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Antibiotic regimens for anthrax: Treatment of systemic anthrax, including meningitis[1]

Antibiotic regimens for anthrax: Treatment of systemic anthrax, including meningitis[1]
  Intravenous dosing for adults Intravenous dosing for children and adolescents (age ≥1 month through 17 years) Comments
FIRST-LINE ANTIBIOTICS: Empiric regimen consists of a combination of 2 bactericidal agents and 1 protein-synthesis inhibitor
First-line bactericidal agents
Meropenem 2 g every 8 hours
  • 40 mg/kg every 8 hours (max 2 g/dose)
  
Ciprofloxacin 400 mg every 8 hours
  • 10 mg/kg every 8 hours (max 400 mg/dose)
  
Levofloxacin 500 mg every 12 hours
  • <50 kg: 10 mg/kg every 12 hours (max 250 mg/dose)
  • ≥50 kg: 750 mg every 24 hours
  
Penicillin G 4 million units every 4 hours
  • 67,000 units/kg every 4 hours (max 4 million units/dose)
  • Do not use for empiric therapy, only for documented penicillin-susceptible strains.
Ampicillin 2 g every 4 hours
  • 50 mg/kg every 6 hours (max 3 g/dose)
  • Do not use for empiric therapy, only for documented penicillin-susceptible strains.
Imipenem-cilastatin 1 g every 6 hours
  • Alternative agent for children: 25 mg/kg every 6 hours (max 1 g/dose)
  • If meropenem is unavailable.
  • Use only with caution in patients with meningitis.
Ampicillin-sulbactam 3 g every 6 hours
  • Alternative agent for children: 50 mg/kg every 6 hours (max 2 g/dose)
  • If meropenem is unavailable.
  • Pediatric dose listed as mg/kg ampicillin component.
  • May have neuroprotective effects.
First-line protein-synthesis inhibitors
Minocycline 200 mg once then 100 mg every 12 hours
  • 4 mg/kg once (max 200 mg) then 2 mg/kg every 12 hours (max 100 mg/dose)
  • Not recommended for pregnant or lactating individuals.
  • May have neuroprotective effects.
Doxycycline 200 mg once then 100 mg every 12 hours
  • <45 kg: 2.2 mg/kg once (max 200 mg), then 2.2 mg/kg every 12 hours (max 100 mg/dose)
  • ≥45 kg: 200 mg once then 100 mg every 12 hours
  • May have neuroprotective effects.
ALTERNATIVE ANTIBIOTICS (reserve for when first-line agents cannot be used or are unavailable, as in a crisis setting; listed in descending order of preference)
Alternative bactericidal agents
Piperacillin-tazobactam 3.375 g every 4 hours
  • 75 mg/kg every 6 hours (max 4 g/dose)
  • Pediatric dose listed as mg/kg piperacillin component.
  • May have neuroprotective effects.
Moxifloxacin 400 mg every 24 hours
  • Age ≥3 to ≤23 months: 6 mg/kg every 12 hours (max 200 mg/dose)
  • Age 2 to <6 years: 5 mg/kg every 12 hours (max 200 mg/dose)
  • Age 6 to <12 years: 4 mg/kg every 12 hours (max 200 mg/dose)
  • Age ≥12 to ≤18 years and <45 kg: 4 mg/kg every 12 hours (max 200 mg/dose)
  • Age ≥12 to <18 years and ≥45 kg: 400 mg every 24 hours (or 200 mg every 12 hours for those at risk for cardiac events)
  
Vancomycin 15 mg/kg over 1 to 2 hours every 12 hours
  • 20 mg/kg every 8 hours
  • For critically ill adults: Loading dose of 20 to 35 mg/kg (max 3 g) once.
  • Target AUC of 400 mcg × h/mL (preferred) or trough concentration 15 to 20 mcg/mL.
Alternative protein-synthesis inhibitors
Omadacycline 200 mg once then 100 mg every 12 hours
  • No dosing available
  • Does not cross an intact blood-brain barrier.
Eravacycline 1 mg/kg every 12 hours
  • Age >8 years: 1 mg/kg every 12 hours
  • Does not cross an intact blood-brain barrier.
Clindamycin 900 mg every 8 hours
  • 13.3 mg/kg every 8 hours (max 900 mg/dose)
  • May have neuroprotective effects.
Linezolid 600 mg every 12 hours
  • Age <12 years: 10 mg/kg every 8 hours (max 600 mg/dose)
  • Age ≥12 years: 15 mg/kg every 12 hours (max 600 mg/dose)
  
Rifampin 600 mg every 12 hours
  • 10 mg/kg every 12 hours (max 300 mg/dose)
  • Categorized as an RNA inhibitor but also is bactericidal.
  • Should not be used as monotherapy because of risk of emergent resistance.

Systemic anthrax includes anthrax meningitis and inhalation, injection, and gastrointestinal anthrax; patients often have temperature abnormalities, tachycardia, tachypnea, hypotension, or leukocytosis or leukopenia.

  • For empiric treatment of systemic anthrax (with or without meningitis) and directed treatment of meningitis, combination therapy with two bactericidal agents from different classes (eg, meropenem plus ciprofloxacin) plus a protein-synthesis inhibitor (eg, minocycline) is recommended.
  • Once susceptibility results are available, directed treatment of systemic anthrax without meningitis can be tailored to one active bactericidal agent plus one active protein-synthesis inhibitor.
  • Other combinations or single agents may be the only options in crisis situations.

In addition to antibiotic therapy, antitoxin therapy (raxibacumab, obiltoxaximab, or anthrax immunoglobulin) should also be given for systemic anthrax. Refer to other UpToDate content for details.

Duration of the intravenous antibiotic is at least 2 to 3 weeks or until clinically stable, whichever is longer. Subsequently, selected patients exposed to aerosolized Bacillus anthracis spores warrant post-exposure prophylaxis. Refer to other UpToDate content on prevention of anthrax.

The doses recommended above are intended for patients with normal kidney function; the doses of some of these agents must be adjusted in patients with kidney insufficiency.

These recommendations are consistent with those from the Centers for Disease Control and Prevention (CDC) in the United States. For dosing in neonates, refer directly to CDC documents.

Reference:
  1. Bower WA, Yu Y, Person MK, et al. CDC Guidelines for the Prevention and Treatment of Anthrax, 2023. MMWR Recomm Rep 2023; 72:1.
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