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==Anthracis 2==
==Aortic Aneurysm Overview==
An ''aortic aneurysm'' is a dilation of the [[aorta]] in which the aortic diameter is ≥ 3.0 cm, usually representing an underlying weakness in the wall of the aorta at that location. While the stretched vessel may occasionally cause discomfort, a greater concern is the risk of ''rupture'' which causes severe pain, massive internal [[hemorrhage]] which are often fatal. Aneurysms often are a source of blood clots ([[embolus|emboli]]) stemming from the most common etiology of atherosclerosis.
==Classification==
There are 2 types of aortic aneurysms: thoracic and abdominal. These can be further classified according to the respective part of the vessel that's been affected:


{{PBI|Bacillus anthracis}}
*[[Thoracic aortic aneurysm]], which occur in the thoracic aorta (runs through the chest);
*[[Abdominal aortic aneurysm]], which occur in the abdominal aorta, are the most common.
**Suprarenal - not as common, often more difficult to repair surgically due to the presence of many aortic branches;
**Infrarenal - often more easily surgically repaired and more common;
**Pararenal - aortic aneurysm is infrarenal but affects renal arteries;
**Juxtarenal - infrarenal aortic aneurysm that affects the aorta just below the renal arteries.


:*  '''Bacillus anthracis treatment'''
Thoracoabdominal aortic aneurysm may also be classified according to Crawford classification into 5 subtypes/groups:


::* 1. '''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>
*Type 1: from the origin of left subclavian artery in descending thoracic aorta to the supra-renal abdominal aorta.
*Type 2: from the left subclavian to the aorto-iliac bifurcation.
*Type 3: from distal thoracic aorta to the aorto-iliac bifurcation
*Type 4: limited to abdominal aorta below the diaphragm
*Type 5: from distal thoracic aorta to celiac and superior mesenteric origins, but not the renal arteries.


:::* Preferred regimen (regardless of penicillin susceptibility or if susceptibility is unknown) (1): [[Ciprofloxacin]] 500 mg PO bid for 7-10 days
==Historical Perspective==
Aortic aneurysm was first recorded by Antyllus, a Greek surgeon, in the second century AD. In the Renaissaince era, in 1555, Vesalius first diagnosed an [[abdominal aortic aneurysm]]. The first publication on the pathology with case studies was published by Lancisi in 1728. Finally, in 1817, Astley Cooper was the first surgeon to ligate the abdominal aorta to treat a ruptured iliac aneurysm. In 1888, Rudoff Matas came up with the concept of endoaneurysmorrhaphy.


:::* Preferred regimen (regardless of penicillin susceptibility or if susceptibility is unknown) (2): [[Doxycycline]] 100 mg PO bid for 7-10 days
==Pathophysiology==
The aortic aneurysms are a multifactorial disease associated with genetic and environmental risk factors. [[Marfan's syndrome]] and [[Ehlers-Danlos syndrome]] are associated with the disease, but there are also rarer syndromes like the [[Loeys-Dietz syndrome]] that are associated as well. Even in patients that do not have genetic syndromes, it has been observed that genetics can also play a role on aortic aneurysms' development. There has been evidence of genetic heterogeneity as there has already been documented in [[intracranial aneurysms]].<ref name=":0" /> The genetic alterations associated with these genetic syndromes are the following:


:::* Preferred regimen (regardless of penicillin susceptibility or if susceptibility is unknown) (3): [[Levofloxacin]] 750 mg PO qd for 7-10 days
{| class="wikitable"
 
|+Genetic diseases associated with aortic aneurysms
:::* Preferred regimen (regardless of penicillin susceptibility or if susceptibility is unknown) (4): [[Moxifloxacin]] 400 mg PO qd for 7-10 days
!Disease
 
!Involved Cellular Pathway
:::* Alternative regimen (1): [[Clindamycin]] 600 mg PO tid for 7-10 days
!Mutated Gene(s)
 
!Affected Protein(s)
:::* Alternative regimen (2): [[Amoxicillin]] 1 g PO tid (for penicillin-susceptible strains) for 7-10 days
|-
 
|Ehlers-Danlos syndrome type IV
:::* Alternative regimen (3): [[Penicillin VK]] 500 mg PO qid (for penicillin-susceptible strains) for 7-10 days
|Extracellular Matrix Proteins
 
|COL3A1
:::* Note: Duration of treatment is 60 days for bioterrorism-related cases and 7-10 days for naturally acquired cases.
|Collagen type III
 
|-
::* 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'''<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>
|Marfan's syndrome
 
|Extracellular Matrix Proteins
:::* 2.1 '''Systemic anthrax with possible/confirmed meningitis'''
|FBN1
 
|Fibrillin-1
::::* 2.1.1 '''Bactericidal agent''' (fluoroquinolone)
|-
 
|Loeys-Dietz syndrome
:::::* Preferred regimen (1): [[Ciprofloxacin]] 400 mg IV q8h for 2-3 weeks
|TGF-β Pathway
 
|TGFBR1/TGFBR2
:::::* 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}}
|Aneurysm-Osteoarthritis Syndrome
 
|
::::* 2.1.2 '''Bactericidal agent (ß-lactam) for all strains, regardless of penicillin susceptibility or if susceptibility is unknown'''
|SMAD3
 
|SMAD3
:::::* Preferred regimen (1): [[Meropenem]] 2 g IV q8h for 2-3 weeks
|-
 
|Autosomal Dominant Polycystic Kidney Disease
:::::* Preferred regimen (2): [[Imipenem]] 1 g IV q6h for 2-3 weeks
|Ciliopathy
 
|''PKD1PKD2''
:::::* Preferred regimen (3): [[Doripenem]] 500 mg IV q8h for 2-3 weeks
|Polycystin 1
 
Polycystin 2
:::::* Preferred regimen (4): [[Penicillin G]] 4 MU IV q4h (for penicillin-susceptible strains) for 2-3 weeks
|-
 
|Turner Syndrome
:::::* Preferred regimen (5): [[Ampicillin]] 3 g IV q6h (for penicillin-susceptible strains) for 2-3 weeks {{and}}
|Meiotic Error with Monosomy, Mosaicism, or De Novo Germ Cell Mutation
 
|45X
::::* 2.1.3 '''Protein synthesis inhibitor'''
45XO
 
|Partial or Complete Absence of X Chromosome
:::::* Preferred regimen (1): [[Linezolid]] 600 mg IV q12h for 2-3 weeks
|-
 
|Bicuspid Aortic Valve with TAA
:::::* Preferred regimen (2): [[Clindamycin]] 900 mg IV q8h for 2-3 weeks
|Neural Crest Migration
 
|''NOTCH1''
:::::* Preferred regimen (3): [[Rifampin]] 600 mg IV q12h for 2-3 weeks
|Notch 1
 
|-
:::::* Preferred regimen (4): [[Chloramphenicol]] 1 g IV q6-8h for 2-3 weeks
|Familial TAA
 
|Smooth Muscle Contraction Proteins
:::::* Note (1): Patients exposed to aerosolized spores will require prophylaxis to complete an antimicrobial drug course of 60 days from onset of illness.
|''ACTA2''
 
|α-Smooth Muscle Actin
:::::* Note (2): Increased risk for seizures associated with [[Imipenem]]/[[Cilastatin]] treatment.
|-
 
|Familial TAA with Patent Ductus Arteriosus
:::::* 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.
|Smooth Muscle Contraction Proteins
 
|''MYH11''
:::::* 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.
|Smooth Muscle Myosin
 
|-
:::* 2.2 '''Systemic anthrax when meningitis has been excluded'''
|Familial TAA
 
|Smooth Muscle Contraction Proteins
::::* 2.2.1 '''Bactericidal agent'''
|''MYLK''
 
|Myosin Light Chain Kinase
:::::* Preferred regimen (1): [[Ciprofloxacin]] 400 mg IV q8h for 2 weeks
|-
 
|Familial TAA
:::::* Preferred regimen (2): [[Levofloxacin]] 750 mg IV q24h for 2 weeks
|Smooth Muscle Contraction Proteins
 
|''PRKG1''
:::::* Preferred regimen (3): [[Moxifloxacin]] 400 mg q24h for 2 weeks
|Protein Kinase c-GMP Dependent, type I
 
|-
:::::* Preferred regimen (4): [[Meropenem]] 2 g IV q8h for 2 weeks
|Loeys-Dietz Syndrome variants
 
|TGF-β Pathway
:::::* Preferred regimen (5): [[Imipenem]] 1 g IV q6h for 2 weeks
|''TGF-βR1TGF-βR2SMAD3TGF-β2TGF-β3''
 
|
:::::* Preferred regimen (6): [[Doripenem]] 500 mg IV q8h for 2 weeks
|}
 
These genetic diseases mostly affect either the synthesis of [[extracellular matrix protein]] or damage the smooth muscle cells both important component's of the aortic wall. Injury to any of these components lead to weakening of the aortic wall and dilation - resulting in aneurysm formation.
:::::* 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''' <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>
 
:::::* 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 weeks{{or}}
 
:::::* 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 (1): [[Ciprofloxacin]] 400 mg IV q8h for 2 weeks
 
::::::* 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'''
 
::::::* Preferred regimen: [[Ciprofloxacin]] 400 mg IV q8h
 
::::::* Note: Duration of treatment is 60 days
 
:::* 3.2 '''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>
 
::::* 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'''
 
::::::::::* Preferred regimen: '''[[Ciprofloxacin]] 20 mg/kg/day PO bid'''
 
::::::::::* '''For 1–4 week of age'''
 
::::::::::* Preferred regimen: '''[[Ciprofloxacin]] 20 mg/kg/day PO bid'''
 
::::::::* 3.2.5.3.1.1.2 '''For 34–37 week gestational age'''
 
:::::::::*  '''For < 1 week of age'''
 
::::::::::* Preferred regimen: '''[[Ciprofloxacin]] 20 mg/kg/day PO bid'''
 
:::::::::* '''For 1–4 week of age'''
 
::::::::::* Preferred regimen: '''[[Ciprofloxacin]] 20 mg/kg/day PO bid'''
 
::::::::* 3.2.5.3.1.1.3 '''Term newborn infant'''
 
:::::::::* '''For < 1 week of age'''
 
::::::::::* Preferred regimen: '''[[Ciprofloxacin]] 30 mg/kg/day PO bid'''
 
:::::::::* '''For 1–4 week of age'''
 
::::::::::* Preferred regimen: '''[[Ciprofloxacin]] 30 mg/kg/day PO bid''' {{or}}
 
:::::::* 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 (1): '''[[Clindamycin]] 10 mg/kg/day PO bid'''
 
:::::::::* Preferred regimen (2): [[Linezolid]] 20 mg/kg/day PO bid
 
::::::::* '''For 1–4 week of age'''
 
:::::::::* Preferred regimen (1):'''[[Clindamycin]] 15 mg/kg/day PO bid'''
 
:::::::::* 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 (1): '''[[Clindamycin]] 15 mg/kg/day PO tid'''
 
:::::::::* Preferred regimen (2): [[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): [[Linezolid]] 30 mg/kg/day PO tid


:::::::* 3.2.5.3.2.3 '''Term newborn infant'''
The [[aorta]] is the largest vessel of the body, but it is not homogenous. Its upper segment is composed by a larger proportion of [[elastin]] in comparison to [[collagen]], therefore being more distensible. The lower segment has a larger proportion of [[collagen]], therefore it is less distensible. It is also where most of the atherosclerotic plaques of the [[aorta]] are located.<ref name=":1" /> Historically it was thought that abdominal and thoracic aortic aneurysms were caused by the same etiology: [[Atherosclerosis|atherosclerotic]] degeneration of the aortic wall, but recently it has been theorized that they are indeed different diseases.<ref name=":1" />


::::::::* '''For < 1 week of age'''
The [[aortic arch]] mostly derives from the [[neural crest cell]] which differentiate into [[Smooth muscle cell|smooth muscle cells]]. These [[Smooth muscle cell|smooth muscle cells]] are probably more adapted to remodel the thoracic [[aorta]] and manage the higher [[pulse pressure]] and ejection volume due to increased production of elastic lamellae during development and growth.<ref name=":1" /> The abdominal aorta remains with cells of [[Mesoderm|mesodermal]] origin, which are more similar to that of the original primitive arterial. That difference results in the [[neural crest cell]] precursors of the thoracic aorta being able to respond differently to various [[cytokines]] and growth factors than the [[Mesoderm|mesodermal]] precursors of the abdominal aorta, such as [[homocysteine]] and [[Angiotensin|angiotensin II]].


:::::::::* Preferred regimen (1): '''[[Clindamycin]] 15 mg/kg/day PO tid'''
When neural crest vascular smooth muscle cells are treated with [[TGF-β]] they demonstrate increased [[collagen]] production, while mesodermal vascular [[smooth muscle cell]] did not. Not coincidently, mutations of the [[TGF-β]] receptor can cause thoracic aortic aneurysm but do not cause abdominal aortic ones.


:::::::::* Preferred regimen (2): [[Doxycycline]] 4.4 mg/kg/day PO bid (loading dose 4.4 mg/kg) 
The thoracic and abdominal aorta are very structurally different. While they both have three layers: [[Tunica intima|intimal]], [[Tunica media|medial]] and [[Tunica externa (vessels)|adventitia]], the media of the thoracic aorta is comprised of approximately 60 units divided into vascular and avascular regions. The abdominal aorta consists of about 30 units and is entirely avascular - being dependent on trans-intimal diffusion of nutrients for its smooth muscle cells to survive. It is believed that both differences explain why the abdominal aorta is more likely to form aneurysms.
:::::::::* 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.
The development of aortic aneurysms is defined by: [[inflammation]]: infiltration of the vessel wall by [[lymphocytes]] and [[macrophage]]; extracellular matrix damage: destruction of [[elastin]] and [[collagen]] by [[proteases]] (also [[metalloproteinases]]) in the media and adventitia; cellular damage: loss of smooth muscle cells with thinning of the media; and insufficient repair: [[neovascularization]].


:::::* 3.2.5.4 '''Treatment of cutaneous anthrax without systemic involvement'''
In summary:


::::::* 3.2.5.4.1 '''For all strains, regardless of penicillin susceptibility or if susceptibility is unknown'''
*The pathogenesis of aortic aneurysm is characterized by progressive dilation, rupture, and may present with [[dissection]];
*The pathological processes that lead to abdominal and thoracic aortic aneurysms may be very different from one another;
*The [[fibrillin-1]] gene mutation has been associated with the development of thoracic aortic aneurysms in [[Marfan's syndrome]];
*Other gene mutations coding for [[collagen]], elastin and other elements of the extracellular matrix have been associated with the development of aneurysms in some genetic disorders, including [[Ehlers-Danlos syndrome]] and others;
*Mutations in the [[TGF-β]] pathway have also been described in the pathogenesis of aortic aneurysms in multiple genetic disorders, including [[Loeys-Dietz syndrome]].


:::::::* 3.2.5.4.1.1 '''For 32–34 weeks gestational age'''
==Clinical Features== 


::::::::* '''For < 1 week of age'''
==Differentiating Aortic Aneurysm from other Diseases==
'''Thoracic aortic aneurysms:''' differential diagnosis include other causes of chest pain: acute [[aortic dissection]], acute [[pericarditis]], [[aortic regurgitation]], [[heart failure]], [[Hypertensive Emergencies|hypertensive emergencies]], [[infective endocarditis]], [[myocardial Infarction]], [[pulmonary embolism]], [[superior vena cava syndrome]].


:::::::::* Preferred regimen (1): '''[[Ciprofloxacin]]''' 20 mg/kg/day PO bid
'''Abdominal aortic aneurysms:''' differential diagnosis include causes of pulsatile abdominal mass and/or abdominal pain such as [[ruptured viscus]], [[strangulated hernia]], ruptured visceral artery aneurysms, [[mesenteric ischemia]], acute [[cholecystitis]], ruptured hepatobiliary cancer, [[acute pancreatitis]], [[lymphomas]], and [[diverticular abscess]].


:::::::::* Preferred regimen (2): [[Clindamycin]] 10 mg/kg/day PO bid
These conditions can be easily differentiated using abdominal or thoracic imaging.
==Epidemiology and Demographics==
In the United States alone 15,000 people die yearly due to aortic aneurysms and it is the 13th leading cause of death. 1-2% of the population may have aortic aneurysms and [[prevalence]] rises up to 10% in older age groups. The disease varies according to where it takes place. In the thorax, the [[aortic arch]] is the less affected segment (10%) and the most common is the ascending aorta (50%). Regarding abdominal aneurysms, the infrarenal segment aortic aneurysms are three times more prevalent than the aortic aneurysms and [[Aortic dissection|dissections]].


::::::::* '''For 1–4 week of age'''
Regarding other factors as age, abdominal aortic aneurysms usually present 10 years later than thoracic aortic aneurysms. Both lesions are more present in men, but the proportion is much higher regarding abdominal aortic aneurysms (6:1 male:female ratio) in comparison to thoracic ones.<ref name=":0" />


:::::::::* Preferred regimen (1):'''[[Ciprofloxacin]]''' 20 mg/kg/day PO bid
Abdominal aortic aneurysms also affect patients differently regarding race, as they are more prevalent among whites than blacks, asians and hispanics. It also seems to be declining in prevalence as evidenced by a Swedish study that found out a 2% prevalence of abdominal aortic aneurysms in comparison to earlier studies which reported 4-8%, probably due to risk-factor modification.
:::::::::* Preferred regimen (2):[[Clindamycin]] 15 mg/kg/day PO tid
==Risk Factors==
Many risk factors are common between both forms of aortic aneurysms, but some are specific for each presentation:


:::::::* 3.2.5.4.1.2 '''For 34–37 week gestational age'''
*'''Abdominal aortic aneurysm:''' smoking, male gender, age (>65 years), race (white), family history, other aneurysms.<ref name=":3" />
*'''Thoracic aortic aneurysm:''' smoking, age (>65 years), [[hypertension]], [[atherosclerosis]], family history, [[Marfan's syndrome]], [[Bicuspid Aortic Valve|bicuspid aortic valve]].


::::::::* '''For < 1 week of age'''
== Natural History, Complications and Prognosis==
Even though the majority of the aortic aneurysms remain asymptomatic for years, their natural history is [[Dissection of aorta|dissection]] or [[Rupture of the aorta|rupture]].<ref name=":4" /> According to Laplace's law, as the aneurysms grow larger they have a higher rate of expansion. Due to that, the frequency of monitoring changes with the diameter of the abdominal aortic aneurysm, being every 3 years for aneurysms with a 3-3.4cm diameter, yearly for diameters of 3.5-4.4cm, and every 6 months for larger than 4.5cm.<ref name=":5" /> For the thoracic one, up to 80% of the aneurysms will eventually rupture, and patients present with a 10-20% five-year survival rate if they remain untreated.<ref name=":4" /> Risk of rupture doubles every 1cm in growth over the 5cm diameter in descending thoracic aorta.


:::::::::* Preferred regimen (1): '''[[Ciprofloxacin]]''' 20 mg/kg/day PO bid
Besides rupturing and dissection of the aorta, aortic aneurysms can also present with systemic embolization and aortic regurgitation (if the thoracic aortic aneurysm is located in the ascending aorta). The altered blood flow in the aneurysm can also lead to the formation of blood cloths and embolization.


:::::::::* Preferred regimen (2): [[Clindamycin]] 15 mg/kg/day PO tid
== Diagnosis ==
===Diagnostic Criteria===
'''Abdominal aortic aneurysms:''' are considered a dilation of the abdominal aorta which presents with a permanent vessel diameter larger than 30mm (normal abdominal aortic diameter ranges from 15 to 25mm). They can be diagnosed by abdominal ultrasound imaging, CT scan or MRI.


::::::::* '''For 1–4 week of age'''
'''Thoracic aortic aneurysms:''' generally an aneurysm is diagnosed when the axial diameter of the ascending aorta is larger than 5cm and 4cm for the descending aorta. When larger than normal but not reaching aneurysmal definition the terms dilatation and ectasia can be used. The transthoracic ultrasound is not used due to the fact that thebones of the chest wall and the air inside the lungs makes the assessment of the aorta difficult. Instead it is chosen the CT scan, MRI or angiography for diagnosis.<ref name=":6" />


:::::::::* Preferred regimen (1): '''[[Ciprofloxacin]]''' 20 mg/kg/day PO bid
=== Symptoms: ===
Aortic aneurysms are largely an asymptomatic condition, but symptoms present differently according to the affected segment of the aorta.


:::::::::* Preferred regimen (2): [[Clindamycin]] 20 mg/kg/day PO qid
'''Thoracic aortic aneurysms:''' patients are usually diagnosed in these contexts:


:::::::* 3.2.5.4.1.3 '''Term newborn infant'''
* Incidental finding as part of a routine examination (transthoracic echocardiography, computerized tomography of the chest, cardiac magnetic resonance imaging, routine chest radiograph);
* Acute presentation with thoracic aortic dissection or aneurysm rupture;
* Screening due to a relative of a patient presenting with aortic disease;
* Part of a known congenital cardiac condition.  


::::::::* '''For < 1 week of age'''
The aneurysms tend to grow slowly and most of them will never rupture. As they grow, however, their symptoms become more evident and present with mass effects over surrounding structures and pain. They may present with thoracic symptoms: interscapular or central pain, ripping chest pain and dyspnea. Atypical presentations include hoarseness, dizziness and dysphagia, due to esophageal compression. Aneurysm rupture lead to massive internal bleeding, hypovolemic shock and it is usually fatal.


:::::::::* Preferred regimen (1): '''[[Ciprofloxacin]]''' 30 mg/kg/day PO bid
'''Abdominal aortic aneurysms:''' as the thoracic aneurysms, they begin asymptomatic but may cause symptoms as they grow and compress surrounding structures.Even though they usually remain asymptomatic, when they rupture they present with an ensuing mortality of 85 to 90%., and symptomatic patients require urgent surgical repair.


:::::::::* Preferred regimen (2): [[Doxycycline]] 4.4 mg/kg/day PO bid (Loading dose 4.4 mg/kg)
When symptomatic, abdominal aortic aneurysms present with:


:::::::::* Preferred regimen (3): [[Clindamycin]] 15 mg/kg/day PO tid
* Pain: in the chest, abdomen, lower back, or flanks. It may radiate to the groin, buttocks, or legs. The pain characteristics vary and may be deep, aching, gnawing, or throbbing It may also last for hours or days, not affected by movement. Occasionally, certain positions can be more comfortable and alleviate the symptoms;
* Pulsating abdominal mass;
* Ischemia: "cold foot" or a black or blue painful toe. This is usually the presentation when an aneurysm forms a blood cloth and it releases emboli to the lower extremities;
* Fever or weight loss if caused by inflammatory states such as [[vasculitis]].<ref name=":2" />


::::::::* '''For 1–4 week of age'''
If ruptured, the abdominal aortic aneurysm can present with sharp abdominal pain, often radiating to the back, discoloration of the skin and mucosa, tachycardia and low blood pressure due to hypovolemic shock.


:::::::::* Preferred regimen (1):'''[[Ciprofloxacin]]''' 30 mg/kg/day PO bid
Differential diagnosis include causes of pulsatile abdominal mass and/or abdominal pain such as ruptured viscus, strangulated hernia, ruptured visceral artery aneurysms, mesenteric ischemia, acute cholecystitis, ruptured hepatobiliary cancer, acute pancreatitis, lymphoma, and diverticular abscess.<ref name=":3" />
== Treatment ==
=== Medical Therapy ===
Focus is to reduce systemic blood pressure, inhibit MMP (zinc endopeptidases that degrade the extracellular matrix in aortic aneurysms)<ref name=":7">Danyi, Peter, John A. Elefteriades, and Ion S. Jovin. "Medical therapy of thoracic aortic aneurysms: are we there yet?." ''Circulation'' 124.13 (2011): 1469-1476.</ref>, and contain the progression of atherosclerosis:


:::::::::* Preferred regimen (2): [[Doxycycline]] 4.4 mg/kg/day PO bid (Loading dose 4.4 mg/kg)
*Beta-blockers may help in reducing the rate of expansion of the aortic aneurysm, reducing shear stress - studies have been mostly on Marfan patients and they found a low compliance with propranolol due to a significant effect on quality of life<ref name=":7" />;
 
*Tetracyclines inhibit the MMP endopeptidases, and has been used in conditions in which MMP are overexpressed such as rheumatoid arthritis. There are studies in humans showing that doxycycline reduced the rate of expansion of aortic aneurysms. Roxithromycin, a macrolide has been also show to reduce the expansion of the aortic aneurysms.
:::::::::* Preferred regimen (3): [[Clindamycin]] 20 mg/kg/day PO qid
*Statins may also be helpful due to their pleiotropic effecs, reducing the oxidative stress by blocking the [[reactive oxygen species]] on aneurysms, suppressing the [[NADH]]/[[NADPH]] oxidase system.
*[[Angiotensin-converting enzyme inhibitors]] and [[Angiotensin receptor blocker|angiotensin receptor blockers]] promotes vascular hypertrophy, cell proliferation and production of extracellular matrix. It also activates the [[NADH]]/[[NADPH]] oxidase system, both stimulating and inhibiting MMPs and degradation of extracellular matrix. There is a controversy of which class is more effective, and ongoing trials are being run to further clarify these questions.<ref name=":7" />
   
   
::::::* 3.2.5.4.2 '''Alternatives for penicillin-susceptible strains'''
=== Surgery ===
 
Indication for elective surgical treatment is commonly discussed
:::::::* 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'''<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>
 
:::* 1.1 '''For all strains, regardless of penicillin susceptibility or if susceptibility is unknown'''
 
::::* Preferred regimen (1): '''[[Ciprofloxacin]] 500 mg IV q12h'''
 
::::* Preferred regimen (2): '''[[Doxycycline]] 100 mg IV q12h'''
 
::::* Preferred regimen (3): [[Levofloxacin]] 750 mg IV q24h
 
::::* Preferred regimen (4): [[Moxifloxacin]] 400 mg IV q24h
 
::::* Preferred regimen (5): [[Clindamycin]] 600 mg IV q8h
 
:::* 1.2 '''Alternatives for penicillin-susceptible strain'''
 
::::* Preferred regimen (1): [[Amoxicillin]] 1 g IV q8h
 
::::* Preferred regimen (2): Penicillin VK 500 mg IV q6h
 
::* 2. '''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>
 
:::* 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):
*The mainstay of therapy for AAA is aneurysmal repair if diameter>5.5cm or size increased>0.5cm over 6 months.
 
*Surgical repair is indicated in cases of TAA dissection and progressive enlargement.
:::::* 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 (1): '''[[Ciprofloxacin]]''' 20 mg/kg/day, PO, bid
 
::::::* Preferred regimen (2): [[Clindamycin]] 10 mg/kg/day, PO, bid
 
:::::* 3.1.1.2 '''For 1–4 week of age '''
 
::::::* Preferred regimen (1): '''[[Ciprofloxacin]]''' 20 mg/kg/day, PO,bid
 
::::::* 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 (1): '''[[Ciprofloxacin]]''' 20 mg/kg/day, PO, bid
 
::::::* Preferred regimen (2): [[Clindamycin]] 15 mg/kg/day, PO, tid
 
:::::* 3.1.2.2 '''For 1–4 week of age'''
 
::::::* Preferred regimen (1): '''[[Ciprofloxacin]]''' 20 mg/kg/day, PO, bid
 
::::::* 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 (1): '''[[Ciprofloxacin]]''' 30 mg/kg/day, PO, bid
 
::::::* 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 (1): '''[[Ciprofloxacin]]''' 30 mg/kg/day, PO, bid
 
::::::* 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
 
 
==Anthracis==
{{PBI|Bacillus anthracis}}
 
:*  '''Bacillus anthracis treatment'''
 
::* 1. '''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) (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'''<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>
 
:::* 2.1 '''Systemic anthrax with possible/confirmed meningitis'''
 
::::* 2.1.1 '''Bactericidal agent''' (fluoroquinolone)
 
:::::* Preferred regimen (1): [[Ciprofloxacin]] 400 mg IV q8h for 2-3 weeks
 
:::::* 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
 
:::::* Preferred regimen (4): [[Chloramphenicol]] 1 g IV q6-8h 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 (2): Increased risk for seizures associated with [[Imipenem]]/[[Cilastatin]] treatment.
 
:::::* 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 (1): [[Ciprofloxacin]] 400 mg IV q8h for 2 weeks
 
:::::* Preferred regimen (2): [[Levofloxacin]] 750 mg IV q24h for 2 weeks
 
:::::* Preferred regimen (3): [[Moxifloxacin]] 400 mg 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''' <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>
 
:::::* 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 weeks{{or}}
 
:::::* 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 (1): [[Ciprofloxacin]] 400 mg IV q8h for 2 weeks
 
::::::* 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'''
 
::::::* Preferred regimen: [[Ciprofloxacin]] 400 mg IV q8h
 
::::::* Note: Duration of treatment is 60 days
 
:::* 3.2 '''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>
 
::::* 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'''
 
::::::::::* Preferred regimen: [[Ciprofloxacin]] 20 mg/kg/day PO bid
 
::::::::::* '''For 1–4 week of age'''
 
::::::::::* Preferred regimen: [[Ciprofloxacin]] 20 mg/kg/day PO bid
 
::::::::* 3.2.5.3.1.1.2 '''For 34–37 week gestational age'''
 
:::::::::*  '''For < 1 week of age'''
 
::::::::::* Preferred regimen: [[Ciprofloxacin]] 20 mg/kg/day PO bid
 
:::::::::* '''For 1–4 week of age'''
 
::::::::::* Preferred regimen: [[Ciprofloxacin]] 20 mg/kg/day PO bid
 
::::::::* 3.2.5.3.1.1.3 '''Term newborn infant'''
 
:::::::::* '''For < 1 week of age'''
 
::::::::::* Preferred regimen: [[Ciprofloxacin]] 30 mg/kg/day PO bid
 
:::::::::* '''For 1–4 week of age'''
 
::::::::::* Preferred regimen: [[Ciprofloxacin]] 30 mg/kg/day PO bid {{or}}
 
:::::::* 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 (1): [[Clindamycin]] 10 mg/kg/day PO bid
 
:::::::::* Preferred regimen (2): [[Linezolid]] 20 mg/kg/day PO bid
 
::::::::* '''For 1–4 week of age'''
 
:::::::::* Preferred regimen (1): [[Clindamycin]] 15 mg/kg/day PO bid
 
:::::::::* 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 (1): [[Clindamycin]] 15 mg/kg/day PO tid
 
:::::::::* Preferred regimen (2): [[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): [[Linezolid]] 30 mg/kg/day PO tid
 
:::::::* 3.2.5.3.2.3 '''Term newborn infant'''
 
::::::::* '''For < 1 week of age'''
 
:::::::::* Preferred regimen (1): [[Clindamycin]] 15 mg/kg/day PO tid
 
:::::::::* 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'''
 
:::::::::* Preferred regimen (1): [[Ciprofloxacin]] 20 mg/kg/day PO bid
 
:::::::::* Preferred regimen (2): [[Clindamycin]] 10 mg/kg/day PO bid
 
::::::::* '''For 1–4 week of age'''
 
:::::::::* Preferred regimen (1): [[Ciprofloxacin]] 20 mg/kg/day PO bid
:::::::::* Preferred regimen (2): [[Clindamycin]] 15 mg/kg/day PO tid
 
:::::::* 3.2.5.4.1.2 '''For 34–37 week gestational age'''
 
::::::::* '''For < 1 week of age'''
 
:::::::::* Preferred regimen (1): [[Ciprofloxacin]] 20 mg/kg/day PO bid
 
:::::::::* Preferred regimen (2): [[Clindamycin]] 15 mg/kg/day PO tid
 
::::::::* '''For 1–4 week of age'''
 
:::::::::* Preferred regimen (1): [[Ciprofloxacin]] 20 mg/kg/day PO bid
 
:::::::::* Preferred regimen (2): [[Clindamycin]] 20 mg/kg/day PO qid
 
:::::::* 3.2.5.4.1.3 '''Term newborn infant'''
 
::::::::* '''For < 1 week of age'''
 
:::::::::* Preferred regimen (1): [[Ciprofloxacin]] 30 mg/kg/day PO bid
 
:::::::::* 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
 
::::::::* '''For 1–4 week of age'''
 
:::::::::* Preferred regimen (1): [[Ciprofloxacin]] 30 mg/kg/day PO bid
 
:::::::::* 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
   
   
::::::* 3.2.5.4.2 '''Alternatives for penicillin-susceptible strains'''
=== Prevention ===
 
*Smoking cessation is an important measure to prevent AAA progression and rupture.  
:::::::* 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'''
==Related Chapters==
 
* [[Aortic dissection|Aortic Dissection]]
::::::::* '''For < 1 week of age'''
* [[Thoracic aortic aneurysms|Thoracic Aortic Aneurysm]]
 
* [[Abdominal aortic aneurysm|Abdominal Aortic Aneurysm]]
:::::::::* Alternative regimen (1): [[Amoxicillin]] 50 mg/kg/day PO bid
* [[Aneurysm]]
:::::::::* 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'''<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>
 
:::* 1.1 '''For all strains, regardless of penicillin susceptibility or if susceptibility is unknown'''
 
::::* Preferred regimen (1): [[Ciprofloxacin]] 500 mg IV q12h
 
::::* Preferred regimen (2): [[Doxycycline]] 100 mg IV q12h
 
::::* Preferred regimen (3): [[Levofloxacin]] 750 mg IV q24h
 
::::* Preferred regimen (4): [[Moxifloxacin]] 400 mg IV q24h
 
::::* Preferred regimen (5): [[Clindamycin]] 600 mg IV q8h
 
:::* 1.2 '''Alternatives for penicillin-susceptible strain'''
 
::::* Preferred regimen (1): [[Amoxicillin]] 1 g IV q8h
 
::::* Preferred regimen (2): Penicillin VK 500 mg IV q6h
 
::* 2. '''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>
 
:::* 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 (1): [[Ciprofloxacin]] 20 mg/kg/day, PO, bid
 
::::::* Preferred regimen (2): [[Clindamycin]] 10 mg/kg/day, PO, bid
 
:::::* 3.1.1.2 '''For 1–4 week of age '''
 
::::::* Preferred regimen (1): [[Ciprofloxacin]] 20 mg/kg/day, PO,bid
 
::::::* 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 (1): [[Ciprofloxacin]] 20 mg/kg/day, PO, bid
 
::::::* Preferred regimen (2): [[Clindamycin]] 15 mg/kg/day, PO, tid
 
:::::* 3.1.2.2 '''For 1–4 week of age'''
 
::::::* Preferred regimen (1): [[Ciprofloxacin]] 20 mg/kg/day, PO, bid
 
::::::* 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 (1): [[Ciprofloxacin]] 30 mg/kg/day, PO, bid
 
::::::* 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 (1): [[Ciprofloxacin]] 30 mg/kg/day, PO, bid
 
::::::* 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'''<ref>Treatment Guidelines from The Medical Letter • Vol. 10 (Issue 122) • October 2012</ref><ref>{{cite book | last = Gilbert | first = David | title = The Sanford guide to antimicrobial therapy | publisher = Antimicrobial Therapy | location = Sperryville, Va | year = 2015 | isbn = 978-1930808843 }}</ref>
 
 
{| border="border" cellpadding=3 style="border-collapse:collapse"
|- bgcolor="#cccccc"
! Procedure
! Causative etiologies
! Recommended antimicrobials
! Usual adult dosage
! Comments
|-
| colspan=5 |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.
|-
| colspan=5 | 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
|
|-
| colspan=5 |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.
|-
| colspan=5 |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.
|-
| colspan=5 |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
|
|-
| colspan=5 | 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.
|-
| colspan=5 | 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
|
|-
| colspan=5 | 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
| 
|-
| colspan=5 | 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.
|-
| colspan=5 | 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==
==References==
{{reflist}}
{{Reflist|2}}

Revision as of 20:02, 8 June 2020

Aortic Aneurysm Overview

An aortic aneurysm is a dilation of the aorta in which the aortic diameter is ≥ 3.0 cm, usually representing an underlying weakness in the wall of the aorta at that location. While the stretched vessel may occasionally cause discomfort, a greater concern is the risk of rupture which causes severe pain, massive internal hemorrhage which are often fatal. Aneurysms often are a source of blood clots (emboli) stemming from the most common etiology of atherosclerosis.

Classification

There are 2 types of aortic aneurysms: thoracic and abdominal. These can be further classified according to the respective part of the vessel that's been affected:

  • Thoracic aortic aneurysm, which occur in the thoracic aorta (runs through the chest);
  • Abdominal aortic aneurysm, which occur in the abdominal aorta, are the most common.
    • Suprarenal - not as common, often more difficult to repair surgically due to the presence of many aortic branches;
    • Infrarenal - often more easily surgically repaired and more common;
    • Pararenal - aortic aneurysm is infrarenal but affects renal arteries;
    • Juxtarenal - infrarenal aortic aneurysm that affects the aorta just below the renal arteries.

Thoracoabdominal aortic aneurysm may also be classified according to Crawford classification into 5 subtypes/groups:

  • Type 1: from the origin of left subclavian artery in descending thoracic aorta to the supra-renal abdominal aorta.
  • Type 2: from the left subclavian to the aorto-iliac bifurcation.
  • Type 3: from distal thoracic aorta to the aorto-iliac bifurcation
  • Type 4: limited to abdominal aorta below the diaphragm
  • Type 5: from distal thoracic aorta to celiac and superior mesenteric origins, but not the renal arteries.

Historical Perspective

Aortic aneurysm was first recorded by Antyllus, a Greek surgeon, in the second century AD. In the Renaissaince era, in 1555, Vesalius first diagnosed an abdominal aortic aneurysm. The first publication on the pathology with case studies was published by Lancisi in 1728. Finally, in 1817, Astley Cooper was the first surgeon to ligate the abdominal aorta to treat a ruptured iliac aneurysm. In 1888, Rudoff Matas came up with the concept of endoaneurysmorrhaphy.

Pathophysiology

The aortic aneurysms are a multifactorial disease associated with genetic and environmental risk factors. Marfan's syndrome and Ehlers-Danlos syndrome are associated with the disease, but there are also rarer syndromes like the Loeys-Dietz syndrome that are associated as well. Even in patients that do not have genetic syndromes, it has been observed that genetics can also play a role on aortic aneurysms' development. There has been evidence of genetic heterogeneity as there has already been documented in intracranial aneurysms.[1] The genetic alterations associated with these genetic syndromes are the following:

Genetic diseases associated with aortic aneurysms
Disease Involved Cellular Pathway Mutated Gene(s) Affected Protein(s)
Ehlers-Danlos syndrome type IV Extracellular Matrix Proteins COL3A1 Collagen type III
Marfan's syndrome Extracellular Matrix Proteins FBN1 Fibrillin-1
Loeys-Dietz syndrome TGF-β Pathway TGFBR1/TGFBR2
Aneurysm-Osteoarthritis Syndrome SMAD3 SMAD3
Autosomal Dominant Polycystic Kidney Disease Ciliopathy PKD1PKD2 Polycystin 1

Polycystin 2

Turner Syndrome Meiotic Error with Monosomy, Mosaicism, or De Novo Germ Cell Mutation 45X

45XO

Partial or Complete Absence of X Chromosome
Bicuspid Aortic Valve with TAA Neural Crest Migration NOTCH1 Notch 1
Familial TAA Smooth Muscle Contraction Proteins ACTA2 α-Smooth Muscle Actin
Familial TAA with Patent Ductus Arteriosus Smooth Muscle Contraction Proteins MYH11 Smooth Muscle Myosin
Familial TAA Smooth Muscle Contraction Proteins MYLK Myosin Light Chain Kinase
Familial TAA Smooth Muscle Contraction Proteins PRKG1 Protein Kinase c-GMP Dependent, type I
Loeys-Dietz Syndrome variants TGF-β Pathway TGF-βR1TGF-βR2SMAD3TGF-β2TGF-β3

These genetic diseases mostly affect either the synthesis of extracellular matrix protein or damage the smooth muscle cells both important component's of the aortic wall. Injury to any of these components lead to weakening of the aortic wall and dilation - resulting in aneurysm formation.

The aorta is the largest vessel of the body, but it is not homogenous. Its upper segment is composed by a larger proportion of elastin in comparison to collagen, therefore being more distensible. The lower segment has a larger proportion of collagen, therefore it is less distensible. It is also where most of the atherosclerotic plaques of the aorta are located.[2] Historically it was thought that abdominal and thoracic aortic aneurysms were caused by the same etiology: atherosclerotic degeneration of the aortic wall, but recently it has been theorized that they are indeed different diseases.[2]

The aortic arch mostly derives from the neural crest cell which differentiate into smooth muscle cells. These smooth muscle cells are probably more adapted to remodel the thoracic aorta and manage the higher pulse pressure and ejection volume due to increased production of elastic lamellae during development and growth.[2] The abdominal aorta remains with cells of mesodermal origin, which are more similar to that of the original primitive arterial. That difference results in the neural crest cell precursors of the thoracic aorta being able to respond differently to various cytokines and growth factors than the mesodermal precursors of the abdominal aorta, such as homocysteine and angiotensin II.

When neural crest vascular smooth muscle cells are treated with TGF-β they demonstrate increased collagen production, while mesodermal vascular smooth muscle cell did not. Not coincidently, mutations of the TGF-β receptor can cause thoracic aortic aneurysm but do not cause abdominal aortic ones.

The thoracic and abdominal aorta are very structurally different. While they both have three layers: intimal, medial and adventitia, the media of the thoracic aorta is comprised of approximately 60 units divided into vascular and avascular regions. The abdominal aorta consists of about 30 units and is entirely avascular - being dependent on trans-intimal diffusion of nutrients for its smooth muscle cells to survive. It is believed that both differences explain why the abdominal aorta is more likely to form aneurysms.

The development of aortic aneurysms is defined by: inflammation: infiltration of the vessel wall by lymphocytes and macrophage; extracellular matrix damage: destruction of elastin and collagen by proteases (also metalloproteinases) in the media and adventitia; cellular damage: loss of smooth muscle cells with thinning of the media; and insufficient repair: neovascularization.

In summary:

  • The pathogenesis of aortic aneurysm is characterized by progressive dilation, rupture, and may present with dissection;
  • The pathological processes that lead to abdominal and thoracic aortic aneurysms may be very different from one another;
  • The fibrillin-1 gene mutation has been associated with the development of thoracic aortic aneurysms in Marfan's syndrome;
  • Other gene mutations coding for collagen, elastin and other elements of the extracellular matrix have been associated with the development of aneurysms in some genetic disorders, including Ehlers-Danlos syndrome and others;
  • Mutations in the TGF-β pathway have also been described in the pathogenesis of aortic aneurysms in multiple genetic disorders, including Loeys-Dietz syndrome.

Clinical Features

Differentiating Aortic Aneurysm from other Diseases

Thoracic aortic aneurysms: differential diagnosis include other causes of chest pain: acute aortic dissection, acute pericarditis, aortic regurgitation, heart failure, hypertensive emergencies, infective endocarditis, myocardial Infarction, pulmonary embolism, superior vena cava syndrome.

Abdominal aortic aneurysms: differential diagnosis include causes of pulsatile abdominal mass and/or abdominal pain such as ruptured viscus, strangulated hernia, ruptured visceral artery aneurysms, mesenteric ischemia, acute cholecystitis, ruptured hepatobiliary cancer, acute pancreatitis, lymphomas, and diverticular abscess.

These conditions can be easily differentiated using abdominal or thoracic imaging.

Epidemiology and Demographics

In the United States alone 15,000 people die yearly due to aortic aneurysms and it is the 13th leading cause of death. 1-2% of the population may have aortic aneurysms and prevalence rises up to 10% in older age groups. The disease varies according to where it takes place. In the thorax, the aortic arch is the less affected segment (10%) and the most common is the ascending aorta (50%). Regarding abdominal aneurysms, the infrarenal segment aortic aneurysms are three times more prevalent than the aortic aneurysms and dissections.

Regarding other factors as age, abdominal aortic aneurysms usually present 10 years later than thoracic aortic aneurysms. Both lesions are more present in men, but the proportion is much higher regarding abdominal aortic aneurysms (6:1 male:female ratio) in comparison to thoracic ones.[1]

Abdominal aortic aneurysms also affect patients differently regarding race, as they are more prevalent among whites than blacks, asians and hispanics. It also seems to be declining in prevalence as evidenced by a Swedish study that found out a 2% prevalence of abdominal aortic aneurysms in comparison to earlier studies which reported 4-8%, probably due to risk-factor modification.

Risk Factors

Many risk factors are common between both forms of aortic aneurysms, but some are specific for each presentation:

Natural History, Complications and Prognosis

Even though the majority of the aortic aneurysms remain asymptomatic for years, their natural history is dissection or rupture.[4] According to Laplace's law, as the aneurysms grow larger they have a higher rate of expansion. Due to that, the frequency of monitoring changes with the diameter of the abdominal aortic aneurysm, being every 3 years for aneurysms with a 3-3.4cm diameter, yearly for diameters of 3.5-4.4cm, and every 6 months for larger than 4.5cm.[5] For the thoracic one, up to 80% of the aneurysms will eventually rupture, and patients present with a 10-20% five-year survival rate if they remain untreated.[4] Risk of rupture doubles every 1cm in growth over the 5cm diameter in descending thoracic aorta.

Besides rupturing and dissection of the aorta, aortic aneurysms can also present with systemic embolization and aortic regurgitation (if the thoracic aortic aneurysm is located in the ascending aorta). The altered blood flow in the aneurysm can also lead to the formation of blood cloths and embolization.

Diagnosis

Diagnostic Criteria

Abdominal aortic aneurysms: are considered a dilation of the abdominal aorta which presents with a permanent vessel diameter larger than 30mm (normal abdominal aortic diameter ranges from 15 to 25mm). They can be diagnosed by abdominal ultrasound imaging, CT scan or MRI.

Thoracic aortic aneurysms: generally an aneurysm is diagnosed when the axial diameter of the ascending aorta is larger than 5cm and 4cm for the descending aorta. When larger than normal but not reaching aneurysmal definition the terms dilatation and ectasia can be used. The transthoracic ultrasound is not used due to the fact that thebones of the chest wall and the air inside the lungs makes the assessment of the aorta difficult. Instead it is chosen the CT scan, MRI or angiography for diagnosis.[6]

Symptoms:

Aortic aneurysms are largely an asymptomatic condition, but symptoms present differently according to the affected segment of the aorta.

Thoracic aortic aneurysms: patients are usually diagnosed in these contexts:

  • Incidental finding as part of a routine examination (transthoracic echocardiography, computerized tomography of the chest, cardiac magnetic resonance imaging, routine chest radiograph);
  • Acute presentation with thoracic aortic dissection or aneurysm rupture;
  • Screening due to a relative of a patient presenting with aortic disease;
  • Part of a known congenital cardiac condition.

The aneurysms tend to grow slowly and most of them will never rupture. As they grow, however, their symptoms become more evident and present with mass effects over surrounding structures and pain. They may present with thoracic symptoms: interscapular or central pain, ripping chest pain and dyspnea. Atypical presentations include hoarseness, dizziness and dysphagia, due to esophageal compression. Aneurysm rupture lead to massive internal bleeding, hypovolemic shock and it is usually fatal.

Abdominal aortic aneurysms: as the thoracic aneurysms, they begin asymptomatic but may cause symptoms as they grow and compress surrounding structures.Even though they usually remain asymptomatic, when they rupture they present with an ensuing mortality of 85 to 90%., and symptomatic patients require urgent surgical repair.

When symptomatic, abdominal aortic aneurysms present with:

  • Pain: in the chest, abdomen, lower back, or flanks. It may radiate to the groin, buttocks, or legs. The pain characteristics vary and may be deep, aching, gnawing, or throbbing It may also last for hours or days, not affected by movement. Occasionally, certain positions can be more comfortable and alleviate the symptoms;
  • Pulsating abdominal mass;
  • Ischemia: "cold foot" or a black or blue painful toe. This is usually the presentation when an aneurysm forms a blood cloth and it releases emboli to the lower extremities;
  • Fever or weight loss if caused by inflammatory states such as vasculitis.[7]

If ruptured, the abdominal aortic aneurysm can present with sharp abdominal pain, often radiating to the back, discoloration of the skin and mucosa, tachycardia and low blood pressure due to hypovolemic shock.

Differential diagnosis include causes of pulsatile abdominal mass and/or abdominal pain such as ruptured viscus, strangulated hernia, ruptured visceral artery aneurysms, mesenteric ischemia, acute cholecystitis, ruptured hepatobiliary cancer, acute pancreatitis, lymphoma, and diverticular abscess.[3]

Treatment

Medical Therapy

Focus is to reduce systemic blood pressure, inhibit MMP (zinc endopeptidases that degrade the extracellular matrix in aortic aneurysms)[8], and contain the progression of atherosclerosis:

  • Beta-blockers may help in reducing the rate of expansion of the aortic aneurysm, reducing shear stress - studies have been mostly on Marfan patients and they found a low compliance with propranolol due to a significant effect on quality of life[8];
  • Tetracyclines inhibit the MMP endopeptidases, and has been used in conditions in which MMP are overexpressed such as rheumatoid arthritis. There are studies in humans showing that doxycycline reduced the rate of expansion of aortic aneurysms. Roxithromycin, a macrolide has been also show to reduce the expansion of the aortic aneurysms.
  • Statins may also be helpful due to their pleiotropic effecs, reducing the oxidative stress by blocking the reactive oxygen species on aneurysms, suppressing the NADH/NADPH oxidase system.
  • Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers promotes vascular hypertrophy, cell proliferation and production of extracellular matrix. It also activates the NADH/NADPH oxidase system, both stimulating and inhibiting MMPs and degradation of extracellular matrix. There is a controversy of which class is more effective, and ongoing trials are being run to further clarify these questions.[8]

Surgery

Indication for elective surgical treatment is commonly discussed

  • The mainstay of therapy for AAA is aneurysmal repair if diameter>5.5cm or size increased>0.5cm over 6 months.
  • Surgical repair is indicated in cases of TAA dissection and progressive enlargement.

Prevention

  • Smoking cessation is an important measure to prevent AAA progression and rupture.

Related Chapters

References

  1. ↑ 1.0 1.1
  2. ↑ 2.0 2.1 2.2
  3. ↑ 3.0 3.1
  4. ↑ 4.0 4.1
  5. ↑
  6. ↑
  7. ↑
  8. ↑ 8.0 8.1 8.2 Danyi, Peter, John A. Elefteriades, and Ion S. Jovin. "Medical therapy of thoracic aortic aneurysms: are we there yet?." Circulation 124.13 (2011): 1469-1476.
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