Anthrax medical therapy: Difference between revisions

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Revision as of 14:18, 5 August 2015

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]

Overview

Medical therapy of anthrax infection includes antibiotic and antitoxin drugs. Uncomplicated cutaneous anthrax is treated with a single oral antimicrobial drug for a duration of 7-10 days for naturally acquired anthrax and 60 days for bioterrorism-related exposure. In case of systemic anthrax without meningitis, the initial treatment should include ≥2 antimicrobial drugs for ≥2 weeks or until the patient is clinically stable, whichever is longer. In case of systemic anthrax with suspected or confirmed meningitis, the initial treatment should include ≥3 antimicrobial drugs for ≥2 weeks or until the patient is clinically stable, whichever is longer. Once patients with systemic illness who were exposed to aerosolized spores have completed initial combination treatment, they should be transitioned to single-agent oral treatment to prevent relapse from surviving B. anthracis spores. These patients should be monitored at all times to evaluate the need for supportive care measures, such as hemodynamic support, mechanical ventilation, corticosteroids, procedures, and surgical interventions in certain occasions. An antitoxin should be added to combination antibiotic treatment. Currently there are 2 antitoxins in the CDC Strategic National Stockpile: raxibacumab and Anthrax Immune Globulin Intravenous (AIGIV).^[1]

Medical Therapy

The treatment of anthrax infection includes antibiotic and antitoxin agents. This treatment and postexposure prophylaxis differs from other bacterial infections because anthrax is associated with:^[1]

Production of toxins
Potential antibiotic resistance
Frequent occurrence of meningitis
Presence of latent spores that must be taken into account when selecting post-exposure prophylaxis or a combination of antibiotics for treatment of anthrax

Bacillus anthracis treatment

1. Treatment for cutaneous anthrax, without systemic involvement^[2]

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^[2]

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 ^[3]

3.1.1.1 A Bactericidal Agent (Fluoroquinolone)

Preferred regimen (1): Ciprofloxacin 400 mg IV q8h for 2–3 weeks OR

Preferred regimen (2): Levofloxacin 750 mg IV q24h for 2–3 weeksOR

3.1.1.2 A Bactericidal Agent (ß-lactam)

3.1.1.2.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown

Preferred regimen: Meropenem 2 g q8h for 2–3 weeks

3.1.1.2.2 Alternatives for penicillin-susceptible strains

Alternative regimen (1): Ampicillin 3 g IV q6h for 2–3 weeks

Alternative regimen (2): Penicillin G 4 MU IV q4h for 2–3 weeks OR

3.1.1.3 A Protein Synthesis Inhibitor

Preferred regimen (1): Clindamycin 900 IV mg q8h for 2–3 weeks

Preferred regimen (2): Rifampin 600 IV mg q12h for 2–3 weeks

Note: At least one antibiotic with transplacental passage is recommended.

3.1.2 Intravenous antimicrobial treatment for systemic anthrax when meningitis has been excluded

3.1.2.1 A Bactericidal Antimicrobial

Preferred regimen (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 ^[4]

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

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^[2]

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^[4]

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

Bacillus cereus Return to Top

1. Food poisoning^[5]

Preferred regimen: Food poisoning is usually self-limited and requires no antibiotic therapy.

2. Bacteremia

Preferred regimen: Vancomycin 15 mg/kg IV q12h
Alternative regimen: Clindamycin 600 mg IV q8h
Note (1): Bacillus cereus is commonly resistant to beta-lactams.
Note (2): Pseudobacteremia is transient and usually results from contaminated blood cultures, gloves, or syringes.

3. Meningitis or brain abscess

Preferred regimen: Vancomycin 15 mg/kg IV q12h
Alternative regimen: Clindamycin 600 mg IV q8h
Note: Blood culture isolates are mostly contaminates until proven otherwise, especially in intravenous drug user population.

4. Endophthalmitis

Preferred regimen: Clindamycin 450 μg intravitreal AND Gentamicin 400 μg intravitreal OR Dexamethasone intravitreal AND Vancomycin 15 mg/kg IV q12h
Alternative regimen: Clindamycin 600 mg IV q8h
Note: Ophthalmological consultation, culture ocular fluids, early vitrectomy, and intravitreal antibiotics are necessary.

5. Endocarditis

Preferred regimen: Vancomycin 15 mg/kg IV q12h
Note: Most blood cultures in intravenous drug users are contaminates or represent transient bacteremia.

6. Soft tissue infection

Preferred regimen: Vancomycin 15 mg/kg IV q12h
Alternative regimen: Clindamycin 600 mg IV q8h

7. Pneumonia

Preferred regimen: Vancomycin 15 mg/kg IV q12h
Alternative regimen: Clindamycin 600 mg IV q8h

Bacillus subtilis Return to Top

Bacillus subtilis infection treatment^[6]^[7]^[8]

1. Food poisoning

Preferred regimen: supportive treatment

2. Other infections

Preferred regimen: Vancomycin OR Clindamycin
Alternative regimen: Ciprofloxacin OR Imipenem
Note: Distinguish clinically significant infection from contamination before administering antibiotics.

Clostridium botulinum Return to Top

1. Antibiotics

Antibiotics are not recommended in gastrointestinal botulism due to the risk of worsening of neurological symptoms caused by the lysis of the bacteria. For wound botulism antibiotics are indicated with surgical treatment as followed:
Preferred regimen: Metronidazole 500 mg IV q8h
Alternative regimen: Penicillin G 3 million units IV q4h

2. Antitoxin ^[9]

Preferred regimen: Trivalent antitoxin (A 7,500 IU, B 5,000 IU, and E 5,000 IU) 1 vial diluted 1:10, IV infusion over 30 min
Alternative regimen: Equine antitoxin

3. General Therapy

Preferred regimen: Mechanical ventilation; IV hydration; tube feedings

Clostridium perfringens Return to Top

Clostridium perfringens ^[10]
Gas gangrene

Preferred regimen: Penicillin G 3-4 million units IV q4h AND (Clindamycin 900 mg IV q8h OR Tetracycline 500 mg IV q6h)^[11]

Clostridium tetani Return to Top

1. General measures

Preferred regimen: Patients should be placed in a quiet shaded area and protected from tactile and auditory stimulation as much as possible; All wounds should be cleaned and debrided as indicated

2. Immunotherapy

Preferred regimen: Human TIG 500 units IV/IM as soon as possible AND Age-appropriate TT-containing vaccine, 0.5 cc IM at a separate site
Note: patients without a history of primary TT vaccination should receive a second dose 1–2 months after the first dose and a third dose 6–12 months later

3. Antibiotic treatment^[12]

Preferred regimen: Metronidazole 500 mg IV/PO q6h OR Penicillin G 100,000–200,000 IU/kg/day IV, administered in 2–4 divided doses
Alternative regimen: Tetracyclines OR Macrolides OR Clindamycin OR Cephalosporins OR Chloramphenicol

4. Muscle spasm control

Preferred regimen: Diazepam 5 mg IV OR Lorazepam 2 mg IV titrating to achieve spasm control without excessive sedation and hypoventilation
Alternative regimen (1): Magnesium sulphate 5 g (or 75mg/kg) IV loading dose, then 2–3 g per hour until spasm control is achieved ± Benzodiazepines
Note: Monitor patellar reflex as areflexia (absence of patellar reflex) occurs at the upper end of the therapeutic range (4mmol/L). If areflexia develops, dose should be decreased
Alternative regimen (2): Baclofen OR Dantrolene 1–2 mg/kg IV/PO q4h
Alternative regimen (3): Barbiturates 100–150 mg q1-4h by any route
Alternative regimen (4): Chlorpromazine 50–150 mg IM q4–8h
Pediatric regimen: Lorazepam 0.1–0.2 mg/kg IV q2–6h, titrating upward as needed; Barbiturates 6–10 mg/kg in children by any route; Chlorpromazine 4–12 mg IM every q4–8h
Note: As for Benzodiazepines, large amounts may be required (up to 600 mg/day); oral preparations could be used but must be accompanied by careful monitoring to avoid respiratory depression or arrest

5. Autonomic dysfunction control

Preferred regimen: Magnesium sulphate OR Morphine OR Esmolol

6. Airway/respiratory control

Note: Drugs used to control spasm and provide sedation can result in respiratory depression. If spasm, including laryngeal spasm, is impeding or threatening adequate ventilation, mechanical ventilation is recommended when possible. Early tracheostomy is preferred as endotracheal tubes can provoke spasm and exacerbate airway compromise.

Clostridium difficile Return to Top

1. Pseudomembranous colitis - mild to moderate^[13]

Preferred regimen:Metronidazole 500 mg PO tid for 10-14 days
Alternative regimen: Vancomycin 125 mg PO qid for 10-14 days
Note: If significant risk of recurrence: Vancomycin 125 mg PO qid for 10-14 days OR Fidaxomicin 200 mg PO bid for 10 days

2. Pseudomembranous colitis - severe^[13]

Preferred regimen: Vancomycin 125 mg PO qid for 10-14 days
Note: If significant risk of recurrence: Vancomycin 125 mg PO qid for 10-14 days OR Fidaxomicin 200 mg PO bid for 10 days

3. Pseudomembranous colitis - severe, complicated^[13]

Preferred regimen: Vancomycin 125-500 mg PO qid for 10-14 days AND Vancomycin 500 mg diluted in 500 ml of saline as enema per rectum q6h AND Metronidazole 500 mg IV q8h
Note: Consider urgent surgical consult

4. Recurrent pseudomembranous colitis^[13]

First recurrence treatment

Preferred regimen: same as first episode or [Fidaxomicin]] 200 mg PO bid for 10 days

Second or more recurrence treatment

Preferred regimen: Vancomycin 125 mg PO qid for 14 days THEN Vancomycin 125 mg PO tid for 7 days THEN Vancomycin 125 mg PO bid for 7 days THEN Vancomycin 125 mg PO qd for 7 days THEN Vancomycin 125 mg PO q48h for 7 days THEN Vancomycin 125 mg PO q72h for 7 days OR Fidaxomicin 200 mg PO bid for 10 days
Note: Consider expert consult for fecal microbiota transplantation

Antitoxins

An antitoxin should be added to combination antibiotic treatment for any patient for whom there is a high level of clinical suspicion for systemic anthrax. Given that systemic anthrax has a high case-fatality rate and the risk for antitoxin treatment appears to be low, the potential benefit achieved by adding antitoxin to combination antibiotic treatment outweighs the potential risk.

Currently there are 2 antitoxins in the CDC Strategic National Stockpile: raxibacumab and Anthrax Immune Globulin Intravenous (AIGIV). Both antitoxins inhibit binding of Protective Antigen (PA) to anthrax toxin receptors and translocation of the 2 primary toxins (Lethal Toxin (LT) and Edema Toxin (ET)) into cells.^[1]

Raxibacumab

Raxibacumab is a recombinant, fully humanized, IgG1λ monoclonal antibody. It appeared safe and well tolerated in 333 healthy adults who received the recommended dose of 40 mg/kg.

Most adverse events were transient and mild to moderate in severity. Pruritis was noted in 2.1% of persons treated with raxibacumab and in none treated with placebo. Although raxibacumab has not been given to patients with systemic anthrax, it is FDA-approved for postexposure prophylaxis.^[1]

Anthrax Immune Globulin

AIGIV is a human polyclonal antiserum made from plasma of persons immunized with Anthrax Vaccine Absorbed (AVA), which might have some direct effect on Lethal Factor (LF) and Edema Factor (EF). It was evaluated in 74 healthy adult volunteers and appears safe and well tolerated at all doses tested.

The most frequently reported adverse events were headache pharyngolaryngeal pain, and nausea.

AIGIV is not FDA approved and could be made available under an Investigational New Drug protocol or an Emergency Use Authorization during a declared emergency.^[1]

Hospitalization

Many patients with cutaneous anthrax can be treated as outpatients.

Patients with symptoms or signs of systemic involvement (e.g., tachycardia, tachypnea, hypotension, hyperthermia, hypothermia, leukocytosis) or with lesions that involve the head, neck, or upper torso or that are large, bullous, multiple, or surrounded by edema, have higher mortality rates. Hospitalization is warranted for all patients with systemic cutaneous anthrax; gastrointestinal, injection, or inhalation anthrax; or anthrax meningitis or bacteremia.

Supportive Treatment

Failure to fulfill systemic inflammatory response syndrome criteria should not decrease concern for sepsis because patients with systemic anthrax might not initially appear critically ill. Inhalation anthrax can have a prodromal phase followed by a fulminant phase. Patients with systemic anthrax have had debilitating symptoms, followed first by transitory improvement and then by precipitous hemodynamic deterioration. Because of this potential for sudden decompensation, hospitalized patients should have careful hemodynamic monitoring, including continuous pulse oximetry and telemetry.

Hemodynamic Support

Standard sepsis and septic shock guidelines should be followed for anthrax patients. Common complications of anthrax infections including microangiopathic hemolytic anemia, coagulopathy, thrombocytopenia, and hemorrhage must be aggressively managed, since they might pose contraindications to invasive central catheter placement.^[14]

Fresh frozen plasma and plasmapheresis should be considered, and fibrinogen levels should be kept >100 mg/dL.

An echocardiogram might be needed to identify pericardial effusions.^[15]

Mechanical Ventilation

In addition to the need for mechanical ventilation for respiratory distress or airway protection for persons with altered mental status, some patients with anthrax might require respiratory support for airway edema. Substantial edema with fatal outcome can occur with cutaneous lesions involving the head, neck, or thorax, and with oropharyngeal lesions.^[16]

In inhalation anthrax, although respiratory failure is more consistent with reaccumulating pleural effusions than with adult respiratory distress syndrome, standard mechanical ventilator principles apply.^[17] The need for ventilation in some patients and the duration of ventilation in others may be reduced by pleural space drainage.

Adjunctive Corticosteroids

There are limited data on steroid use for documented anthrax meningitis, however, adjunctive intravenous dexamethasone is the standard of care for patients with suspected bacterial meningitis and should be started at the time of initial antibiotic therapy to prevent neurologic sequelae.^[18]

Adjunctive corticosteroids should be considered in patients who had a history of use of:^[19]^[20]

Endocrine therapy
Corticosteroid therapy
Edema, especially of the head or neck
Evidence of anthrax meningitis
Vasopressor-resistant shock

Interventions

Procedures

Drainage of pleural fluid and ascites is believed to improve survival by reducing the toxin level and by decreasing mechanical lung compression. These data support the need for early and aggressive drainage of any clinically or radiographically apparent pleural effusions; chest tube drainage is recommended over thoracentesis because many effusions will require prolonged drainage. ^[1]

Thoracotomy or video-assisted thoracic surgery might be required to remove gelatinous or loculated collections. Ascites should also be drained and monitored for reaccumulation.^[1]

Surgery

Surgery for cutaneous anthrax can lead to dissemination and poor outcome. Surgery is contraindicated for acute disease, with the exception of tracheotomy for airway obstruction and surgical intervention for large or circumferential extremity lesions causing compartment syndrome.

Surgery may be indicated for gastrointestinal anthrax to identify and address potentially fatal complications, such as bowel ischemia, necrosis, and perforation.^[21]

For injection anthrax, surgery is used to obtain diagnostic specimens to differentiate the infection from necrotizing fasciitis and to remove the necrotic nidus of infection, which may be a toxin and spore reservoir. Surgery for injection anthrax should be more limited than that for necrotizing fasciitis, and resection should be performed only to healthy tissue. Compression of soft tissues can be released by incision, excision, or fasciotomy and might be required for treatment of compartment syndrome.^[22]

References

↑ ^1.0 ^1.1 ^1.2 ^1.3 ^1.4 ^1.5 ^1.6 "Centers for Disease Control and Prevention Expert Panel Meetings on Prevention and Treatment of Anthrax in Adults".
↑ ^2.0 ^2.1 ^2.2 Hendricks KA, Wright ME, Shadomy SV, Bradley JS, Morrow MG, Pavia AT; et al. (2014). "Centers for disease control and prevention expert panel meetings on prevention and treatment of anthrax in adults". Emerg Infect Dis. 20 (2). doi:10.3201/eid2002.130687. PMC 3901462. PMID 24447897.
↑ Meaney-Delman D, Zotti ME, Creanga AA, Misegades LK, Wako E, Treadwell TA; et al. (2014). "Special considerations for prophylaxis for and treatment of anthrax in pregnant and postpartum women". Emerg Infect Dis. 20 (2). doi:10.3201/eid2002.130611. PMC 3901460. PMID 24457117.
↑ ^4.0 ^4.1 Bradley JS, Peacock G, Krug SE, Bower WA, Cohn AC, Meaney-Delman D; et al. (2014). "Pediatric anthrax clinical management". Pediatrics. 133 (5): e1411–36. doi:10.1542/peds.2014-0563. PMID 24777226.
↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
↑ Andrews, J. M.; Wise, R. (2002-06). "Susceptibility testing of Bacillus species". The Journal of Antimicrobial Chemotherapy. 49 (6): 1040–1042. ISSN 0305-7453. PMID 12039902. Check date values in: |date= (help)
↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
↑ Altemeier WA, Fullen WD (1971). "Prevention and treatment of gas gangrene". JAMA. 217 (6): 806–13. PMID 5109333.
↑ http://www.who.int/diseasecontrol_emergencies/who_hse_gar_dce_2010_en.pdf
↑ ^13.0 ^13.1 ^13.2 ^13.3 Bagdasarian N, Rao K, Malani PN (2015). "Diagnosis and treatment of Clostridium difficile in adults: a systematic review". JAMA. 313 (4): 398–408. doi:10.1001/jama.2014.17103. PMID 25626036.
↑ Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM; et al. (2013). "Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012". Intensive Care Med. 39 (2): 165–228. doi:10.1007/s00134-012-2769-8. PMID 23361625.
↑ Jernigan JA, Stephens DS, Ashford DA, Omenaca C, Topiel MS, Galbraith M; et al. (2001). "Bioterrorism-related inhalational anthrax: the first 10 cases reported in the United States". Emerg Infect Dis. 7 (6): 933–44. doi:10.3201/eid0706.010604. PMC 2631903. PMID 11747719.
↑ Peck RN, Fitzgerald DW (2007). "Cutaneous anthrax in the Artibonite Valley of Haiti: 1992-2002". Am J Trop Med Hyg. 77 (5): 806–11. PMID 17984330.
↑ Artigas A, Bernard GR, Carlet J, Dreyfuss D, Gattinoni L, Hudson L; et al. (1998). "The American-European Consensus Conference on ARDS, part 2: Ventilatory, pharmacologic, supportive therapy, study design strategies, and issues related to recovery and remodeling. Acute respiratory distress syndrome". Am J Respir Crit Care Med. 157 (4 Pt 1): 1332–47. doi:10.1164/ajrccm.157.4.ats2-98. PMID 9563759.
↑ de Gans J, van de Beek D, European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators (2002). "Dexamethasone in adults with bacterial meningitis". N Engl J Med. 347 (20): 1549–56. doi:10.1056/NEJMoa021334. PMID 12432041. Review in: ACP J Club. 2003 May-Jun;138(3):60
↑ Sejvar JJ, Tenover FC, Stephens DS (2005). "Management of anthrax meningitis". Lancet Infect Dis. 5 (5): 287–95. doi:10.1016/S1473-3099(05)70113-4. PMID 15854884.
↑ Annane D, Bellissant E, Bollaert PE, Briegel J, Confalonieri M, De Gaudio R; et al. (2009). "Corticosteroids in the treatment of severe sepsis and septic shock in adults: a systematic review". JAMA. 301 (22): 2362–75. doi:10.1001/jama.2009.815. PMID 19509383.
↑ Binkley CE, Cinti S, Simeone DM, Colletti LM (2002). "Bacillus anthracis as an agent of bioterrorism: a review emphasizing surgical treatment". Ann Surg. 236 (1): 9–16. PMC 1422543. PMID 12131080.
↑ Knox D, Murray G, Millar M, Hamilton D, Connor M, Ferdinand RD; et al. (2011). "Subcutaneous anthrax in three intravenous drug users: a new clinical diagnosis". J Bone Joint Surg Br. 93 (3): 414–7. doi:10.1302/0301-620X.93B3.25976. PMID 21357967.

Template:WikiDoc Sources

[CDC-1] 1.0 ^1.1 ^1.2 ^1.3 ^1.4 ^1.5 ^1.6 "Centers for Disease Control and Prevention Expert Panel Meetings on Prevention and Treatment of Anthrax in Adults".

[pmid24447897-2] 2.0 ^2.1 ^2.2 Hendricks KA, Wright ME, Shadomy SV, Bradley JS, Morrow MG, Pavia AT; et al. (2014). "Centers for disease control and prevention expert panel meetings on prevention and treatment of anthrax in adults". Emerg Infect Dis. 20 (2). doi:10.3201/eid2002.130687. PMC 3901462. PMID 24447897.

[pmid24457117-3] Meaney-Delman D, Zotti ME, Creanga AA, Misegades LK, Wako E, Treadwell TA; et al. (2014). "Special considerations for prophylaxis for and treatment of anthrax in pregnant and postpartum women". Emerg Infect Dis. 20 (2). doi:10.3201/eid2002.130611. PMC 3901460. PMID 24457117.

[pmid24777226-4] 4.0 ^4.1 Bradley JS, Peacock G, Krug SE, Bower WA, Cohn AC, Meaney-Delman D; et al. (2014). "Pediatric anthrax clinical management". Pediatrics. 133 (5): e1411–36. doi:10.1542/peds.2014-0563. PMID 24777226.

[5] Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.

[6] Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.

[7] Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.

[8] Andrews, J. M.; Wise, R. (2002-06). "Susceptibility testing of Bacillus species". The Journal of Antimicrobial Chemotherapy. 49 (6): 1040–1042. ISSN 0305-7453. PMID 12039902. Check date values in: |date= (help)

[9] Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.

[10] Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.

[pmid5109333-11] Altemeier WA, Fullen WD (1971). "Prevention and treatment of gas gangrene". JAMA. 217 (6): 806–13. PMID 5109333.

[12] ttp://www.who.int/diseasecontrol_emergencies/who_hse_gar_dce_2010_en.pdf

[pmid25626036-13] 13.0 ^13.1 ^13.2 ^13.3 Bagdasarian N, Rao K, Malani PN (2015). "Diagnosis and treatment of Clostridium difficile in adults: a systematic review". JAMA. 313 (4): 398–408. doi:10.1001/jama.2014.17103. PMID 25626036.

[pmid23361625-14] Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM; et al. (2013). "Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012". Intensive Care Med. 39 (2): 165–228. doi:10.1007/s00134-012-2769-8. PMID 23361625.

[pmid11747719-15] Jernigan JA, Stephens DS, Ashford DA, Omenaca C, Topiel MS, Galbraith M; et al. (2001). "Bioterrorism-related inhalational anthrax: the first 10 cases reported in the United States". Emerg Infect Dis. 7 (6): 933–44. doi:10.3201/eid0706.010604. PMC 2631903. PMID 11747719.

[pmid17984330-16] Peck RN, Fitzgerald DW (2007). "Cutaneous anthrax in the Artibonite Valley of Haiti: 1992-2002". Am J Trop Med Hyg. 77 (5): 806–11. PMID 17984330.

[pmid9563759-17] Artigas A, Bernard GR, Carlet J, Dreyfuss D, Gattinoni L, Hudson L; et al. (1998). "The American-European Consensus Conference on ARDS, part 2: Ventilatory, pharmacologic, supportive therapy, study design strategies, and issues related to recovery and remodeling. Acute respiratory distress syndrome". Am J Respir Crit Care Med. 157 (4 Pt 1): 1332–47. doi:10.1164/ajrccm.157.4.ats2-98. PMID 9563759.

[pmid12432041-18] Gans J, van de Beek D, European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators (2002). "Dexamethasone in adults with bacterial meningitis". N Engl J Med. 347 (20): 1549–56. doi:10.1056/NEJMoa021334. PMID 12432041. Review in: ACP J Club. 2003 May-Jun;138(3):60

[pmid15854884-19] Sejvar JJ, Tenover FC, Stephens DS (2005). "Management of anthrax meningitis". Lancet Infect Dis. 5 (5): 287–95. doi:10.1016/S1473-3099(05)70113-4. PMID 15854884.

[pmid19509383-20] Annane D, Bellissant E, Bollaert PE, Briegel J, Confalonieri M, De Gaudio R; et al. (2009). "Corticosteroids in the treatment of severe sepsis and septic shock in adults: a systematic review". JAMA. 301 (22): 2362–75. doi:10.1001/jama.2009.815. PMID 19509383.

[pmid12131080-21] Binkley CE, Cinti S, Simeone DM, Colletti LM (2002). "Bacillus anthracis as an agent of bioterrorism: a review emphasizing surgical treatment". Ann Surg. 236 (1): 9–16. PMC 1422543. PMID 12131080.

[pmid21357967-22] Knox D, Murray G, Millar M, Hamilton D, Connor M, Ferdinand RD; et al. (2011). "Subcutaneous anthrax in three intravenous drug users: a new clinical diagnosis". J Bone Joint Surg Br. 93 (3): 414–7. doi:10.1302/0301-620X.93B3.25976. PMID 21357967.

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@@ Line 12: / Line 12: @@
 * Presence of latent [[spores]] that must be taken into account when selecting post-exposure [[prophylaxis]] or a combination of [[antibiotics]] for treatment of [[anthrax]]
-==Antibiotic Treatment==
+:*  '''Bacillus anthracis treatment'''
-===Cutaneous Anthrax without Systemic Involvement===
-====Choice of Antibiotics====
-* Uncomplicated cutaneous anthrax has been successfully treated with a '''single oral antimicrobial drug'''.
-* Oral [[fluoroquinolone]]s ([[ciprofloxacin]], [[levofloxacin]], and [[moxifloxacin]]) and [[doxycycline]] are equivalent first-line agents.
-* [[Clindamycin]] is an alternative option if [[fluoroquinolone]]s and [[doxycycline]] are contraindicated or unavailable.
-* Given the long history of successful treatment of localized uncomplicated cutaneous anthrax with [[penicillin]], [[amoxicillin]] and [[penicillin]] VK are also alternative therapeutic options if the isolate is known to be susceptible to [[penicillin]]. However, adequate dosages must be used because of the potential for development of drug resistance during treatment with subtherapeutic dosing.<ref name=CDC>{{cite web | title = Centers for Disease Control and Prevention Expert Panel Meetings on Prevention and Treatment of Anthrax in Adults | url = http://wwwnc.cdc.gov/eid/article/20/2/13-0687_article }}</ref>
-====Duration of 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>
-* Duration of treatment for localized or uncomplicated cutaneous disease depends on the [[B. anthracis]] exposure source:<ref name=CDC>{{cite web | title = Centers for Disease Control and Prevention Expert Panel Meetings on Prevention and Treatment of Anthrax in Adults | url = http://wwwnc.cdc.gov/eid/article/20/2/13-0687_article }}</ref>
-** Naturally acquired (e.g., animals with anthrax, products such as hides from animals with anthrax): 7–10-day course
-** Bioterrorism-related exposure or an aerosol exposure is suspected: 60 days (because the patient is likely to have also inhaled spores.)
-===Systemic Anthrax When Meningitis Has Been Excluded===
+:::* Preferred regimen (regardless of penicillin susceptibility or if susceptibility is unknown) (1): [[Ciprofloxacin]] 500 mg PO bid for 7-10 days
-====Choice of Antibiotics====
+:::* Preferred regimen (regardless of penicillin susceptibility or if susceptibility is unknown) (2): [[Doxycycline]] 100 mg PO bid for 7-10 days
-* The initial treatment should include '''≥2 antimicrobial drugs''' with activity against B. anthracis:<ref name=CDC>{{cite web | title = Centers for Disease Control and Prevention Expert Panel Meetings on Prevention and Treatment of Anthrax in Adults | url = http://wwwnc.cdc.gov/eid/article/20/2/13-0687_article }}</ref>
-** ≥1 should have bactericidal activity, and
-** ≥1 should be a protein synthesis inhibitor
-* Intravenous ciprofloxacin is preferred as the primary bactericidal component in the treatment of systemic disease.  [[Linezolid]] or [[clindamycin]] are the preferred as the first-line protein synthesis inhibitor.<ref name=CDC>{{cite web | title = Centers for Disease Control and Prevention Expert Panel Meetings on Prevention and Treatment of Anthrax in Adults | url = http://wwwnc.cdc.gov/eid/article/20/2/13-0687_article }}</ref>
+:::* Preferred regimen (regardless of penicillin susceptibility or if susceptibility is unknown) (3): [[Levofloxacin]] 750 mg PO qd for 7-10 days
-* If the [[B. anthracis]] strain is susceptible to [[penicillin]], then [[penicillin G]] is considered equivalent to the [[fluoroquinolone]] options for primary bactericidal treatment.<ref name=CDC>{{cite web | title = Centers for Disease Control and Prevention Expert Panel Meetings on Prevention and Treatment of Anthrax in Adults | url = http://wwwnc.cdc.gov/eid/article/20/2/13-0687_article }}</ref>
+:::* Preferred regimen (regardless of penicillin susceptibility or if susceptibility is unknown) (4): [[Moxifloxacin]] 400 mg PO qd for 7-10 days
-* Treatment with antimicrobial drugs that have good central nervous system (CNS) penetration is not a crucial factor. Thus, [[meropenem]] is recommended as an acceptable alternative option than as a first-line antimicrobial drug, and [[vancomycin]] is also an acceptable alternative. [[Clindamycin]] and [[linezolid]] are considered equivalent first-line choices for protein synthesis inhibitors. [[Doxycycline]] is added as an alternative protein synthesis inhibitor option if [[linezolid]] or [[clindamycin]] are contraindicated or unavailable.<ref name=CDC>{{cite web | title = Centers for Disease Control and Prevention Expert Panel Meetings on Prevention and Treatment of Anthrax in Adults | url = http://wwwnc.cdc.gov/eid/article/20/2/13-0687_article }}</ref>
+:::* Alternative regimen (1): [[Clindamycin]] 600 mg PO tid for 7-10 days
-====Duration of Treatment====
+:::* Alternative regimen (2): [[Amoxicillin]] 1 g PO tid (for penicillin-susceptible strains) for 7-10 days
-* Initial intravenous combination treatment should be given for ≥2 weeks or until the patient is clinically stable, whichever is longer.<ref name=CDC>{{cite web | title = Centers for Disease Control and Prevention Expert Panel Meetings on Prevention and Treatment of Anthrax in Adults | url = http://wwwnc.cdc.gov/eid/article/20/2/13-0687_article }}</ref>
-====Follow–up Oral Treatment for Systemic Disease====
+:::* Alternative regimen (3): [[Penicillin VK]] 500 mg PO qid (for penicillin-susceptible strains) for 7-10 days
-Once patients with systemic illness who were exposed to aerosolized [[spore]]s have completed initial combination treatment, they should be transitioned to '''single-agent oral treatment''' to prevent relapse from surviving [[B. anthracis]] spores.<ref name=CDC>{{cite web | title = Centers for Disease Control and Prevention Expert Panel Meetings on Prevention and Treatment of Anthrax in Adults | url = http://wwwnc.cdc.gov/eid/article/20/2/13-0687_article }}</ref>
+:::* Note: Duration of treatment is 60 days for bioterrorism-related cases and 7-10 days for naturally acquired cases.
-===Systemic Anthrax with Possible/Confirmed Meningitis===
+::* 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>
-====Choice of Antibiotics====
-* Empiric treatment for anthrax in which anthrax meningitis is suspected or cannot be ruled out should include '''≥3 antimicrobial drugs''' with activity against B. anthracis:<ref name=CDC>{{cite web | title = Centers for Disease Control and Prevention Expert Panel Meetings on Prevention and Treatment of Anthrax in Adults | url = http://wwwnc.cdc.gov/eid/article/20/2/13-0687_article }}</ref>
-** ≥1 drug should have bactericidal activity
-** ≥1 should be a protein synthesis inhibitor
-** All should have good CNS penetration
-* Hospitalized patients for systemic [[anthrax]] should be immediately treated with a combination of [[broad-spectrum]] [[intravenous]] [[antibiotic]] drug treatment pending confirmatory test results because any delay may prove fatal. Because [[meningitis]] and hemorrhagic brain parenchymal [[infection]] was observed in ≤50% of cases, [[meningitis]] must be considered in all cases of systemic [[anthrax]]. Therefore [[antibiotics]] to treat possible [[meningitis]] must have good penetration of the [[central nervous system]] (CNS).<ref name=CDC>{{cite web | title = Centers for Disease Control and Prevention Expert Panel Meetings on Prevention and Treatment of Anthrax in Adults | url = http://wwwnc.cdc.gov/eid/article/20/2/13-0687_article }}</ref>
+:::* 2.1 '''Systemic anthrax with possible/confirmed meningitis'''
-* Intravenous [[ciprofloxacin]] is preferred as the primary bactericidal component in the treatment of systemic disease on the basis of efficacy in non-human primates (NHP) infection models and recent use for anthrax cases. [[Levofloxacin]] and [[moxifloxacin]] are considered equivalent alternatives to [[ciprofloxacin]]. The [[fluoroquinolone]]s have adequate CNS penetration and there are no reports of natural resistance.<ref name=CDC>{{cite web | title = Centers for Disease Control and Prevention Expert Panel Meetings on Prevention and Treatment of Anthrax in Adults | url = http://wwwnc.cdc.gov/eid/article/20/2/13-0687_article }}</ref>
+::::* 2.1.1 '''Bactericidal agent''' (fluoroquinolone)
-* The [[carbapenem]] class of antimicrobial drugs is highly resistant to [[β-lactamase]]s and provides good [[CNS]] penetration. [[Meropenem]] is preferred as the second antimicrobial drug in the combination antimicrobial drug regimen for anthrax meningitis. If [[meropenem]] is unavailable, [[doripenem]] and [[imipenem]]/[[cilastatin]] are considered equivalent alternatives. [[Imipenem]]/[[cilastatin]] is associated with increased [[seizure]] risk and should be used with caution in patients with suspected meningitis. If the [[B. anthracis]] strain is susceptible to [[penicillin]] ([[MIC]] <0.125 µg/mL), [[penicillin G]] or [[ampicillin]] are acceptable alternatives to [[carbapenem]]s.<ref name=CDC>{{cite web | title = Centers for Disease Control and Prevention Expert Panel Meetings on Prevention and Treatment of Anthrax in Adults | url = http://wwwnc.cdc.gov/eid/article/20/2/13-0687_article }}</ref>
+:::::* Preferred regimen (1): [[Ciprofloxacin]] 400 mg IV q8h for 2-3 weeks
-* At least 1 antimicrobial drug that inhibits protein synthesis should be used to reduce [[exotoxin]] production. [[Linezolid]] is preferred as the first-line protein synthesis inhibitor. It is preferred over [[clindamycin]] because it is likely to provide better [[CNS]] penetration, although [[randomized controlled trial]]s on treatment for [[CNS]] infections with either agent are lacking. However, [[linezolid]] toxicity issues must be taken into consideration. Myelosuppression, peripheral and optic neuropathies, and [[serotonin syndrome]] have been reported in patients receiving [[linezolid]]. [[Linezolid]] should be used cautiously in patients with pre-existing [[myelosuppression]]. In patients receiving [[monoamine oxidase inhibitor]]s or [[serotonin reuptake inhibitor]]s, the benefit of [[linezolid]] treatment should be weighed against the risk for [[serotonin]] toxicity and an alternative should be considered. If patients experience visual impairment, prompt ophthalmic evaluation is recommended. If patients have contraindications to [[linezolid]] use or it is unavailable, [[clindamycin]] is an acceptable alternative. [[Rifampin]], although not a protein synthesis inhibitor, has been widely used for its synergistic effect with a primary drug and could also be used in this capacity if [[linezolid]] or [[clindamycin]] are unavailable. The protein synthesis inhibitor [[chloramphenicol]] has good CNS penetration and has historically been used to successfully treat anthrax. Where available, it could be an acceptable alternative if [[linezolid]], [[clindamycin]], and [[rifampin]] are unavailable. [[Doxycycline]] should not be used if [[meningitis]] is suspected because it does not adequately penetrate the CNS.<ref name=CDC>{{cite web | title = Centers for Disease Control and Prevention Expert Panel Meetings on Prevention and Treatment of Anthrax in Adults | url = http://wwwnc.cdc.gov/eid/article/20/2/13-0687_article }}</ref>
+:::::* Preferred regimen (2): [[Levofloxacin]] 750 mg IV q24h for 2-3 weeks
-====Duration of Treatment====
+:::::* Preferred regimen (3): [[Moxifloxacin]] 400 mg IV q24h for 2-3 weeks {{and}}
-* Intravenous combination treatment for systemic anthrax with possible meningitis should be provided for ≥2 weeks or until the patient is clinically stable, whichever is longer.
-* Given the high mortality rate associated with meningitis, some expert panelists favored 3 weeks of treatment for patients in whom meningitis could not be ruled out.<ref name=CDC>{{cite web | title = Centers for Disease Control and Prevention Expert Panel Meetings on Prevention and Treatment of Anthrax in Adults | url = http://wwwnc.cdc.gov/eid/article/20/2/13-0687_article }}</ref>
-====Follow–up Oral Treatment for Systemic Disease====
+::::* 2.1.2 '''Bactericidal agent (ß-lactam) for all strains, regardless of penicillin susceptibility or if susceptibility is unknown'''
-Once patients with systemic illness who were exposed to aerosolized [[spore]]s have completed initial combination treatment, they should be transitioned to '''single-agent oral treatment''' to prevent relapse from surviving [[B. anthracis]] spores.
+:::::* Preferred regimen (1): [[Meropenem]] 2 g IV q8h for 2-3 weeks
-===Dosage of Antibiotics===
+:::::* Preferred regimen (2): [[Imipenem]] 1 g IV q6h for 2-3 weeks
-<!--
+:::::* Preferred regimen (3): [[Doripenem]] 500 mg IV q8h for 2-3 weeks
-<SMALL><font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font></SMALL><ref>{{Cite journal | doi = 10.3201/eid2002.130687 | issn = 1080-6059 | volume = 20 | issue = 2 | last = Hendricks | first = Katherine A. | coauthors = Mary E. Wright, Sean V. Shadomy, John S. Bradley, Meredith G. Morrow, Andy T. Pavia, Ethan Rubinstein, Jon-Erik C. Holty, Nancy E. Messonnier, Theresa L. Smith, Nicki Pesik, Tracee A. Treadwell, William A. Bower, Workgroup on Anthrax Clinical Guidelines | title = Centers for disease control and prevention expert panel meetings on prevention and treatment of anthrax in adults | journal = Emerging Infectious Diseases | date = 2014-02 | pmid = 24447897 | pmc = PMC3901462 }}</ref><ref>{{Cite journal | doi = 10.1542/peds.2014-0563 | issn = 1098-4275 | last = Bradley | first = John S. | coauthors = Georgina Peacock, Steven E. Krug, William A. Bower, Amanda C. Cohn, Dana Meaney-Delman, Andrew T. Pavia, AAP COMMITTEE ON INFECTIOUS DISEASES and DISASTER PREPAREDNESS ADVISORY COUNCIL | title = Pediatric Anthrax Clinical Management | journal = Pediatrics | date = 2014-04-28 | pmid = 24777226 }}</ref><ref>{{Cite journal | doi = 10.3201/eid2002.130611 | issn = 1080-6059 | volume = 20 | issue = 2 | last = Meaney-Delman | first = Dana | coauthors = Marianne E. Zotti, Andreea A. Creanga, Lara K. Misegades, Etobssie Wako, Tracee A. Treadwell, Nancy E. Messonnier, Denise J. Jamieson, Workgroup on Anthrax in Pregnant and Postpartum Women | title = Special considerations for prophylaxis for and treatment of anthrax in pregnant and postpartum women | journal = Emerging Infectious Diseases | date = 2014-02 | pmid = 24457117 | pmc = PMC3901460 }}</ref>
+:::::* 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}}
-<SMALL><font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font></SMALL><ref>{{Cite journal | doi = 10.3201/eid2002.130687 | issn = 1080-6059 | volume = 20 | issue = 2 | last = Hendricks | first = Katherine A. | coauthors = Mary E. Wright, Sean V. Shadomy, John S. Bradley, Meredith G. Morrow, Andy T. Pavia, Ethan Rubinstein, Jon-Erik C. Holty, Nancy E. Messonnier, Theresa L. Smith, Nicki Pesik, Tracee A. Treadwell, William A. Bower, Workgroup on Anthrax Clinical Guidelines | title = Centers for disease control and prevention expert panel meetings on prevention and treatment of anthrax in adults | journal = Emerging Infectious Diseases | date = 2014-02 | pmid = 24447897 | pmc = PMC3901462 }}</ref><ref>{{Cite journal | doi = 10.1542/peds.2014-0563 | issn = 1098-4275 | last = Bradley | first = John S. | coauthors = Georgina Peacock, Steven E. Krug, William A. Bower, Amanda C. Cohn, Dana Meaney-Delman, Andrew T. Pavia, AAP COMMITTEE ON INFECTIOUS DISEASES and DISASTER PREPAREDNESS ADVISORY COUNCIL | title = Pediatric Anthrax Clinical Management | journal = Pediatrics | date = 2014-04-28 | pmid = 24777226 }}</ref><ref>{{Cite journal | doi = 10.3201/eid2002.130611 | issn = 1080-6059 | volume = 20 | issue = 2 | last = Meaney-Delman | first = Dana | coauthors = Marianne E. Zotti, Andreea A. Creanga, Lara K. Misegades, Etobssie Wako, Tracee A. Treadwell, Nancy E. Messonnier, Denise J. Jamieson, Workgroup on Anthrax in Pregnant and Postpartum Women | title = Special considerations for prophylaxis for and treatment of anthrax in pregnant and postpartum women | journal = Emerging Infectious Diseases | date = 2014-02 | pmid = 24457117 | pmc = PMC3901460 }}</ref>
+::::* 2.1.3 '''Protein synthesis inhibitor'''
-{|
+:::::* Preferred regimen (1): [[Linezolid]] 600 mg IV q12h for 2-3 weeks
-| valign=top |
-<div style="border-radius: 5px 5px 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 350px; background: #A1BCDD; text-align: center;">
+:::::* Preferred regimen (2): [[Clindamycin]] 900 mg IV q8h for 2-3 weeks
-<font color="#FFF">
-'''Cutaneous Anthrax Without Systemic Involvement'''
-</font>
-</div>
-<div class="mw-customtoggle-table01" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 350px; background: #4479BA;">
+:::::* Preferred regimen (3): [[Rifampin]] 600 mg IV q12h for 2-3 weeks
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Adult Patients'''
-</font>
-</div>
-<div class="mw-customtoggle-table02" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 350px; background: #4479BA;">
+:::::* Preferred regimen (4): [[Chloramphenicol]] 1 g IV q6-8h for 2-3 weeks
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Pediatric Patients'''
-</font>
-</div>
-<div class="mw-customtoggle-table03" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 350px; background: #4479BA;">
+:::::* Note (1): Patients exposed to aerosolized spores will require prophylaxis to complete an antimicrobial drug course of 60 days from onset of illness.
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Pregnant Patients'''
-</font>
-</div>
-<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 350px; background: #A1BCDD; text-align: center;">
+:::::* Note (2): Increased risk for seizures associated with [[Imipenem]]/[[Cilastatin]] treatment.
-<font color="#FFF">
-'''Systemic Anthrax with Possible/Confirmed Meningitis'''
-</font>
-</div>
-<div class="mw-customtoggle-table04" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 350px; background: #4479BA;">
+:::::* 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.
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Adult Patients'''
-</font>
-</div>
-<div class="mw-customtoggle-table05" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 350px; background: #4479BA;">
+:::::* 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.
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Pediatric Patients'''
-</font>
-</div>
-<div class="mw-customtoggle-table06" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 350px; background: #4479BA;">
+:::* 2.2 '''Systemic anthrax when meningitis has been excluded'''
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Pregnant Patients'''
-</font>
-</div>
-<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 350px; background: #A1BCDD; text-align: center;">
+::::* 2.2.1 '''Bactericidal agent'''
-<font color="#FFF">
-'''Systemic Anthrax Without Meningitis'''
-</font>
-</div>
-<div class="mw-customtoggle-table07" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 350px; background: #4479BA;">
+:::::* Preferred regimen (1): [[Ciprofloxacin]] 400 mg IV q8h for 2 weeks
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Adult Patients'''
-</font>
-</div>
-<div class="mw-customtoggle-table08" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 350px; background: #4479BA;">
+:::::* Preferred regimen (2): [[Levofloxacin]] 750 mg IV q24h for 2 weeks
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Pediatric Patients'''
-</font>
-</div>
-<div class="mw-customtoggle-table09" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 350px; background: #4479BA;">
+:::::* Preferred regimen (3): [[Moxifloxacin]] 400 mg q24h for 2 weeks
-<font color="#FFF">
-&nbsp;&nbsp;▸&nbsp;&nbsp;'''Pregnant Patients'''
-</font>
-</div>
-<!--COLLECT ALL THE BOXES BELOW-->
+:::::* Preferred regimen (4): [[Meropenem]] 2 g IV q8h for 2 weeks
-| valign=top |
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table01" style="background: #FFFFFF;"
+:::::* Preferred regimen (5): [[Imipenem]] 1 g IV q6h for 2 weeks
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 450px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Cutaneous Anthrax, Adult Patients}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ciprofloxacin]]  500 mg PO q12h'''''<BR> OR <BR> ▸ '''''[[Levofloxacin]]  750 mg PO q24h'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]]  400 mg PO q24h'''''<BR> OR <BR> ▸ '''''[[Doxycycline]]  100 mg PO q12h'''''
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Clindamycin]] 600 mg PO q8h'''''<BR> OR <BR> ▸ '''''[[Penicillin VK]] 500 mg PO q6h'''''<BR> OR <BR> ▸ '''''[[Amoxicillin]] 1 g PO q8h'''''
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table02" style="background: #FFFFFF;"
+:::::* Preferred regimen (6): [[Doripenem]] 500 mg IV q8h for 2 weeks
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 450px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Cutaneous Anthrax, Pediatric Patients}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ciprofloxacin]] 30 mg/kg/day PO q12h, max: 500 mg/dose'''''<BR> OR <BR> ▸ '''''[[Levofloxacin]]  16 mg/kg/day PO q12h, max: 250 mg/dose (<50 kg)'''''<BR> OR <BR> ▸ '''''[[Levofloxacin]]  500 mg PO q24h (≥50 kg)'''''<BR> OR <BR> ▸ '''''[[Doxycycline]]  4.4 mg/kg/day PO q12h, max: 100 mg/dose (<45 kg)'''''<BR> OR <BR> ▸ '''''[[Doxycycline]]  100 mg/dose PO q12h (≥45 kg)'''''
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Clindamycin]] 30 mg/kg/day PO q8h, max: 600 mg/dose'''''<BR> OR <BR> ▸ '''''[[Penicillin VK]] 50–75 mg/kg/day PO q6–8h'''''<BR> OR <BR> ▸ '''''[[Amoxicillin]] 75 mg/kg/day PO q8h, max: 1 g/dose'''''
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table03" style="background: #FFFFFF;"
+:::::* Preferred regimen (7): [[Vancomycin]] 20 mg/kg IV q8h (maintain serum trough concentrations of 15-20 µg/mL) for 2 weeks
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 450px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Cutaneous Anthrax, Pregnant Patients}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ciprofloxacin]]  500 mg PO q12h'''''
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table04" style="background: #FFFFFF;"
+:::::* Preferred regimen (8): [[Penicillin G]] 4 MU IV q4h (penicillin-susceptible strains) for 2 weeks
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 450px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Systemic Anthrax with Meningitis, Adult Patients}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ciprofloxacin]]  400 mg IV q8h'''''<BR> OR <BR> ▸ '''''[[Levofloxacin]]  750 mg IV q24h'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]]  400 mg IV q24h'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Meropenem]]  2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Imipenem]]  1 g IV q6h'''''<BR> OR <BR> ▸ '''''[[Doripenem]]  500 mg IV q8h'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Linezolid]]  600 mg IV q12h'''''<BR> OR <BR> ▸ '''''[[Clindamycin]]  900 mg IV q8h'''''<BR> OR <BR> ▸ '''''[[Rifampin]]  600 mg IV q12h'''''<BR> OR <BR> ▸ '''''[[Chloramphenicol]] 1 g IV q6–8h'''''
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ciprofloxacin]]  400 mg IV q8h'''''<BR> OR <BR> ▸ '''''[[Levofloxacin]]  750 mg IV q24h'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]]  400 mg IV q24h'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G]]  4 MU IV q4h'''''<BR> OR <BR> ▸ '''''[[Ampicillin]]  3 g IV q6h'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Linezolid]]  600 mg IV q12h'''''<BR> OR <BR> ▸ '''''[[Clindamycin]]  900 mg IV q8h'''''<BR> OR <BR> ▸ '''''[[Rifampin]]  600 mg IV q12h'''''<BR> OR <BR> ▸ '''''[[Chloramphenicol]] 1 g IV q6–8h'''''
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table05" style="background: #FFFFFF;"
+:::::* Preferred regimen (9): [[Ampicillin]] 3 g IV q6h (penicillin-susceptible strains) for 2 weeks {{and}}
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 450px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Systemic Anthrax with Meningitis, Pediatric Patients}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ciprofloxacin]] 30 mg/kg/day IV q8h, max: 400 mg/dose'''''<BR> OR <BR> ▸ '''''[[Levofloxacin]]  20 mg/kg/day IV q12h, max: 250 mg/dose (<50 kg)'''''<BR> OR <BR> ▸ '''''[[Levofloxacin]]  500 mg IV q24h (≥50 kg)'''''<BR> OR <BR> ▸ '''''[[Meropenem]]  60 mg/kg/day IV q12h, max: 2 g/dose'''''<BR> OR <BR> ▸ '''''[[Imipenem/Cilastatin]]  100 mg/kg/day IV q6h, max: 1 g/dose'''''<BR> OR <BR> ▸ '''''[[Vancomycin]]  60 mg/kg/day IV q8h'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Clindamycin]] 30 mg/kg/day PO q8h, max: 600 mg/dose'''''<BR> OR <BR> ▸ '''''[[Linezolid]] 30 mg/kg/day IV q8h, max: 1 g/dose (<12 yr)'''''<BR> OR <BR> ▸ '''''[[Linezolid]] 30 mg/kg/day IV q12h, max: 600 mg/dose (≥12 yr)'''''<BR> OR <BR> ▸ '''''[[Doxycycline]]  4.4 mg/kg/day IV q12h, max: 100 mg/dose (<45 kg)'''''<BR> OR <BR> ▸ '''''[[Doxycycline]]  200 mg IV x1 then 100 mg IV q12h, max: 200 mg/dose (≥45 kg)'''''<BR> OR <BR> ▸ '''''[[Rifampin]]  20 mg/kg/day IV q12h, max: 300 mg/dose'''''
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G]] 0.4 MU/kg/day IV q4h, max: 4 MU/dose'''''<BR> OR <BR> ▸ '''''[[Ampicillin]] 200 mg/kg/day IV q6h, max: 900 mg/dose'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Clindamycin]] 30 mg/kg/day PO q8h, max: 600 mg/dose'''''<BR> OR <BR> ▸ '''''[[Linezolid]] 30 mg/kg/day IV q8h, max: 1 g/dose (<12 yr)'''''<BR> OR <BR> ▸ '''''[[Linezolid]] 30 mg/kg/day IV q12h, max: 600 mg/dose (≥12 yr)'''''<BR> OR <BR> ▸ '''''[[Doxycycline]]  4.4 mg/kg/day IV q12h, max: 100 mg/dose (<45 kg)'''''<BR> OR <BR> ▸ '''''[[Doxycycline]]  200 mg IV x1 then 100 mg IV q12h, max: 200 mg/dose (≥45 kg)'''''<BR> OR <BR> ▸ '''''[[Rifampin]]  20 mg/kg/day IV q12h, max: 300 mg/dose'''''
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table06" style="background: #FFFFFF;"
+::::* 2.2.2 '''Protein synthesis inhibitor'''
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 450px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Systemic Anthrax with Meningitis, Pregnant Patients}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ciprofloxacin]]  400 mg IV q8h'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Clindamycin]]  900 mg IV q8h'''''<BR> OR <BR> ▸ '''''[[Rifampin]]  600 mg IV q12h'''''
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Levofloxacin]]  750 mg IV q24h'''''<BR> OR <BR> ▸ '''''[[Meropenem]]  2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Penicillin G]]  4 MU IV q4h'''''<BR> OR <BR> ▸ '''''[[Ampicillin]]  3 g IV q6h'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Clindamycin]]  900 mg IV q8h'''''<BR> OR <BR> ▸ '''''[[Rifampin]]  600 mg IV q12h'''''
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table07" style="background: #FFFFFF;"
+:::::* Preferred regimen (1): [[Clindamycin]] 900 mg IV q8h for 2 weeks
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 450px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Systemic Anthrax Without Meningitis, Adult Patients}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ciprofloxacin]]  400 mg q8h'''''<BR> OR <BR> ▸ '''''[[Levofloxacin]]  750 mg q24h'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]]  400 mg PO q24h'''''<BR> OR <BR> ▸ '''''[[Meropenem]]  2 g q8h'''''<BR> OR <BR> ▸ '''''[[Imipenem]]  1 g IV q6h'''''<BR> OR <BR> ▸ '''''[[Doripenem]]  500 mg q8h'''''<BR> OR <BR> ▸ '''''[[Vancomycin]]  60 mg/kg/day IV q8h, trough: 15–20 μg/mL'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Clindamycin]]  900 mg q8h'''''<BR> OR <BR> ▸ '''''[[Linezolid]]  600 mg q12h'''''<BR> OR <BR> ▸ '''''[[Doxycycline]]  200 mg x1 then 100 mg IV q12h'''''<BR> OR <BR> ▸ '''''[[Rifampin]]  600 mg q12h'''''
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G]] 4 MU IV q4h'''''<BR> OR <BR> ▸ '''''[[Ampicillin]] 3 g IV q6h'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Clindamycin]]  900 mg q8h'''''<BR> OR <BR> ▸ '''''[[Linezolid]]  600 mg q12h'''''<BR> OR <BR> ▸ '''''[[Doxycycline]]  200 mg x1 then 100 mg IV q12h'''''<BR> OR <BR> ▸ '''''[[Rifampin]]  600 mg q12h'''''
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table08" style="background: #FFFFFF;"
+:::::* Preferred regimen (2): [[Linezolid]] 600 mg IV q12h for 2 weeks
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 450px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Systemic Anthrax Without Meningitis, Pediatric Patients}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ciprofloxacin]] 30 mg/kg/day IV q8h, max: 400 mg/dose'''''<BR> OR <BR> ▸ '''''[[Levofloxacin]]  16 mg/kg/day IV q12h, max: 250 mg/dose (<50 kg)'''''<BR> OR <BR> ▸ '''''[[Levofloxacin]]  500 mg IV q24h (≥50 kg)'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]] 12 mg/kg/day IV q12h, max: 200 mg/dose (3 mo–2 yr)'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]] 10 mg/kg/day IV q12h, max: 200 mg/dose (2 yr–5 yr)'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]] 8 mg/kg/day IV q12h, max: 200 mg/dose (6 yr–11 yr)'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]] 8 mg/kg/day IV q12h, max: 200 mg/dose (12 yr–17 yr, <45 kg)'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]] 400 mg IV q24h (12 yr–17 yr, ≥45 kg)'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Meropenem]] 120 mg/kg/day IV q8h, max: 2 g/dose'''''<BR> OR <BR> ▸ '''''[[Imipenem/Cilastatin]] 100 mg/kg/day IV q6h, max: 1 g/dose'''''<BR> OR <BR> ▸ '''''[[Doripenem]] 120 mg/kg/day IV q8h, max: 1 g/dose'''''<BR> OR <BR> ▸ '''''[[Vancomycin]]  60 mg/kg/day IV q8h'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Linezolid]] 30 mg/kg/day IV q8h, max: 600 mg/dose (<12 yr)'''''<BR> OR <BR> ▸ '''''[[Linezolid]] 30 mg/kg/day IV q12h, max: 600 mg/dose (≥12 yr)'''''<BR> OR <BR> ▸ '''''[[Clindamycin]] 40 mg/kg/day IV q8h, max: 900 mg/dose'''''<BR> OR <BR> ▸ '''''[[Rifampin]] 20 mg/kg/day IV q12h, max: 300 mg/dose'''''<BR> OR <BR> ▸ '''''[[Chloramphenicol]] 100 mg/kg/day IV q6h'''''
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ciprofloxacin]] 30 mg/kg/day IV q8h, max: 400 mg/dose'''''<BR> OR <BR> ▸ '''''[[Levofloxacin]]  16 mg/kg/day IV q12h, max: 250 mg/dose (<50 kg)'''''<BR> OR <BR> ▸ '''''[[Levofloxacin]]  500 mg IV q24h (≥50 kg)'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]] 12 mg/kg/day IV q12h, max: 200 mg/dose (3 mo–2 yr)'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]] 10 mg/kg/day IV q12h, max: 200 mg/dose (2 yr–5 yr)'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]] 8 mg/kg/day IV q12h, max: 200 mg/dose (6 yr–11 yr)'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]] 8 mg/kg/day IV q12h, max: 200 mg/dose (12 yr–17 yr, <45 kg)'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]] 400 mg IV q24h (12 yr–17 yr, ≥45 kg)'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G]] 0.4 MU/kg/day IV q4h, max: 4 MU/dose'''''<BR> OR <BR> ▸ '''''[[Ampicillin]] 400 mg/kg/day IV q6h, max: 3 g/dose'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Linezolid]] 30 mg/kg/day IV q8h, max: 600 mg/dose (<12 yr)'''''<BR> OR <BR> ▸ '''''[[Linezolid]] 30 mg/kg/day IV q12h, max: 600 mg/dose (≥12 yr)'''''<BR> OR <BR> ▸ '''''[[Clindamycin]] 40 mg/kg/day IV q8h, max: 900 mg/dose'''''<BR> OR <BR> ▸ '''''[[Rifampin]] 20 mg/kg/day IV q12h, max: 300 mg/dose'''''<BR> OR <BR> ▸ '''''[[Chloramphenicol]] 100 mg/kg/day IV q6h'''''
-|-
-|}
-|}
-{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table09" style="background: #FFFFFF;"
+:::::* Preferred regimen (3): [[Doxycycline]] 200 mg IV initially, then 100 mg IV q12h for 2 weeks
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 450px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Systemic Anthrax Without Meningitis, Pregnant Patients}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ciprofloxacin]]  400 mg IV q8h'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Clindamycin]]  900 mg IV q8h'''''<BR> OR <BR> ▸ '''''[[Rifampin]]  600 mg IV q12h'''''
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Levofloxacin]]  750 mg IV q24h'''''<BR> OR <BR> ▸ '''''[[Meropenem]]  2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Penicillin G]]  4 MU IV q4h'''''<BR> OR <BR> ▸ '''''[[Ampicillin]]  3 g IV q6h'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Clindamycin]]  900 mg IV q8h'''''<BR> OR <BR> ▸ '''''[[Rifampin]]  600 mg IV q12h'''''
-|}
-|}
-|}
+:::::* 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'''
+:::::::* 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):
+:::::* 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
+----
+{{PBI|Bacillus cereus}}
+:* 1. '''Food poisoning'''<ref>{{cite book | last = Bartlett | first = John | title = Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases | publisher = Jones and Bartlett Learning | location = Burlington, MA | year = 2012 | isbn = 978-1449625580 }}</ref>
+::* Preferred regimen: Food poisoning is usually self-limited and requires no antibiotic therapy.
+:* 2. '''Bacteremia'''
+::* Preferred regimen: [[Vancomycin]] 15 mg/kg IV q12h
+::* Alternative regimen: [[Clindamycin]] 600 mg IV q8h
+::* Note (1): Bacillus cereus is commonly resistant to beta-lactams.
+::* Note (2): Pseudobacteremia is transient and usually results from contaminated blood cultures, gloves, or syringes.
+:* 3. '''Meningitis or brain abscess'''
+::* Preferred regimen: [[Vancomycin]] 15 mg/kg IV q12h
+::* Alternative regimen: [[Clindamycin]] 600 mg IV q8h
+::* Note: Blood culture isolates are mostly contaminates until proven otherwise, especially in intravenous drug user population.
+:* 4. '''Endophthalmitis'''
+::* Preferred regimen: [[Clindamycin]] 450 μg intravitreal {{and}} [[Gentamicin]] 400 μg intravitreal {{or}} [[Dexamethasone]] intravitreal {{and}} [[Vancomycin]] 15 mg/kg IV q12h
+::* Alternative regimen: [[Clindamycin]] 600 mg IV q8h
+::* Note: Ophthalmological consultation, culture ocular fluids, early vitrectomy, and intravitreal antibiotics are necessary.
+:* 5. '''Endocarditis'''
+::* Preferred regimen: [[Vancomycin]] 15 mg/kg IV q12h
+::* Note: Most blood cultures in intravenous drug users are contaminates or represent transient bacteremia.
+:* 6. ''' Soft tissue infection'''
+::* Preferred regimen: [[Vancomycin]] 15 mg/kg IV q12h
+::* Alternative regimen: [[Clindamycin]] 600 mg IV q8h
+:* 7. '''Pneumonia'''
+::* Preferred regimen: [[Vancomycin]] 15 mg/kg IV q12h
+::* Alternative regimen: [[Clindamycin]] 600 mg IV q8h
+----
+{{PBI|Bacillus subtilis}}
+:* Bacillus subtilis infection treatment<ref>{{cite book | last = Bennett | first = John | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2015 | isbn = 978-1455748013 }}</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><ref>{{Cite journal| issn = 0305-7453| volume = 49| issue = 6| pages = 1040–1042| last1 = Andrews| first1 = J. M.| last2 = Wise| first2 = R.| title = Susceptibility testing of Bacillus species| journal = The Journal of Antimicrobial Chemotherapy| date = 2002-06| pmid = 12039902}}</ref>
+::* 1. Food poisoning
+:::* Preferred regimen: supportive treatment
+::* 2. Other infections
+:::* Preferred regimen: [[Vancomycin]] {{or}} [[Clindamycin]]
+:::* Alternative regimen: [[Ciprofloxacin]] {{or}} [[Imipenem]]
+:::* Note: Distinguish clinically significant infection from contamination before administering antibiotics.
+----
+{{PBI|Clostridium botulinum}}
+:*'''1. Antibiotics'''
+::* Antibiotics are not recommended in gastrointestinal botulism due to the risk of worsening of neurological symptoms caused by the lysis of the bacteria. For wound botulism antibiotics are indicated with surgical treatment as followed:
+::* Preferred regimen: [[Metronidazole]] 500 mg IV q8h
+::* Alternative regimen: [[Penicillin G]] 3 million units IV q4h
+:*'''2. Antitoxin''' <ref>{{cite book | last = Bartlett | first = John | title = Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases | publisher = Jones and Bartlett Learning | location = Burlington, MA | year = 2012 | isbn = 978-1449625580 }}</ref>
+::* Preferred regimen: Trivalent antitoxin (A 7,500 IU, B 5,000 IU, and E 5,000 IU) 1 vial diluted 1:10, IV infusion over 30 min
+::* Alternative regimen: Equine antitoxin
+:*'''3. General Therapy'''
+::* Preferred regimen: Mechanical ventilation; IV hydration; tube feedings
+{{PBI|Clostridium perfringens}}
+:* Clostridium perfringens <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>
+:*'''Gas gangrene'''
+:::* Preferred regimen: [[Penicillin G]] 3-4 million units IV q4h {{and}} ([[Clindamycin]] 900 mg IV q8h {{or}} [[Tetracycline]] 500 mg IV q6h)<ref name="pmid5109333">{{cite journal| author=Altemeier WA, Fullen WD| title=Prevention and treatment of gas gangrene. | journal=JAMA | year= 1971 | volume= 217 | issue= 6 | pages= 806-13 | pmid=5109333 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=5109333  }} </ref>
+{{PBI|Clostridium tetani}}
+:*1. '''General measures''' <ref name=World Health Organization>{{cite web | title = Current recommendations for treatment of tetanus during humanitarian emergencies| url =http://www.who.int/diseasecontrol_emergencies/publications/who_hse_gar_dce_2010.2/en/ }}</ref>
+::*Preferred regimen: Patients should be placed in a quiet shaded area and protected from tactile and auditory stimulation as much as possible; All wounds should be cleaned and debrided as indicated
+:*2. '''Immunotherapy'''
+::*Preferred regimen: Human TIG 500 units IV/IM as soon as possible {{and}} Age-appropriate TT-containing vaccine, 0.5 cc IM at a separate site
+::*Note: patients without a history of primary TT vaccination should receive a second dose 1–2 months after the first dose and a third dose 6–12 months later
+:*3. '''Antibiotic treatment'''<ref>http://www.who.int/diseasecontrol_emergencies/who_hse_gar_dce_2010_en.pdf</ref>
+::*Preferred regimen: [[Metronidazole]] 500 mg IV/PO q6h {{or}} [[Penicillin G]] 100,000–200,000 IU/kg/day IV, administered in 2–4 divided doses
+::*Alternative regimen: [[Tetracyclines]] {{or}} [[Macrolides]] {{or}} [[Clindamycin]] {{or}} [[Cephalosporins]] {{or}} [[Chloramphenicol]]
+:*4. '''Muscle spasm control'''
+::*Preferred regimen: [[Diazepam]] 5 mg IV {{or}} [[Lorazepam]] 2 mg IV titrating to achieve spasm control without excessive sedation and hypoventilation
+::*Alternative regimen (1): [[Magnesium]] sulphate 5 g (or 75mg/kg) IV loading dose, then 2–3 g per hour until spasm control is achieved {{withorwithout}} [[Benzodiazepines]]
+::*Note: Monitor patellar reflex as areflexia (absence of patellar reflex) occurs at the upper end of the therapeutic range (4mmol/L). If areflexia develops, dose should be decreased
+::*Alternative regimen (2): [[Baclofen]] {{or}} [[Dantrolene]] 1–2 mg/kg IV/PO q4h
+::*Alternative regimen (3): [[Barbiturates]] 100–150 mg q1-4h by any route
+::*Alternative regimen (4): [[Chlorpromazine]] 50–150 mg IM q4–8h
+::*Pediatric regimen: [[Lorazepam]] 0.1–0.2 mg/kg IV q2–6h, titrating upward as needed; [[Barbiturates]] 6–10 mg/kg in children by any route; [[Chlorpromazine]] 4–12 mg IM every q4–8h
+::*Note: As for [[Benzodiazepines]], large amounts may be required (up to 600 mg/day); oral preparations could be used but must be accompanied by careful monitoring to avoid respiratory depression or arrest
+:* 5. '''Autonomic dysfunction control'''
+::*Preferred regimen: [[Magnesium]] sulphate {{or}} [[Morphine]] {{or}} [[Esmolol]]
+:* 6. '''Airway/respiratory control'''
+::*Note: Drugs used to control spasm and provide sedation can result in respiratory depression. If spasm, including laryngeal spasm, is impeding or threatening adequate ventilation, mechanical ventilation is recommended when possible. Early tracheostomy is preferred as endotracheal tubes can provoke spasm and exacerbate airway compromise.
+{{PBI|Clostridium difficile}}
+:*1. '''Pseudomembranous colitis - mild to moderate'''<ref name="pmid25626036">{{cite journal| author=Bagdasarian N, Rao K, Malani PN| title=Diagnosis and treatment of Clostridium difficile in adults: a systematic review. | journal=JAMA | year= 2015 | volume= 313 | issue= 4 | pages= 398-408 | pmid=25626036 | doi=10.1001/jama.2014.17103 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25626036  }} </ref>
+::*Preferred regimen:[[Metronidazole]] 500 mg PO tid for 10-14 days
+::*Alternative regimen: [[Vancomycin]] 125 mg PO qid for 10-14 days
+::*Note: If significant risk of recurrence: [[Vancomycin]] 125 mg PO qid for 10-14 days {{or}} [[Fidaxomicin]] 200 mg PO bid for 10 days
+:*2. '''Pseudomembranous colitis - severe'''<ref name="pmid25626036">{{cite journal| author=Bagdasarian N, Rao K, Malani PN| title=Diagnosis and treatment of Clostridium difficile in adults: a systematic review. | journal=JAMA | year= 2015 | volume= 313 | issue= 4 | pages= 398-408 | pmid=25626036 | doi=10.1001/jama.2014.17103 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25626036  }} </ref>
+::*Preferred regimen: [[Vancomycin]] 125 mg PO qid for 10-14 days
+::*Note: If significant risk of recurrence: [[Vancomycin]] 125 mg PO qid for 10-14 days {{or}} [[Fidaxomicin]] 200 mg PO bid for 10 days
+:*3. '''Pseudomembranous colitis - severe, complicated'''<ref name="pmid25626036">{{cite journal| author=Bagdasarian N, Rao K, Malani PN| title=Diagnosis and treatment of Clostridium difficile in adults: a systematic review. | journal=JAMA | year= 2015 | volume= 313 | issue= 4 | pages= 398-408 | pmid=25626036 | doi=10.1001/jama.2014.17103 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25626036  }} </ref>
+::*Preferred regimen: [[Vancomycin]] 125-500 mg PO qid for 10-14 days {{and}} [[Vancomycin]] 500 mg diluted in 500 ml of saline as enema per rectum q6h {{and}} [[Metronidazole]] 500 mg IV q8h
+::*Note: Consider urgent surgical consult
+:*4. '''Recurrent pseudomembranous colitis'''<ref name="pmid25626036">{{cite journal| author=Bagdasarian N, Rao K, Malani PN| title=Diagnosis and treatment of Clostridium difficile in adults: a systematic review. | journal=JAMA | year= 2015 | volume= 313 | issue= 4 | pages= 398-408 | pmid=25626036 | doi=10.1001/jama.2014.17103 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25626036  }} </ref>
+::*First recurrence treatment
+:::*Preferred regimen: same as first episode or [Fidaxomicin]] 200 mg PO bid for 10 days
+::*Second or more recurrence treatment
+:::*Preferred regimen: [[Vancomycin]] 125 mg PO qid for 14 days {{then}} [[Vancomycin]] 125 mg PO tid for 7 days {{then}} [[Vancomycin]] 125 mg PO bid for 7 days {{then}} [[Vancomycin]] 125 mg PO qd for 7 days {{then}} [[Vancomycin]] 125 mg PO q48h for 7 days {{then}} [[Vancomycin]] 125 mg PO q72h for 7 days {{or}} [[Fidaxomicin]] 200 mg PO bid for 10 days
+:::*Note: Consider expert consult for fecal microbiota transplantation
 ==Antitoxins==