Oral post-exposure prophylaxis for anthrax*^[1-4]

Nonpregnant adults^¶	Children and adolescents (age ≥1 month through 17 years)
Preferred regimens:
Doxycycline 100 mg every 12 hours OR Ciprofloxacin 500 mg every 12 hours	Doxycycline:^Δ <45 kg: 4.4 mg/kg per day divided every 12 hours, not to exceed 100 mg per dose ≥45 kg: 100 mg every 12 hours OR Ciprofloxacin 30 mg/kg per day divided every 12 hours, not to exceed 500 mg per dose OR If amoxicillin susceptible (MIC ≤0.12 mcg/mL): Amoxicillin 75 mg/kg per day divided every 8 hours, not to exceed 1 g per dose^◊
Alternatives if preferred agent(s) is unavailable, in order of preference:
Levofloxacin 750 mg every 24 hours OR Moxifloxacin 400 mg every 24 hours OR Clindamycin 600 mg every 8 hours OR If amoxicillin susceptible (MIC ≤0.12 mcg/mL): Amoxicillin 1 g every 8 hours^◊ OR If penicillin susceptible (MIC ≤0.5 mcg/mL): Penicillin V potassium 500 mg every 6 hours^◊	Clindamycin 30 mg/kg per day divided every 8 hours, not to exceed 600 mg per dose OR Levofloxacin:^§ <50 kg: 16 mg/kg per day divided every 12 hours, not to exceed 250 mg per dose ≥50 kg: 500 mg every 24 hours OR If penicillin susceptible (MIC ≤0.5 mcg/mL): Penicillin V potassium 50 to 75 mg/kg per day divided every 6 to 8 hours, not to exceed 500 mg per dose^◊

PEP with antimicrobials and vaccination is started as soon as possible for suspected aerosolized exposure to Bacillus anthracis, pending risk assessment. Recommendations for PEP antimicrobial regimens are based on the susceptibilities of B. anthracis isolated during the 2001 bioterrorism event in the United States. In the setting of another bioterrorism event, susceptibilities must be rechecked and antimicrobial therapy modified accordingly. The duration of antimicrobial PEP depends on the age, immune status, pregnancy status, and vaccination status; for individuals who have not previously received anthrax vaccine, the duration ranges from 42 to 60 days. Refer to the UpToDate topic on prevention of anthrax for additional details.

MIC: minimum inhibitory concentration; PEP: post-exposure prophylaxis.
* The doses recommended above are intended for patients with normal renal function; the doses of some of these agents must be adjusted in patients with renal insufficiency.
¶ For pregnant, post-partum, or breastfeeding individuals, the preferred agent is ciprofloxacin. Clindamycin and doxycycline are alternative agents for such individuals.
Δ A single 14-day course of doxycycline is not routinely associated with tooth staining, but some degree of staining is likely with a prolonged treatment course of up to 60 days in children <8 years of age.
◊ Be aware of the possibility of emergence of penicillin resistance during monotherapy with amoxicillin or penicillin.
§ Safety data for levofloxacin are limited to 14 days for duration of therapy in children and 30 days in adults.

References:

Hendricks KA, Wright ME, Shadomy SV, et al. Centers for Disease Control and Prevention expert panel meetings on prevention and treatment of anthrax in adults. Emerg Infect Dis 2014; 20:e130687.
Meaney-Delman D, Zotti ME, Creanga AA, et al. Special considerations for prophylaxis for and treatment of anthrax in pregnant and postpartum women. Emerg Infect Dis 2014; 20:e130611.
Bradley JS, Peacock G, Krug SE, et al. Pediatric anthrax clinical management. Pediatrics 2014; 133:e1411.
Bower WA, Schiffer J, Atmar RL, et al. Use of Anthrax Vaccine in the United States: Recommendations of the Advisory Committee on Immunization Practices, 2019. MMWR Recomm Rep 2019; 68:1.

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Oral post-exposure prophylaxis for anthrax*[1-4]

Oral post-exposure prophylaxis for anthrax*^[1-4]