Emergency Preparedness

Kern Medical Bioterrorism Response Guide Section 2-A-1 – Anthrax ( Bacillus anthracis )

Table 1: Anthrax – Antibiotic Therapy for Contained Casualty Settings Contained casualty setting: assumes a limited number of persons seeking treatment. Start IV therapy as soon as diagnosis suspected. Patient Category Antibiotic Comment Adults: In vitro studies suggest that

Preferred Therapy: * Ciprofloxacin 1 400 mg IV q 12 hours *Doxycycline 200 mg IV loading, then 100 mg IV q 12 hours, or Erythromycin 15 – 20 mg/kg/day in divided doses Therapy if stain is susceptible: *Penicillin 2 G 20 MU/day IV in divided doses (if susceptible) Preferred Therapy: *Ciprofloxacin 1, 3 15 mg/kg q 12 hours, or *Doxycycline 4  If >8 years and > 45 kg: give 200 mg loading dose, then 100 mg q 12 hours;  If > 8 years and = 45 kg: give 4.4mg/kg loading dose then 2.2 – 4.4 mg/kg/day in 2 divided doses;  If = 8 years: same as > 8 years and = 45 kg, Therapy if stain is susceptible: *Penicillin G 2 400,000 units/kg/day in divided doses (if susceptible) Same as for non-pregnant adults Oral doxycycline not recommended for more than 14 days

Give IV antibiotics until clinically stable then switch to an oral antibiotic to complete 60 days of treatment. Switch IV penicillin to Amoxicillin 500 mg PO q 8 hours when clinically stable to complete 60 days treatment. Give IV antibiotics until clinically stable then switch to an oral antibiotic to complete 60 days of treatment. Switch IV penicillin to PO Amoxicillin:  If = 20 kg: give 500 mg PO q 8 hour; or  If < 20 kg : give 40 mg/kg divided into 3 doses to be taken q 8 hours To complete 60 days of treatment.

ofloxacin 400 mg IV q 12 hours or levofloxacin 500 mg IV q 24 hours can be substituted for ciprofloxacin however these antibiotics will, most likely not be included in the National Pharmaceutical Stockpile. Children: The use of tetracyclines and fluoroquinolones in children has well known adverse effects. These risks must be weighed carefully against the risk of developing life- threatening disease. If a release of B anthracis is confirmed, children should be treated initially with ciprofloxacin or doxycycline but therapy should be changed to penicillin as soon as penicillin susceptibility is confirmed. Pregnancy: 5 High mortality rate from the infection outweighs the risk posed by antibiotics. Immunocompromised

Same as adults and children * Antibiotics supplied as part of the National Pharmaceutical Stockpile (NPS)

1. Therapy with ciprofloxacin may be initiated either as intravenous or oral dosage. The pharmacokinetics are such that oral ciprofloxacin is rapidly absorbed in the GI tract with no substantial loss by first-pass metabolism. Maximum serum concentrations are attained 1 – 2 hours after oral dosing. 2. If tested for susceptibility, therapy should be changed to IV penicillin. 3. Ciprofloxacin dose should not exceed 1 gram/day in children. 4. In 1991 the American Academy of Pediatrics amended their recommendation to allow treatment of young children with tetracyclines for serious infections such as Rocky Mountain Spotted Fever for which doxycycline may be indicated. Doxycycline is preferred for its twice-a-day dosing and low incidence of gastrointestinal side effects. 5. Although tetracyclines are not recommended during pregnancy, its use may be indicated for life- threatening infections. Adverse affects on developing teeth and bone are dose related, therefore, doxycycline might be used for short course therapy (7 – 14 days) prior to the 6 th month of gestation. After the 6 th month, professional consultation should be obtained.

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