mg/kg/day, by mouth (PO), divided q12h (not to exceed 500 mg/dose) {{or}} [[Levofloxacin]] <50 kg: 16 mg/kg/day, PO, divided q12h (not to exceed 250 mg/dose) ≥50 kg: 500 mg, PO, given q24h {{or}}
:::::: (b). Alternatives for penicillin-susceptible strains: [[Amoxicillin]], 75 mg/kg/day, PO, divided q8h (not to exceed 1 g/dose) {{or}} [[Penicillin VK]], 50–75 mg/kg/day, PO, divided q6h-q8h {{and}}
:::::* (B). A protein synthesis inhibitor: [[Clindamycin]] 30 mg/kg/day, PO, divided q8h (not to exceed 600 mg/dose) {{or}} [[Doxycycline]] <45 kg: 4.4 mg/kg/day, PO, divided q12h (not exceed 100 mg/dose) ≥45 kg: 100 mg, PO, given q12h {{or}} [[Linezolid]] (non-CNS infection dose):
:::::: <12 y old: 30 mg/kg/day, PO, divided q8h
:::::: ≥12 years old: 30 mg/kg/day, PO, divided q12h (not to exceed 600 mg/dose)
::::::: Note (1): 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.
::::::: Note (2): Severe anthrax includes inhalation anthrax; injection, gastrointestinal, or cutaneous anthrax with systemic involvement, extensive edema, or lesions of the head or neck.
::::::: Note (3): Bold font for  preferred antimicrobial agent.
::::::: Note (4): Normal font for alternative selections are listed in order of preference for therapy for patients who cannot take first-line therapy or if first-line therapy is unavailable.
::::::: Note (5): Doses are provided for children with normal renal and hepatic function. Doses may vary for those with some degree of organ failure.
::::::: Note (6):  A single 14-day course of doxycycline is not routinely associated with tooth staining.
::::::: Note (7): [[Linezolid]] should be used with caution in patients with thrombocytopenia, as it may exacerbate it. [[Linezolid]] use for >14 days carries additional hematopoietic toxicity.
::::* (5).''' Dosing in preterm and term neonates 32 to 44 Weeks postmenstrual Age (Gestational Age Plus Chronologic Age)'''
:::::* (A). Triple therapy for severe anthrax(anthrax meningitis or disseminated infection and meningitis cannot be ruled out)
::::::* (1). '''Bactericidal antimicrobial (fluoroquinolone) therapy'''
:::::::* (a) For 32–34 weeks gestational age 
:::::::: For 0–1 week of Age : '''[[Ciprofloxacin]] IV 20 mg/kg/day, divided q12h''' {{or}} [[Moxifloxacin]] IV 5 mg/kg/day, q24h
:::::::: For 1–4 weeks of Age : '''[[Ciprofloxacin]] IV 20 mg/kg/day, divided q12h''' {{or}} [[Moxifloxacin]] IV 5 mg/kg/day, q24h
:::::::* (b) For 34–37 week gestational age
:::::::: For 0–1 wk of Age : '''[[Ciprofloxacin]] IV 20 mg/kg/day, divided q12h''' {{or}} [[Moxifloxacin]] IV 5 mg/kg/day, q24h
:::::::: For 1–4 wk of Age : '''[[Ciprofloxacin]] IV 20 mg/kg/day, divided q12h''' {{or}} [[Moxifloxacin]] IV 5 mg/kg/day, q24h
:::::::* (c) Term Newborn Infant
:::::::: For 0–1 week of Age : '''[[Ciprofloxacin]] IV 30 mg/kg/day, divided q12h''' {{or}} [[Moxifloxacin]] IV 10 mg/kg/day, q24h
:::::::: For 1–4 weeks of Age : '''[[Ciprofloxacin]] IV 30 mg/kg/day, divided q12h''' {{or}} [[Moxifloxacin]] IV 10 mg/kg/day, q24h {{and}}
::::::* (2). '''A bactericidal antimicrobial (β-lactam)'''
:::::::* a. For all strains, regardless of penicillin susceptibility or if susceptibility is unknown :
::::::::* (a) For 32–34 weeks gestational age
::::::::: For 0–1 week of Age : '''[[Meropenem]]''' IV 60 mg/kg/day, divided q8h {{or}} [[Imipenem]] IV 50 mg/kg/day, divided q12h {{or}} [[Doripenem]] IV 20 mg/kg/day, divided q12h
::::::::: For 1–4 wk of Age : '''[[Meropenem]]''' IV 90 mg/kg/day, divided q8h {{or}} [[Imipenem]] IV 75 mg/kg/day, divided q8h {{or}} [[Doripenem]] IV 30 mg/kg/day,divided q8h
::::::::* (b) For 34–37 week gestational age
::::::::: For 0–1 week of Age : '''[[Meropenem]]''' IV 60 mg/kg/day, divided q8h {{or}} [[Imipenem]] IV 50 mg/kg/day, divided q12h {{or}} [[Doripenem]] IV 20 mg/kg/day, divided q12h
::::::::: For 1–4 week of Age : '''[[Meropenem]]''' IV 90 mg/kg/day, divided q8h {{or}} [[Imipenem]] IV 75 mg/kg/day, divided q8h {{or}} [[Doripenem]] IV 30 mg/kg/day,divided q8h
::::::::* (c) Term Newborn Infant
::::::::: For 0–1 week of Age: '''[[Meropenem]]''' IV 60 mg/kg/day, divided q8h {{or}} [[Imipenem]] IV 50 mg/kg/day, divided q12h {{or}} [[Doripenem]] IV 20 mg/kg/day, divided q12h
::::::::: For 1–4 week of Age : '''[[Meropenem]]''' IV 90 mg/kg/day, divided q8h {{or}} [[Imipenem]] IV 75 mg/kg/day, divided q8h {{or}} [[Doripenem]] IV 30 mg/kg/day,divided q8h {{or}}
:::::::* b. Alternatives for penicillin-susceptible strains
::::::::* (a) For 32–34 weeks gestational age
::::::::: For 0–1 week of Age : '''[[Penicillin G]]''' 200000 Units/kg/day divided q12h,{{or}} [[Ampicillin]] 100 mg/kg/day divided q12h,
::::::::: For 1–4 week of Age : '''[[Penicillin G]]''' 300000 Units/kg/day divided q12h,{{or}} [[Ampicillin]] 150 mg/kg/day divided q12h,
::::::::* (b) For 34–37 week gestational age
::::::::: For 0–1 week of Age : '''[[Penicillin G]]''' 300000 Units/kg/day divided q12h,{{or}} [[Ampicillin]] 150 mg/kg/day divided q12h,
::::::::: For 1–4 week of Age : '''[[Penicillin G]]''' 400000 Units/kg/day divided q12h,{{or}} [[Ampicillin]] 200 mg/kg/day divided q12h,
::::::::* (c) Term Newborn Infant
::::::::: For 0–1 week of Age : '''[[Penicillin G]]''' 300000 Units/kg/day divided q12h,{{or}} [[Ampicillin]] 150 mg/kg/day divided q12h,
::::::::: For 1–4 week of Age : '''[[Penicillin G]]''' 400000 Units/kg/day divided q12h,{{or}} [[Ampicillin]] 200 mg/kg/day divided q12h, {{and}}
::::::* (3).'''A protein synthesis inhibitor'''
:::::::* (a) For 32–34 weeks gestational age
:::::::: For 0–1 week of Age : '''[[Linezolid]]''' 20 mg/kg/day,divided q12h, {{or}} [[Clindamycin]] 10 mg/kg/day,divided q12h {{or}} [[Rifampin]] 10 mg/kg/day,divided q12h , {{or}} [[Chloramphenicol]] 25 mg/kg/day,q24h
:::::::: For 1–4 week of Age : '''[[Linezolid]]''' 30 mg/kg/day,divided q8h, {{or}} [[Clindamycin]] 15 mg/kg/day,divided q8h {{or}} [[Rifampin]] 10 mg/kg/day,divided q12h, {{or}} [[Chloramphenicol]] 50 mg/kg/day,q12h
:::::::* (b) For 34–37 week gestational age
:::::::: For 0–1 week of Age : '''[[Linezolid]]''' 30 mg/kg/day,divided q8h, {{or}} [[Clindamycin]] 15 mg/kg/day,divided q8h {{or}} [[Rifampin]] 10 mg/kg/day,divided q12h, {{or}} [[Chloramphenicol]] 25 mg/kg/day,q24h
:::::::: For 1–4 week of Age : '''[[Linezolid]]''' 30 mg/kg/day,divided q8h, {{or}} [[Clindamycin]] 20 mg/kg/day,divided q6h {{or}} [[Rifampin]] 10 mg/kg/day,divided q12h, {{or}} [[Chloramphenicol]] 50 mg/kg/day,q12h
:::::::* (c) Term Newborn Infant
:::::::: For 0–1 week of Age : '''[[Linezolid]]''' 30 mg/kg/day,divided q8h, {{or}} [[Clindamycin]] 15 mg/kg/day,divided q8h {{or}} [[Rifampin]] 10 mg/kg/day,divided q12h, {{or}} [[Chloramphenicol]] 25 mg/kg/day,q24h
:::::::: For 1–4 week of Age : '''[[Linezolid]]''' 30 mg/kg/day,divided q8h, {{or}} [[Clindamycin]] 20 mg/kg/day,divided q6h {{or}} {[Rifampin]] 20 mg/kg/day,divided q12h, {{or}} [[Chloramphenicol]] 50 mg/kg/day,q12h
:::::::: Note :Duration of therapy For ≥2–3 week, until clinical criteria for stability are met. Will require prophylaxis to complete an antibiotic course of upto 60 days from onset of illness.
:::::* (B). Therapy for severe anthrax when meningitis can be ruled out
::::::* (1).'''A bactericidal antimicrobial'''
::::::: (a). For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
::::::::* (a) For 32–34 weeks gestational age
::::::::: For 0–1 week of Age : '''[[Ciprofloxacin]] IV 20 mg/kg/day,divided q12h''' {{or}} [[Meropenem]] IV 40 mg/kg/day,divided q8h {{or}} [[Imipenem]] IV 40 mg/kg/day,divided q12h
::::::::: For 1–4 week of Age : '''[[Ciprofloxacin]] IV 20 mg/kg/day,divided q12h'''  {{or}}  [[Meropenem]] IV 60 mg/kg/day,divided q8h {{or}} [[Imipenem]] 50 mg/kg/day,divided q12h
::::::::* (b) For 34–37 week gestational age
::::::::: For 0–1 week of Age : '''[[Ciprofloxacin]] IV 20 mg/kg/day,divided q12h''' {{or}}  [[Meropenem]] IV 60 mg/kg/day,divided q8h {{or}} [[Imipenem]] 50 mg/kg/day,divided q12h
::::::::: For 1–4 week of Age : '''[[Ciprofloxacin]] IV 20 mg/kg/day,divided q12h''' {{or}}  [[Meropenem]] IV 60 mg/kg/day,divided q8h {{or}}  [[Imipenem]] 75 mg/kg/day,divided q8h
::::::::* (c) Term Newborn Infant
::::::::: For 0–1 week of Age : '''[[Ciprofloxacin]] IV 30 mg/kg/day,divided q12h''' {{or}}  [[Meropenem]] IV 60 mg/kg/day,divided q8h {{or}}  [[Imipenem]] 50 mg/kg/day,divided q12h
::::::::: For 1–4 week of Age : '''[[Ciprofloxacin]] IV 30 mg/kg/day,divided q12h''' {{or}}  [[Meropenem]] IV 60 mg/kg/day,divided q8h {{or}} [[Imipenem]] 75 mg/kg/day,divided q8h {{or}}
::::::::: [[Vancomycin]] IV (dosing based on serum creatinine for infants ≥32 wk gestational age). Follow vancomycin serum concentrations to modify dose.
:::::::::: If  Serum creatinine <0.7 then [[Vancomycin]] IV 15 mg/kg/dose q12h
:::::::::: If Serum creatinine 0.7 -0.9 then  [[Vancomycin]] IV 20 mg/kg/dose q24h
:::::::::: If Serum creatinine 1–1.2 then [[Vancomycin]] IV 15 mg/kg/dose q24h
:::::::::: If Serum creatinine 1.3–1.6 then  [[Vancomycin]] IV 10 mg/kg/dose q24h
:::::::::: If Serum creatinine >1.6 15 then [[Vancomycin]] IV mg/kg/dose q48h
::::::::::: Note : Begin treatment with a 20-mg/kg loading dose {{or}}
:::::::: (b). Alternatives for penicillin-susceptible strains
:::::::::* (a) For 32–34 weeks gestational age
:::::::::: For 0–1 week of Age : [[Penicillin G]] IV 200000 U/kg/day,divided q12h, {{or}} [[Ampicillin]] IV 100 mg/kg/day,divided q12h
:::::::::: For 1–4 week of Age : [[Penicillin G]] IV 300000 U/kg/day,divided q8h, {{or}} [[Ampicillin]] IV 150 mg/kg/day,divided q8h
:::::::::* (b) For 34–37 week gestational age
:::::::::: For 0–1 week of Age : [[Penicillin G]] IV 300000 U/kg/day,divided q8h, {{or}}  [[Ampicillin]] IV 150 mg/kg/day,divided q8h
:::::::::: For 1–4 week of Age : [[Penicillin G]] IV 400000 U/kg/day,divided q6h, {{or}} [[Ampicillin]] IV 200 mg/kg/day,divided q6h
:::::::::* (c) Term Newborn Infant
:::::::::: For 0–1 week of Age : [[Penicillin G]] IV 300000 U/kg/day,divided q8h, {{or}} [[Ampicillin]] IV 150 mg/kg/day,divided q8h
:::::::::: For 1–4 week of Age : [[Penicillin G]] IV 400000 U/kg/day,divided q6h, {{or}} [[Ampicillin]] IV 200 mg/kg/day,divided q6h {{and}}
::::::*(2).'''A protein synthesis inhibitor'''
:::::::* (a) For 32–34 weeks gestational age
:::::::: For 0–1 week of Age : [[Clindamycin]] IV 10 mg/kg/day, divided q12h, {{or}} [[Linezolid]] IV 20 mg/kg/day, divided q12h, {{or}} [[Rifampin]] IV 10 mg/kg/day, q24h
:::::::: For 1–4 week of Age : [[Clindamycin]] IV 15 mg/kg/day, divided q8h, {{or}}  [[Linezolid]] IV 30 mg/kg/day, divided q8h, {{or}}  [[Rifampin]] IV 10 mg/kg/day, q24h
:::::::* (b) For 34–37 week gestational age
:::::::: For 0–1 week of Age : [[Clindamycin]] IV 15 mg/kg/day, divided q8h, {{or}} [[Linezolid]] IV 30 mg/kg/day, divided q8h, {{or}}  [[Rifampin]] IV 10 mg/kg/day, q24h
:::::::: For 1–4 week of Age : [[Clindamycin]] IV 20 mg/kg/day, divided q6h, {{or}} [[Linezolid]] IV 30 mg/kg/day, divided q8h, {{or}}  [[Rifampin]] IV 10 mg/kg/day, q24h
:::::::* (c) Term Newborn Infant
:::::::: For 0–1 week of Age : [[Clindamycin]] IV 15 mg/kg/day, divided q8h, {{or}}  [[Linezolid]] IV 30 mg/kg/day, divided q8h, {{or}} [[Doxycycline]] IV 4.4 mg/kg/day, divided q12h, (loading dose 4.4 mg/kg)  {{or}} [[Rifampin]] IV 10 mg/kg/day, q24h
:::::::: For 1–4 week of Age : [[Clindamycin]] IV 20 mg/kg/day, divided q6h, {{or}} [[Linezolid]] IV 30 mg/kg/day, divided q8h, {{or}} [[Doxycycline]] IV 4.4 mg/kg/day, divided q12h, (loading dose 4.4 mg/kg)  {{or}} [[Rifampin]] IV 10 mg/kg/day, q24h
::::::::: Note: Duration of therapy: For ≥2–3 wk, 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
:::::*(C). Oral follow-up combination therapy for severe anthrax
::::::(1).'''A bactericidal antimicrobial'''
::::::: (a). For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
::::::::* (a) For 32–34 weeks gestational age
::::::::: For 0–1 week of Age : '''[[Ciprofloxacin]] PO 20 mg/kg/day, divided q12h'''
::::::::: For 1–4 week of Age : '''[[Ciprofloxacin]] PO 20 mg/kg/day, divided q12h'''
::::::::* (b) For 34–37 week gestational age
::::::::: For 0–1 week of Age : '''[[Ciprofloxacin]] PO 20 mg/kg/day, divided q12h'''
::::::::: For 1–4 week of Age : '''[[Ciprofloxacin]] PO 20 mg/kg/day, divided q12h'''
::::::::* (c) Term Newborn Infant
::::::::: For 0–1 week of Age : '''[[Ciprofloxacin]] PO 30 mg/kg/day, divided q12h'''
::::::::: For 1–4 week of Age : '''[[Ciprofloxacin]] PO 30 mg/kg/day, divided q12h''' {{or}}
:::::::(b). Alternatives for penicillin-susceptible strains
::::::::* (a) For 32–34 weeks gestational age
::::::::: For 0–1 week of Age : '''[[Amoxicillin]]''' PO 50 mg/kg/day, divided q12h, {{or}} Penicillin VK PO 50 mg/kg/day, divided q12h
::::::::: For 1–4 week of Age : '''[[Amoxicillin]]''' PO 75 mg/kg/day, divided q8h {{or}} Penicillin VK PO 75 mg/kg/day, divided q8h
::::::::* (b) For 34–37 week gestational age
::::::::: For 0–1 week of Age : '''[[Amoxicillin]]''' PO 50 mg/kg/day, divided q12h {{or}} Penicillin VK PO  50 mg/kg/day, divided q12h
::::::::: For 1–4 week of Age : '''[[Amoxicillin]]''' PO 75 mg/kg/day, divided q8h {{or}} Penicillin VK PO 75 mg/kg/day, divided q8h
::::::::* (c) Term Newborn Infant
::::::::: For 0–1 week of Age : '''[[Amoxicillin]]''' PO 75 mg/kg/day, divided q8h {{or}} Penicillin VK PO 75 mg/kg/day, divided q8h
::::::::: For 1–4 week of Age : '''[[Amoxicillin]]''' PO 75 mg/kg/day, divided q8h {{or}} Penicillin VK PO 75 mg/kg/day, divided q6–8h  {{and}}
::::::(2).'''A protein synthesis inhibitor'''
:::::::* (a) For 32–34 weeks gestational age
:::::::: For 0–1 week of Age : '''[[Clindamycin]] PO 10 mg/kg/day, divided q12h''' {{or}} [[Linezolid]] PO 20 mg/kg/day, divided q12h
:::::::: For 1–4 week of Age : '''[[Clindamycin]] PO 15 mg/kg/day, divided q8h''' {{or}} [[Linezolid]] PO 30 mg/kg/day, divided q8h
:::::::* (b) For 34–37 week gestational age
:::::::: For 0–1 week of Age : '''[[Clindamycin]] PO 15 mg/kg/day, divided q8h''' {{or}} [[Linezolid]] PO 30 mg/kg/day, divided q8h
:::::::: For 1–4 week of Age : '''[[Clindamycin]] PO 20 mg/kg/day, divided q6h''' {{or}} [[Linezolid]] PO 30 mg/kg/day, divided q8h
:::::::* (c) Term Newborn Infant
:::::::: For 0–1 week of Age : '''[[Clindamycin]] PO 15 mg/kg/day, divided q8h''' {{or}} [[Doxycycline]] PO 4.4 mg/kg/day, divided q12h (loading dose 4.4 mg/kg)  {{or}} [[Linezolid]] PO 30 mg/kg/day, divided q8h
:::::::: For 1–4 week of Age :'''[[Clindamycin]] PO 20 mg/kg/day, divided q6h''' {{or}} [[Doxycycline]] PO 4.4 mg/kg/day, divided q12h (loading dose 4.4 mg/kg) {{or}} [[Linezolid]] PO 30 mg/kg/day, divided q8h  {{or}}
::::::::: 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.
:::::*(D).Treatment of cutaneous anthrax without systemic involvement
::::::*(1).'''For all strains, regardless of penicillin susceptibility or if susceptibility is unknown'''
:::::::* (a) For 32–34 weeks gestational age
:::::::: For 0–1 week of Age : '''[[Ciprofloxacin]]''' PO 20 mg/kg/day, divided q12h {{or}} [[Clindamycin]] PO 10 mg/kg/day, divided q12h
:::::::: For 1–4 week of Age : '''[[Ciprofloxacin]]''' PO 20 mg/kg/day, divided q12h {{or}} [[Clindamycin]] PO 15 mg/kg/day, divided q8h
:::::::* (b) For 34–37 week gestational age
:::::::: For 0–1 week of Age : '''[[Ciprofloxacin]]''' PO 20 mg/kg/day, divided q12h {{or}} [[Clindamycin]] PO 15 mg/kg/day, divided q8h
:::::::: For 1–4 week of Age : '''[[Ciprofloxacin]]''' PO 20 mg/kg/day, divided q12h {{or}} [[Clindamycin]] PO 20 mg/kg/day, divided q6h
:::::::* (c) Term Newborn Infant
:::::::: For 0–1 week of Age : '''[[Ciprofloxacin]]''' PO 30 mg/kg/day, divided q12h {{or}} [[Doxycycline]] PO 4.4 mg/kg/day, divided q12h (Loading dose 4.4 mg/kg) {{or}} [[Clindamycin]] PO 15 mg/kg/day, divided q8h
:::::::: For 1–4 week of Age : '''[[Ciprofloxacin]]''' PO 30 mg/kg/day, divided q12h {{or}} [[Doxycycline]] PO 4.4 mg/kg/day, divided q12h (Loading dose 4.4 mg/kg) {{or}} [[Clindamycin]] PO 20 mg/kg/day, divided q6h
::::::*(2).'''Alternatives for penicillin-susceptible strains'''
:::::::* (a) For 32–34 weeks gestational age
:::::::: For 0–1 week of Age : '''[[Amoxicillin]]''' PO 50 mg/kg/day, divided q12h {{or}} Penicillin Vk PO 50 mg/kg/day, divided q12h
:::::::: For 1–4 week of Age : '''[[Amoxicillin]]''' PO 75 mg/kg/day, divided q8h  {{or}} Penicillin Vk PO 75 mg/kg/day, divided q8h
:::::::* (b) For 34–37 week gestational age
:::::::: For 0–1 week of Age : '''[[Amoxicillin]]''' PO 50 mg/kg/day, divided q12h {{or}} Penicillin Vk PO 50 mg/kg/day, divided q12h
:::::::: For 1–4 week of Age : '''[[Amoxicillin]]''' PO 75 mg/kg/day, divided q8h {{or}} Penicillin Vk PO 75 mg/kg/day, divided q8h
:::::::* (c) Term Newborn Infant
:::::::: For 0–1 week of Age : '''[[Amoxicillin]]''' PO 75 mg/kg/day, divided q8h {{or}} Penicillin Vk PO 75 mg/kg/day, divided q8h
:::::::: For 1–4 week of Age : '''[[Amoxicillin]]''' PO 75 mg/kg/day, divided q8h {{or}} Penicillin Vk PO 75 mg/kg/day, divided q6–8h
::::::::: 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
::* '''For adults'''<ref name="pmid24447897">{{cite journal| author=Hendricks KA, Wright ME, Shadomy SV, Bradley JS, Morrow MG, Pavia AT et al.| title=Centers for disease control and prevention expert panel meetings on prevention and treatment of anthrax in adults. | journal=Emerg Infect Dis | year= 2014 | volume= 20 | issue= 2 | pages=  | pmid=24447897 | doi=10.3201/eid2002.130687 | pmc=PMC3901462 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24447897  }} </ref>
:::* (1) For all strains, regardless of penicillin susceptibility or if susceptibility is unknown: '''[[Ciprofloxacin]], 500 mg q12h''' {{or}} '''Doxycycline, 100 mg q12h''' {{or}} Levofloxacin, 750 mg q24h {{or}} Moxifloxacin, 400 mg q24h {{or}} Clindamycin, 600 mg q8h {{or}}
:::* (2) Alternatives for penicillin-susceptible strain Amoxicillin, 1 g q8h {{or}} Penicillin VK, 500 mg q6h
:::: Note (1): Preferred drugs are indicated in boldface.
:::: Note (2): Alternative drugs are listed in order of preference for treatment for patients who cannot take first-line treatment or if first-line treatment is unavailable.
::* '''For children ≥ 1 month'''<ref name="pmid24777226">{{cite journal| author=Bradley JS, Peacock G, Krug SE, Bower WA, Cohn AC, Meaney-Delman D et al.| title=Pediatric anthrax clinical management. | journal=Pediatrics | year= 2014 | volume= 133 | issue= 5 | pages= e1411-36 | pmid=24777226 | doi=10.1542/peds.2014-0563 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24777226  }} </ref>
:::* (1) For penicillin-resistant strains or prior to susceptibility testing: '''[[Ciprofloxacin]], 30 mg/kg/day, by mouth (PO), divided q12h (not to exceed 500 mg/dose)''' {{or}} '''[[Doxycycline]], <45 kg: 4.4 mg/kg/day, PO, divided q12h (not to exceed 100 mg/dose)''' >45 kg: 100 mg/dose, PO, given q12h {{or}} [[Clindamycin]], 30 mg/kg/day, PO, divided q8h (not to exceed 900 mg/dose) {{or}} [[Levofloxacin]], <50 kg: 16 mg/kg/day, PO, divided q12h (not to exceed 250 mg/dose) >50 kg: 500 mg, PO, given q24h {{or}}
:::* (2) For penicillin-susceptible strains: '''[[Amoxicillin]], 75 mg/kg/day, PO, divided every q8h (not to exceed 1 g/dose)''' {{or}} [[Penicillin VK]], 50-75 mg/kg/day, PO, divided q6h to q8h
:::: Note (1) : '''Duration of Therapy is 60 days after exposure'''
:::: Note (2) : Bold font are  preferred antimicrobial agent (when 2 bolded antimicrobial agents are present, both are considered equivalent in overall safety and efficacy).
:::: Note (3) : Normal font are alternative selections are listed in order of preference for therapy for patients who cannot take first-line therapy or if first-line therapy is unavailable.
:::: Note (4) : Doses are provided for children with normal renal and hepatic function. Doses may vary for those with some degree of organ failure.
:::: Note (5) : Italicized font: indicates FDA approval for the indication in the pediatric population.
:::: Note (6) : A single 14-day course of doxycycline is not routinely associated with tooth staining, but some degree of staining is likely for a prolonged treatment course of up to 60 days.
:::: Note (7) : Safety data for [[Levofloxacin]] in the pediatric population are limited to 14 days for duration therapy.
:::: Note (8) : Be aware of the possibility of emergence of penicillin-resistance during monotherapy with [[Amoxicillin]] or [[Penicillin]].
::* '''For children < 1 month'''
:::* (1) '''For all strains, regardless of penicillin susceptibility or if susceptibility is unknown'''
::::* (a) For 32–34 weeks gestational age
::::: For 0–1 week of Age : '''[[Ciprofloxacin]]''' PO 20 mg/kg/day, divided q12h {{or}} [[Clindamycin]] PO 10 mg/kg/day, divided q12h
::::: For 1–4 week of Age : '''[[Ciprofloxacin]]''' PO 20 mg/kg/day, divided q12h {{or}} [[Clindamycin]] PO 15 mg/kg/day, divided q8h
::::* (b) For 34–37 week gestational age
::::: For 0–1 week of Age : '''[[Ciprofloxacin]]''' PO 20 mg/kg/day, divided q12h {{or}} [[Clindamycin]] PO 15 mg/kg/day, divided q8h
::::: For 1–4 week of Age : '''[[Ciprofloxacin]]''' PO 20 mg/kg/day, divided q12h {{or}} [[Clindamycin]] PO 20 mg/kg/day, divided q6h
::::* (c) Term Newborn Infant
::::: For 0–1 week of Age : '''[[Ciprofloxacin]]''' PO 30 mg/kg/day, divided q12h {{or}} [[Doxycycline]] PO 4.4 mg/kg/day, divided q12h (Loading dose 4.4 mg/kg) {{or}} [[Clindamycin]] PO 15 mg/kg/day, divided q8h
::::: For 1–4 week of Age : '''[[Ciprofloxacin]]''' PO 30 mg/kg/day, divided q12h {{or}} [[Doxycycline]] PO 4.4 mg/kg/day, divided q12h (Loading dose 4.4 mg/kg) {{or}} [[Clindamycin]] PO 20 mg/kg/day, divided q6h  {{or}}
:::* (2) '''Alternatives for penicillin-susceptible strains'''
::::* (a) For 32–34 weeks gestational age
::::: For 0–1 week of Age : [[Amoxicillin]] PO 50 mg/kg/day, divided q12h {{or}} [[Penicillin Vk]] PO 50 mg/kg/day, divided q12h
::::: For 1–4 week of Age : [[Amoxicillin]] PO 75 mg/kg/day, divided q8h {{or}} [[Penicillin Vk]] PO 75 mg/kg/day, divided q8h
::::* (b) For 34–37 week gestational age
:::::: For 0–1 week of Age : [[Amoxicillin]] PO 50 mg/kg/day, divided q12h {{or}} [[Penicillin Vk]] PO 50 mg/kg/day, divided q12h
:::::: For 1–4 week of Age : [[Amoxicillin]] PO 75 mg/kg/day, divided q8h {{or}} [[Penicillin Vk]] PO 75 mg/kg/day, divided q8h
::::* (c) Term Newborn Infant
::::: For 0–1 week of Age : [[Amoxicillin]] PO 75 mg/kg/day, divided q8h {{or}} [[Penicillin Vk]] PO 75 mg/kg/day, divided q8h
::::: For 1–4 week of Age : [[Amoxicillin]] PO 75 mg/kg/day, divided q8h {{or}} [[Penicillin Vk]] PO 75 mg/kg/day, divided q6–8h
::::: Note: Duration of therapy is  60 days from exposure


==Gallery==
==Gallery==

Revision as of 20:32, 26 June 2015

Bacillus anthracis
Photomicrograph of Bacillus anthracis (fuchsin-methylene blue spore stain).
Photomicrograph of Bacillus anthracis (fuchsin-methylene blue spore stain).
Scientific classification
Kingdom: Bacteria
Phylum: Firmicutes
Class: Bacilli
Order: Bacillales
Family: Bacillaceae
Genus: Bacillus
Species: B. anthracis
Binomial name
Bacillus anthracis
Cohn 1872
File:B anthracis diagram en.png
Structure of Bacillus anthracis.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Jesus Rosario Hernandez, M.D. [2]

Overview

Bacillus anthracis is a Gram-positive, facultatively anaerobic, rod-shaped bacterium of the genus Bacillus. An endospore forming bacterium, B. anthracis is a natural soil-dwelling organism, as well as the causative agent of anthrax.[1]

Each cell is about 1 by 6 μm in size.

Historical background

B. anthracis was the first bacterium conclusively demonstrated to cause disease, by Robert Koch in 1877.[2] The species name anthracis is from the Greek anthrakis (ἄνθραξ), meaning coal and referring to the most common form of the disease, cutaneous anthrax, in which large black skin lesions are formed.

Pathogenicity

Under conditions of environmental stress, B. anthracis bacteria naturally produce endospores which rest in the soil and can survive for decades in this state. When ingested by a cattle, sheep, or other herbivores, the bacteria begin to reproduce inside the animal and eventually kill it, then continue to reproduce in its carcass. Once the nutrients are exhausted, new endospores are produced and the cycle repeats.[3]

B. anthracis has at least 89 known strains, ranging from highly virulent strains with biological warfare and bioterrorism applications (Ames and Vollum) to benign strains used for inoculations (Sterne). The strains differ in presence and activity of various genes, determining their virulence and production of antigens and toxins. The form associated with the 2001 anthrax attacks produced both toxin (consisting of three proteins: the protective antigen, the edema factor and the lethal factor) and a capsule (consisting of a polymer of glutamic acid). Infection with anthrax requires the presence of all three of these exotoxins.[4]

The bacterium can be cultivated in ordinary nutrient medium under aerobic or anaerobic conditions.

Treatment

Main article: Anthrax

Infections with B. anthracis can be treated with β-lactam antibiotics such as penicillin, and others which are active against Gram-positive bacteria.[5]

Treatment

Antimicrobial therapy

  • (A) Treatment for cutaneous anthrax, without systemic involvement[6]
Note: Duration of treatment is 60 days for bioterrorism-related cases and 7-10 days for naturally acquired cases.
  • (B) 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[6]
  • (B-1) Systemic anthrax with possible/confirmed meningitis
Note (1): Duration of treatment: ≥ 2-3 weeks until clinical criteria for stability are met (Preferred drugs are indicated in boldface).
Note (2): Patients exposed to aerosolized spores will require prophylaxis to complete an antimicrobial drug course of 60 days from onset of illness.
Note (3): Alternative drugs are listed in order of preference for treatment for patients who cannot take first-line treatment, or if first-line treatment is unavailable.
Note (4): Increased risk for seizures associated with Imipenem/Cilastatin treatment.
Note (5): 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 (6): 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.
Note (7): Chloramphenicol should only be used if other options are not available because of toxicity concerns.
  • (B-2) Systemic anthrax when meningitis has been excluded
Note (1): Duration of treatment: for 2 weeks until clinical criteria for stability are met (Preferred drugs are indicated in boldface).
Note (2): Patients exposed to aerosolized spores will require prophylaxis to complete an antimicrobial drug course of 60 days from onset of illness.
Note (3): Alternative drugs are listed in order of preference for treatment for patients who cannot take first-line treatment, or if first-line treatment is unavailable.
Note (4): Increased risk for seizures associated with Imipenem/Cilastatin treatment.
Note (5): 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 (6): 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.
Note (7): A single 10-14 days course of Doxycycline is not routinely associated with tooth staining.
  • Specific considerations
  • Treatment of anthrax for pregnant Women
  • (A) Intravenous antimicrobial treatment for systemic anthrax with possible/confirmed meningitis [7]
  • (1) A Bactericidal Agent (Fluoroquinolone): Ciprofloxacin 400 mg IV q8h is preferred, OR Levofloxacin 750 mg IV q24h, OR
  • (2). A Bactericidal Agent (β-lactam)
  • (a). For all strains, regardless of penicillin susceptibility or if susceptibility is unknown : Meropenem 2 g q8h,OR
  • (b). Alternatives for penicillin-susceptible strains: Ampicillin 3 g IV q6h,OR Penicillin G 4 million units IV q4h, OR
Note (1): At least one antibiotic with transplacental passage is recommended.
Note (2): Duration of treatment is for ≥2–3 weeks until clinical criteria for stability are met. Patients exposed to aerosolized spores will require prophylaxis to complete an antimicrobial drug course of 60 days from onset of illness.
  • (B) Intravenous antimicrobial treatment for systemic anthrax when meningitis has been excluded
  • (1). A Bactericidal Antimicrobial: Ciprofloxacin 400 mg IV q8h is preferred, OR Levofloxacin 750 mg IV q24h, OR
  • (2). A Bactericidal Agent (β-lactam)
  • (a). For all strains, regardless of penicillin susceptibility or if susceptibility is unknown : Meropenem 2 g q8h,OR
  • (b). Alternatives for penicillin-susceptible strains:Ampicillin 3 g IV q6h,OR Penicillin G 4 million units IV q4h, OR
Note (1): At least one antibiotic with transplacental passage is recommended.
Note (2):Duration of treatment: for ≥2 weeks until clinical criteria for stability are met. Patients exposed to aerosolized spores will require prophylaxis to complete an antimicrobial drug course of 60 days from onset of illness
  • (C) Oral antimicrobial treatment for cutaneous anthrax without systemic involvement
  • (a).For all strains, regardless of penicillin susceptibility or if susceptibility is unknown: Ciprofloxacin 400 mg IV q8h is preferred.
Note (1): duration of treatment is 60 days
Note (2): Recommendations are specific to cutaneous anthrax in the setting of bioterrorism.
  • Treatment for anthrax in childern [8]
  • (1). Treatment of cutaneous anthrax without systemic involvement (for children 1 month of age and older)
  • (A). For all strains, regardless of penicillin susceptibility or if susceptibility is unknown : Ciprofloxacin, 30 mg/kg/day, by mouth (PO), divided q12h (not to exceed 500 mg/dose) OR Doxycycline, <45 kg: 4.4 mg/kg/day, PO, divided q12h (not to exceed 100 mg/dose) ≥45 kg: 100 mg/dose, PO, given q12h OR Clindamycin, 30 mg/kg/day, PO, divided q8h (not to exceed 600 mg/dose) OR Levofloxacin <50 kg: 16 mg/kg/day, PO, divided q12h (not to exceed 250 mg/dose) >50 kg: 500 mg, PO, given q24h OR
  • (B). Alternatives for penicillin-susceptible strains: Amoxicillin, 75 mg/kg/day, PO, divided q8h (not to exceed 1 g/dose) OR Penicillin VK, 50-75 mg/kg/day, PO, divided q6h to q8h
Note (1): Duration of therapy for naturally acquired infection: 7-10 days and for a biological weapon-related event: will require additional prophylaxis for inhaled spores, to complete an antimicrobial course of up to 60 days from onset of illness.
Note (2): Bold font for preferred antimicrobial agent.
Note (3): Normal font for alternative selections are listed in order of preference for therapy for patients who cannot take first-line therapy or first-line therapy is unavailable.
Note (4): Doses are provided for children with normal renal and hepatic function. Doses may vary for those with some degree of organ failure.
Note (5): Italicized font indicates FDA approval for the indication in the pediatric population.
Note (6): A single 10- to 14-day course of doxycycline is not routinely associated with tooth staining.
Note (7): Be aware of the possibility of emergence of penicillin-resistance during monotherapy with amoxicillin or penicillin.
  • (2). Combination therapy for systemic anthrax when meningitis can be ruled out (for children 1 month of age and older)
  • (A). A bactericidal antimicrobial
  • (a). For all strains, regardless of penicillin susceptibility or if susceptibility is unknown: Ciprofloxacin, 30 mg/kg/day, intravenously (IV), divided q8h (not to exceed 400 mg/dose) OR Meropenem, 60 mg/kg/day, IV, divided q8h (not to exceed 2 g/dose) OR Levofloxacin <50 kg: 20 mg/kg/day, IV, divided q12h (not to exceed 250 mg/dose >50 kg: 500 mg, IV, q24h OR Imipenem/Cilastatin,a 100 mg/kg/day, IV, divided q6h (not to exceed 1 g/dose) OR Vancomycin, 60 mg/kg/day, IV, divided q8h (follow serum concentrations)
  • (b). Alternatives for penicillin-susceptible strains: Penicillin G, 400 000 U/kg/day, IV, divided q4h (not to exceed 4 MU/dose) OR Ampicillin, 200 mg/kg/day, IV, divided q6h (not to exceed 3 g/dose) AND
  • (B). A Protein Synthesis Inhibitor: Clindamycin, 40 mg/kg/day, IV, divided q8h (not to exceed 900 mg/dose) OR Linezolid (non-CNS infection dose): <12 y old: 30 mg/kg/day, IV, divided q8h ≥12 y old: 30 mg/kg/day, IV, divided q12h (not to exceed 600 mg/dose) OR Doxycycline <45 kg: 4.4 mg/kg/day, IV, loading dose (not to exceed 200 mg); ≥45 kg: 200 mg, IV, loading dose then <45 kg: 4.4 mg/kg/day, IV, divided q12h (not to exceed 100 mg/dose); ≥45 kg: 100 mg, IV, given q12h OR Rifampin,d 20 mg/kg/day, IV, divided q12h (not to exceed 300 mg/dose)
Note (1): 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.
Note (2): Systemic anthrax includes inhalation anthrax; injection, gastrointestinal, or cutaneous anthrax with systemic involvement, extensive edema, or lesions of the head or neck.
Note (3): Children with altered mental status, signs of meningeal inflammation, or focal neurologic deficits should be considered to have CNS infection if CSF examination is not possible. A normal CSF may not completely exclude deep brain hemorrhage/abscess.
Note (4): Bold font for preferred antimicrobial agent.
Note (5): Normal font for alternative selections are listed in order of preference for therapy for patients who cannot tolerate first-line therapy or if first-line therapy is unavailable.
Note (6): Doses are provided for children with normal renal and hepatic function. Doses may vary for those with some degree of organ failure.
Note (7): Increased risk of seizures associated with Imipenem/Cilastatin therapy.
Note (8): Linezolid should be used with caution in patients with thrombocytopenia, as it may exacerbate it.Linezolid use for >14 days carries additional hematopoietic toxicity.
Note (9): A single 14-day course of Doxycycline is not routinely associated with tooth staining.
Note (10): Rifampin is not a protein synthesis inhibitor; it may also be used in combination therapy based on in vitro synergy
  • (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
  • (A). A bactericidal antimicrobial (fluoroquinolone): Ciprofloxacin, 30 mg/kg/day, intravenously (IV), divided q8h (not to exceed 400 mg/dose)OR Levofloxacin <50 kg: 16 mg/kg/day, IV, divided q12h (not to exceed 250 mg/dose); >50 kg: 500 mg, IV, q24h OR Moxifloxacin 3 months to <2 years: 12 mg/kg/day, IV, divided q12h (not to exceed 200 mg/dose)
2-5 years: 10 mg/kg/day, IV, divided q12h (not to exceed 200 mg/dose)
6–11 years: 8 mg/kg/day, IV, divided q12h (not to exceed 200 mg/dose)
12–17 years, ≥45 kg body weight: 400 mg, IV, once daily
12–17 years, <45 kg body weight: 8 mg/kg/day, IV, divided q12h (not to exceed 200 mg/dose) AND
  • (B). A bactericidal antimicrobial (β-lactam or glycopeptide)
  • (a). For all strains, regardless of penicillin susceptibility testing or if susceptibility is unknown : Meropenem, 120 mg/kg/day, IV, divided q8h (not to exceed 2 g/dose) OR Imipenem/Cilastatin, 100 mg/kg/day, IV, divided q6h (not to exceed 1 g/dose) OR Doripenem, 120 mg/kg/day, IV, divided q8h (not to exceed 1 g/dose) OR Vancomycin, 60 mg/kg/day, IV, divided q8h
  • (b). Alternatives for penicillin-susceptible strains: Penicillin G, 400 000 U/kg/day, IV, divided q4h (not to exceed 4 MU/dose) OR Ampicillin, 400 mg/kg/day, IV, divided q6h (not to exceed 3 g/dose) AND
  • (C). A Protein Synthesis Inhibitor: Linezolid <12 y old: 30 mg/kg/day, IV, divided every 8 h≥12 y old: 30 mg/kg/day, IV, divided q12h (not to exceed 600 mg/dose) OR Clindamycin, 40 mg/kg/day, IV, divided q8h (not to exceed 900 mg/dose) OR Rifampin, 20 mg/kg/day, IV, divided q12h (not to exceed 300 mg/dose) OR Chloramphenicol, 100 mg/kg/day, IV, divided q6h
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): Systemic anthrax includes anthrax meningitis; inhalation anthrax; or injection, gastrointestinal, and cutaneous anthrax with systemic involvement, extensive edema, or lesions of the head or neck.
Note (3): Children with altered mental status, signs of meningeal inflammation, or focal neurologic deficits should be considered to have CNS infection if CSF examination is not possible. Normal CSF may not completely exclude deep brain hemorrhage/abscess.
Note (4): Bold font for preferred antimicrobial agent.
Note (5): Normal font for alternative selections are listed in order of preference for therapy for patients who cannot tolerate first-line therapy or if first-line therapy is unavailable.
Note (6): Doses are provided for children with normal renal and hepatic function. Doses may vary for those with some degree of organ failure.
Note (7): A 400-mg dose of Ciprofloxacin, IV, provides an equivalent exposure to that of a 500-mg ciprofloxacin oral tablet.
Note (8): Increased risk of seizures associated with Imipenem/Cilastatin therapy.
Note (9): Doripenem is approved in Japan at this dose for the treatment of community-acquired bacterial meningitis.
Note (10): Linezolid should be used with caution in patients with thrombocytopenia, as it may exacerbate it. Linezolid use for >14 days carries additional hematopoietic toxicity.
Note (11): Rifampin is not a protein synthesis inhibitor; it may also be used in combination therapy based on in vitro synergy for some strains of staphylococci. Not evaluated for Bacillus anthracis.
Note (12) : Chloramphenicol Should be used only if other options are not available, because of toxicity concerns.
  • (4).Oral follow-up combination therapy for severe anthrax (for Children 1 Month of Age and Older)
  • (A). A bactericidal antimicrobial
(a). For all strains, regardless of penicillin susceptibility or if susceptibility is unknown: Ciprofloxacin, 30 mg/kg/day, by mouth (PO), divided q12h (not to exceed 500 mg/dose) OR Levofloxacin <50 kg: 16 mg/kg/day, PO, divided q12h (not to exceed 250 mg/dose) ≥50 kg: 500 mg, PO, given q24h OR
(b). Alternatives for penicillin-susceptible strains: Amoxicillin, 75 mg/kg/day, PO, divided q8h (not to exceed 1 g/dose) OR Penicillin VK, 50–75 mg/kg/day, PO, divided q6h-q8h AND
  • (B). A protein synthesis inhibitor: Clindamycin 30 mg/kg/day, PO, divided q8h (not to exceed 600 mg/dose) OR Doxycycline <45 kg: 4.4 mg/kg/day, PO, divided q12h (not exceed 100 mg/dose) ≥45 kg: 100 mg, PO, given q12h OR Linezolid (non-CNS infection dose):
<12 y old: 30 mg/kg/day, PO, divided q8h
≥12 years old: 30 mg/kg/day, PO, divided q12h (not to exceed 600 mg/dose)
Note (1): 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.
Note (2): Severe anthrax includes inhalation anthrax; injection, gastrointestinal, or cutaneous anthrax with systemic involvement, extensive edema, or lesions of the head or neck.
Note (3): Bold font for preferred antimicrobial agent.
Note (4): Normal font for alternative selections are listed in order of preference for therapy for patients who cannot take first-line therapy or if first-line therapy is unavailable.
Note (5): Doses are provided for children with normal renal and hepatic function. Doses may vary for those with some degree of organ failure.
Note (6): A single 14-day course of doxycycline is not routinely associated with tooth staining.
Note (7): Linezolid should be used with caution in patients with thrombocytopenia, as it may exacerbate it. Linezolid use for >14 days carries additional hematopoietic toxicity.
  • (5). Dosing in preterm and term neonates 32 to 44 Weeks postmenstrual Age (Gestational Age Plus Chronologic Age)
  • (A). Triple therapy for severe anthrax(anthrax meningitis or disseminated infection and meningitis cannot be ruled out)
  • (1). Bactericidal antimicrobial (fluoroquinolone) therapy
  • (a) For 32–34 weeks gestational age
For 0–1 week of Age : Ciprofloxacin IV 20 mg/kg/day, divided q12h OR Moxifloxacin IV 5 mg/kg/day, q24h
For 1–4 weeks of Age : Ciprofloxacin IV 20 mg/kg/day, divided q12h OR Moxifloxacin IV 5 mg/kg/day, q24h
  • (b) For 34–37 week gestational age
For 0–1 wk of Age : Ciprofloxacin IV 20 mg/kg/day, divided q12h OR Moxifloxacin IV 5 mg/kg/day, q24h
For 1–4 wk of Age : Ciprofloxacin IV 20 mg/kg/day, divided q12h OR Moxifloxacin IV 5 mg/kg/day, q24h
  • (c) Term Newborn Infant
For 0–1 week of Age : Ciprofloxacin IV 30 mg/kg/day, divided q12h OR Moxifloxacin IV 10 mg/kg/day, q24h
For 1–4 weeks of Age : Ciprofloxacin IV 30 mg/kg/day, divided q12h OR Moxifloxacin IV 10 mg/kg/day, q24h AND
  • (2). A bactericidal antimicrobial (β-lactam)
  • a. For all strains, regardless of penicillin susceptibility or if susceptibility is unknown :
  • (a) For 32–34 weeks gestational age
For 0–1 week of Age : Meropenem IV 60 mg/kg/day, divided q8h OR Imipenem IV 50 mg/kg/day, divided q12h OR Doripenem IV 20 mg/kg/day, divided q12h
For 1–4 wk of Age : Meropenem IV 90 mg/kg/day, divided q8h OR Imipenem IV 75 mg/kg/day, divided q8h OR Doripenem IV 30 mg/kg/day,divided q8h
  • (b) For 34–37 week gestational age
For 0–1 week of Age : Meropenem IV 60 mg/kg/day, divided q8h OR Imipenem IV 50 mg/kg/day, divided q12h OR Doripenem IV 20 mg/kg/day, divided q12h
For 1–4 week of Age : Meropenem IV 90 mg/kg/day, divided q8h OR Imipenem IV 75 mg/kg/day, divided q8h OR Doripenem IV 30 mg/kg/day,divided q8h
  • (c) Term Newborn Infant
For 0–1 week of Age: Meropenem IV 60 mg/kg/day, divided q8h OR Imipenem IV 50 mg/kg/day, divided q12h OR Doripenem IV 20 mg/kg/day, divided q12h
For 1–4 week of Age : Meropenem IV 90 mg/kg/day, divided q8h OR Imipenem IV 75 mg/kg/day, divided q8h OR Doripenem IV 30 mg/kg/day,divided q8h OR
  • b. Alternatives for penicillin-susceptible strains
  • (a) For 32–34 weeks gestational age
For 0–1 week of Age : Penicillin G 200000 Units/kg/day divided q12h,OR Ampicillin 100 mg/kg/day divided q12h,
For 1–4 week of Age : Penicillin G 300000 Units/kg/day divided q12h,OR Ampicillin 150 mg/kg/day divided q12h,
  • (b) For 34–37 week gestational age
For 0–1 week of Age : Penicillin G 300000 Units/kg/day divided q12h,OR Ampicillin 150 mg/kg/day divided q12h,
For 1–4 week of Age : Penicillin G 400000 Units/kg/day divided q12h,OR Ampicillin 200 mg/kg/day divided q12h,
  • (c) Term Newborn Infant
For 0–1 week of Age : Penicillin G 300000 Units/kg/day divided q12h,OR Ampicillin 150 mg/kg/day divided q12h,
For 1–4 week of Age : Penicillin G 400000 Units/kg/day divided q12h,OR Ampicillin 200 mg/kg/day divided q12h, AND
  • (3).A protein synthesis inhibitor
  • (a) For 32–34 weeks gestational age
For 0–1 week of Age : Linezolid 20 mg/kg/day,divided q12h, OR Clindamycin 10 mg/kg/day,divided q12h OR Rifampin 10 mg/kg/day,divided q12h , OR Chloramphenicol 25 mg/kg/day,q24h
For 1–4 week of Age : Linezolid 30 mg/kg/day,divided q8h, OR Clindamycin 15 mg/kg/day,divided q8h OR Rifampin 10 mg/kg/day,divided q12h, OR Chloramphenicol 50 mg/kg/day,q12h
  • (b) For 34–37 week gestational age
For 0–1 week of Age : Linezolid 30 mg/kg/day,divided q8h, OR Clindamycin 15 mg/kg/day,divided q8h OR Rifampin 10 mg/kg/day,divided q12h, OR Chloramphenicol 25 mg/kg/day,q24h
For 1–4 week of Age : Linezolid 30 mg/kg/day,divided q8h, OR Clindamycin 20 mg/kg/day,divided q6h OR Rifampin 10 mg/kg/day,divided q12h, OR Chloramphenicol 50 mg/kg/day,q12h
  • (c) Term Newborn Infant
For 0–1 week of Age : Linezolid 30 mg/kg/day,divided q8h, OR Clindamycin 15 mg/kg/day,divided q8h OR Rifampin 10 mg/kg/day,divided q12h, OR Chloramphenicol 25 mg/kg/day,q24h
For 1–4 week of Age : Linezolid 30 mg/kg/day,divided q8h, OR Clindamycin 20 mg/kg/day,divided q6h OR {[Rifampin]] 20 mg/kg/day,divided q12h, OR Chloramphenicol 50 mg/kg/day,q12h
Note :Duration of therapy For ≥2–3 week, until clinical criteria for stability are met. Will require prophylaxis to complete an antibiotic course of upto 60 days from onset of illness.
  • (B). Therapy for severe anthrax when meningitis can be ruled out
  • (1).A bactericidal antimicrobial
(a). For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • (a) For 32–34 weeks gestational age
For 0–1 week of Age : Ciprofloxacin IV 20 mg/kg/day,divided q12h OR Meropenem IV 40 mg/kg/day,divided q8h OR Imipenem IV 40 mg/kg/day,divided q12h
For 1–4 week of Age : Ciprofloxacin IV 20 mg/kg/day,divided q12h OR Meropenem IV 60 mg/kg/day,divided q8h OR Imipenem 50 mg/kg/day,divided q12h
  • (b) For 34–37 week gestational age
For 0–1 week of Age : Ciprofloxacin IV 20 mg/kg/day,divided q12h OR Meropenem IV 60 mg/kg/day,divided q8h OR Imipenem 50 mg/kg/day,divided q12h
For 1–4 week of Age : Ciprofloxacin IV 20 mg/kg/day,divided q12h OR Meropenem IV 60 mg/kg/day,divided q8h OR Imipenem 75 mg/kg/day,divided q8h
  • (c) Term Newborn Infant
For 0–1 week of Age : Ciprofloxacin IV 30 mg/kg/day,divided q12h OR Meropenem IV 60 mg/kg/day,divided q8h OR Imipenem 50 mg/kg/day,divided q12h
For 1–4 week of Age : Ciprofloxacin IV 30 mg/kg/day,divided q12h OR Meropenem IV 60 mg/kg/day,divided q8h OR Imipenem 75 mg/kg/day,divided q8h OR
Vancomycin IV (dosing based on serum creatinine for infants ≥32 wk gestational age). Follow vancomycin serum concentrations to modify dose.
If Serum creatinine <0.7 then Vancomycin IV 15 mg/kg/dose q12h
If Serum creatinine 0.7 -0.9 then Vancomycin IV 20 mg/kg/dose q24h
If Serum creatinine 1–1.2 then Vancomycin IV 15 mg/kg/dose q24h
If Serum creatinine 1.3–1.6 then Vancomycin IV 10 mg/kg/dose q24h
If Serum creatinine >1.6 15 then Vancomycin IV mg/kg/dose q48h
Note : Begin treatment with a 20-mg/kg loading dose OR
(b). Alternatives for penicillin-susceptible strains
  • (a) For 32–34 weeks gestational age
For 0–1 week of Age : Penicillin G IV 200000 U/kg/day,divided q12h, OR Ampicillin IV 100 mg/kg/day,divided q12h
For 1–4 week of Age : Penicillin G IV 300000 U/kg/day,divided q8h, OR Ampicillin IV 150 mg/kg/day,divided q8h
  • (b) For 34–37 week gestational age
For 0–1 week of Age : Penicillin G IV 300000 U/kg/day,divided q8h, OR Ampicillin IV 150 mg/kg/day,divided q8h
For 1–4 week of Age : Penicillin G IV 400000 U/kg/day,divided q6h, OR Ampicillin IV 200 mg/kg/day,divided q6h
  • (c) Term Newborn Infant
For 0–1 week of Age : Penicillin G IV 300000 U/kg/day,divided q8h, OR Ampicillin IV 150 mg/kg/day,divided q8h
For 1–4 week of Age : Penicillin G IV 400000 U/kg/day,divided q6h, OR Ampicillin IV 200 mg/kg/day,divided q6h AND
  • (2).A protein synthesis inhibitor
  • (a) For 32–34 weeks gestational age
For 0–1 week of Age : Clindamycin IV 10 mg/kg/day, divided q12h, OR Linezolid IV 20 mg/kg/day, divided q12h, OR Rifampin IV 10 mg/kg/day, q24h
For 1–4 week of Age : Clindamycin IV 15 mg/kg/day, divided q8h, OR Linezolid IV 30 mg/kg/day, divided q8h, OR Rifampin IV 10 mg/kg/day, q24h
  • (b) For 34–37 week gestational age
For 0–1 week of Age : Clindamycin IV 15 mg/kg/day, divided q8h, OR Linezolid IV 30 mg/kg/day, divided q8h, OR Rifampin IV 10 mg/kg/day, q24h
For 1–4 week of Age : Clindamycin IV 20 mg/kg/day, divided q6h, OR Linezolid IV 30 mg/kg/day, divided q8h, OR Rifampin IV 10 mg/kg/day, q24h
  • (c) Term Newborn Infant
For 0–1 week of Age : Clindamycin IV 15 mg/kg/day, divided q8h, OR Linezolid IV 30 mg/kg/day, divided q8h, OR Doxycycline IV 4.4 mg/kg/day, divided q12h, (loading dose 4.4 mg/kg) OR Rifampin IV 10 mg/kg/day, q24h
For 1–4 week of Age : Clindamycin IV 20 mg/kg/day, divided q6h, OR Linezolid IV 30 mg/kg/day, divided q8h, OR Doxycycline IV 4.4 mg/kg/day, divided q12h, (loading dose 4.4 mg/kg) OR Rifampin IV 10 mg/kg/day, q24h
Note: Duration of therapy: For ≥2–3 wk, 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
  • (C). Oral follow-up combination therapy for severe anthrax
(1).A bactericidal antimicrobial
(a). For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • (a) For 32–34 weeks gestational age
For 0–1 week of Age : Ciprofloxacin PO 20 mg/kg/day, divided q12h
For 1–4 week of Age : Ciprofloxacin PO 20 mg/kg/day, divided q12h
  • (b) For 34–37 week gestational age
For 0–1 week of Age : Ciprofloxacin PO 20 mg/kg/day, divided q12h
For 1–4 week of Age : Ciprofloxacin PO 20 mg/kg/day, divided q12h
  • (c) Term Newborn Infant
For 0–1 week of Age : Ciprofloxacin PO 30 mg/kg/day, divided q12h
For 1–4 week of Age : Ciprofloxacin PO 30 mg/kg/day, divided q12h OR
(b). Alternatives for penicillin-susceptible strains
  • (a) For 32–34 weeks gestational age
For 0–1 week of Age : Amoxicillin PO 50 mg/kg/day, divided q12h, OR Penicillin VK PO 50 mg/kg/day, divided q12h
For 1–4 week of Age : Amoxicillin PO 75 mg/kg/day, divided q8h OR Penicillin VK PO 75 mg/kg/day, divided q8h
  • (b) For 34–37 week gestational age
For 0–1 week of Age : Amoxicillin PO 50 mg/kg/day, divided q12h OR Penicillin VK PO 50 mg/kg/day, divided q12h
For 1–4 week of Age : Amoxicillin PO 75 mg/kg/day, divided q8h OR Penicillin VK PO 75 mg/kg/day, divided q8h
  • (c) Term Newborn Infant
For 0–1 week of Age : Amoxicillin PO 75 mg/kg/day, divided q8h OR Penicillin VK PO 75 mg/kg/day, divided q8h
For 1–4 week of Age : Amoxicillin PO 75 mg/kg/day, divided q8h OR Penicillin VK PO 75 mg/kg/day, divided q6–8h AND
(2).A protein synthesis inhibitor
  • (a) For 32–34 weeks gestational age
For 0–1 week of Age : Clindamycin PO 10 mg/kg/day, divided q12h OR Linezolid PO 20 mg/kg/day, divided q12h
For 1–4 week of Age : Clindamycin PO 15 mg/kg/day, divided q8h OR Linezolid PO 30 mg/kg/day, divided q8h
  • (b) For 34–37 week gestational age
For 0–1 week of Age : Clindamycin PO 15 mg/kg/day, divided q8h OR Linezolid PO 30 mg/kg/day, divided q8h
For 1–4 week of Age : Clindamycin PO 20 mg/kg/day, divided q6h OR Linezolid PO 30 mg/kg/day, divided q8h
  • (c) Term Newborn Infant
For 0–1 week of Age : Clindamycin PO 15 mg/kg/day, divided q8h OR Doxycycline PO 4.4 mg/kg/day, divided q12h (loading dose 4.4 mg/kg) OR Linezolid PO 30 mg/kg/day, divided q8h
For 1–4 week of Age :Clindamycin PO 20 mg/kg/day, divided q6h OR Doxycycline PO 4.4 mg/kg/day, divided q12h (loading dose 4.4 mg/kg) OR Linezolid PO 30 mg/kg/day, divided q8h OR
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.
  • (D).Treatment of cutaneous anthrax without systemic involvement
  • (1).For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • (a) For 32–34 weeks gestational age
For 0–1 week of Age : Ciprofloxacin PO 20 mg/kg/day, divided q12h OR Clindamycin PO 10 mg/kg/day, divided q12h
For 1–4 week of Age : Ciprofloxacin PO 20 mg/kg/day, divided q12h OR Clindamycin PO 15 mg/kg/day, divided q8h
  • (b) For 34–37 week gestational age
For 0–1 week of Age : Ciprofloxacin PO 20 mg/kg/day, divided q12h OR Clindamycin PO 15 mg/kg/day, divided q8h
For 1–4 week of Age : Ciprofloxacin PO 20 mg/kg/day, divided q12h OR Clindamycin PO 20 mg/kg/day, divided q6h
  • (c) Term Newborn Infant
For 0–1 week of Age : Ciprofloxacin PO 30 mg/kg/day, divided q12h OR Doxycycline PO 4.4 mg/kg/day, divided q12h (Loading dose 4.4 mg/kg) OR Clindamycin PO 15 mg/kg/day, divided q8h
For 1–4 week of Age : Ciprofloxacin PO 30 mg/kg/day, divided q12h OR Doxycycline PO 4.4 mg/kg/day, divided q12h (Loading dose 4.4 mg/kg) OR Clindamycin PO 20 mg/kg/day, divided q6h
  • (2).Alternatives for penicillin-susceptible strains
  • (a) For 32–34 weeks gestational age
For 0–1 week of Age : Amoxicillin PO 50 mg/kg/day, divided q12h OR Penicillin Vk PO 50 mg/kg/day, divided q12h
For 1–4 week of Age : Amoxicillin PO 75 mg/kg/day, divided q8h OR Penicillin Vk PO 75 mg/kg/day, divided q8h
  • (b) For 34–37 week gestational age
For 0–1 week of Age : Amoxicillin PO 50 mg/kg/day, divided q12h OR Penicillin Vk PO 50 mg/kg/day, divided q12h
For 1–4 week of Age : Amoxicillin PO 75 mg/kg/day, divided q8h OR Penicillin Vk PO 75 mg/kg/day, divided q8h
  • (c) Term Newborn Infant
For 0–1 week of Age : Amoxicillin PO 75 mg/kg/day, divided q8h OR Penicillin Vk PO 75 mg/kg/day, divided q8h
For 1–4 week of Age : Amoxicillin PO 75 mg/kg/day, divided q8h OR Penicillin Vk PO 75 mg/kg/day, divided q6–8h
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.
  • (1) For all strains, regardless of penicillin susceptibility or if susceptibility is unknown: Ciprofloxacin, 500 mg q12h OR Doxycycline, 100 mg q12h OR Levofloxacin, 750 mg q24h OR Moxifloxacin, 400 mg q24h OR Clindamycin, 600 mg q8h OR
  • (2) Alternatives for penicillin-susceptible strain Amoxicillin, 1 g q8h OR Penicillin VK, 500 mg q6h
Note (1): Preferred drugs are indicated in boldface.
Note (2): Alternative drugs are listed in order of preference for treatment for patients who cannot take first-line treatment or if first-line treatment is unavailable.
  • For children ≥ 1 month[8]
  • (1) For penicillin-resistant strains or prior to susceptibility testing: Ciprofloxacin, 30 mg/kg/day, by mouth (PO), divided q12h (not to exceed 500 mg/dose) OR Doxycycline, <45 kg: 4.4 mg/kg/day, PO, divided q12h (not to exceed 100 mg/dose) >45 kg: 100 mg/dose, PO, given q12h OR Clindamycin, 30 mg/kg/day, PO, divided q8h (not to exceed 900 mg/dose) OR Levofloxacin, <50 kg: 16 mg/kg/day, PO, divided q12h (not to exceed 250 mg/dose) >50 kg: 500 mg, PO, given q24h OR
  • (2) For penicillin-susceptible strains: Amoxicillin, 75 mg/kg/day, PO, divided every q8h (not to exceed 1 g/dose) OR Penicillin VK, 50-75 mg/kg/day, PO, divided q6h to q8h
Note (1) : Duration of Therapy is 60 days after exposure
Note (2) : Bold font are preferred antimicrobial agent (when 2 bolded antimicrobial agents are present, both are considered equivalent in overall safety and efficacy).
Note (3) : Normal font are alternative selections are listed in order of preference for therapy for patients who cannot take first-line therapy or if first-line therapy is unavailable.
Note (4) : Doses are provided for children with normal renal and hepatic function. Doses may vary for those with some degree of organ failure.
Note (5) : Italicized font: indicates FDA approval for the indication in the pediatric population.
Note (6) : A single 14-day course of doxycycline is not routinely associated with tooth staining, but some degree of staining is likely for a prolonged treatment course of up to 60 days.
Note (7) : Safety data for Levofloxacin in the pediatric population are limited to 14 days for duration therapy.
Note (8) : Be aware of the possibility of emergence of penicillin-resistance during monotherapy with Amoxicillin or Penicillin.
  • For children < 1 month
  • (1) For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • (a) For 32–34 weeks gestational age
For 0–1 week of Age : Ciprofloxacin PO 20 mg/kg/day, divided q12h OR Clindamycin PO 10 mg/kg/day, divided q12h
For 1–4 week of Age : Ciprofloxacin PO 20 mg/kg/day, divided q12h OR Clindamycin PO 15 mg/kg/day, divided q8h
  • (b) For 34–37 week gestational age
For 0–1 week of Age : Ciprofloxacin PO 20 mg/kg/day, divided q12h OR Clindamycin PO 15 mg/kg/day, divided q8h
For 1–4 week of Age : Ciprofloxacin PO 20 mg/kg/day, divided q12h OR Clindamycin PO 20 mg/kg/day, divided q6h
  • (c) Term Newborn Infant
For 0–1 week of Age : Ciprofloxacin PO 30 mg/kg/day, divided q12h OR Doxycycline PO 4.4 mg/kg/day, divided q12h (Loading dose 4.4 mg/kg) OR Clindamycin PO 15 mg/kg/day, divided q8h
For 1–4 week of Age : Ciprofloxacin PO 30 mg/kg/day, divided q12h OR Doxycycline PO 4.4 mg/kg/day, divided q12h (Loading dose 4.4 mg/kg) OR Clindamycin PO 20 mg/kg/day, divided q6h OR
  • (2) Alternatives for penicillin-susceptible strains
  • (a) For 32–34 weeks gestational age
For 0–1 week of Age : Amoxicillin PO 50 mg/kg/day, divided q12h OR Penicillin Vk PO 50 mg/kg/day, divided q12h
For 1–4 week of Age : Amoxicillin PO 75 mg/kg/day, divided q8h OR Penicillin Vk PO 75 mg/kg/day, divided q8h
  • (b) For 34–37 week gestational age
For 0–1 week of Age : Amoxicillin PO 50 mg/kg/day, divided q12h OR Penicillin Vk PO 50 mg/kg/day, divided q12h
For 1–4 week of Age : Amoxicillin PO 75 mg/kg/day, divided q8h OR Penicillin Vk PO 75 mg/kg/day, divided q8h
  • (c) Term Newborn Infant
For 0–1 week of Age : Amoxicillin PO 75 mg/kg/day, divided q8h OR Penicillin Vk PO 75 mg/kg/day, divided q8h
For 1–4 week of Age : Amoxicillin PO 75 mg/kg/day, divided q8h OR Penicillin Vk PO 75 mg/kg/day, divided q6–8h
Note: Duration of therapy is 60 days from exposure

Gallery

References

  1. ↑ Ryan KJ, Ray CG (editors) (2004). Sherris Medical Microbiology (4th ed. ed.). McGraw Hill. ISBN 0-8385-8529-9.
  2. ↑ Madigan M, Martinko J (editors). (2005). Brock Biology of Microorganisms (11th ed. ed.). Prentice Hall. ISBN 0-13-144329-1.
  3. ↑ Turnbull PCB (1996). Bacillus. In: Barron's Medical Microbiology (Baron S et al, eds.) (4th ed. ed.). Univ of Texas Medical Branch. ISBN 0-9631172-1-1.
  4. ↑ Dixon TC, Meselson M, Guillemin J, Hanna PC (1999). "Anthrax". N. Engl. J. Med. 341 (11): 815–26. PMID 10477781.
  5. ↑ Barnes JM (1947). "Penicillin and B. anthracis". J Path Bacteriol. 194: 113.
  6. ↑ 6.0 6.1 6.2 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.
  7. ↑ 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.
  8. ↑ 8.0 8.1 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.
  9. ↑ 9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 9.10 9.11 9.12 9.13 9.14 9.15 9.16 9.17 9.18 9.19 9.20 "Public Health Image Library (PHIL)".


Template:WikiDoc Sources

Retrieved from "https://www.wikidoc.org/index.php?title=Bacillus_anthracis&oldid=1114225"