Volume 26, Number 12—December 2020
Synopsis
Control and Prevention of Anthrax, Texas, USA, 2019
Table 3
Intravenous antimicrobials for treatment of adults with severe anthrax*
| Dual therapy for when meningitis has been excluded | Triple therapy for when meningitis might be present | |
|---|---|---|
| Bactericidal agent | Bactericidal agent (fluoroquinolone) | |
| Antimicrobial drugs before susceptibility testing | ||
| Ciprofloxacin 400 mg every 8 h† | Ciprofloxacin 400 mg every 8 h† | |
| OR | OR | |
| Levofloxacin 750 mg every 24 h | Levofloxacin 750 mg every 24 h | |
| OR | OR | |
| Moxifloxacin 400 mg every 24 h | Moxifloxacin 400 mg every 24 h | |
| OR | PLUS |
|
| Meropenem 2 g every 8 h | Bactericidal agent (beta-lactam) | |
| OR | For all strains, regardless of penicillin susceptibility or if susceptibility is unknown | |
| Imipenem‡ 1 g every 6 h | ||
| OR | Meropenem 2 g every 8 h | |
| Doripenem 500 mg every 8 h | OR | |
| OR | Imipenem‡ 1 g every 6 h | |
| Vancomycin 60 mg/kg/day divided every 8 h (maintain serum trough concentrations of 15–20 µg/mL) | OR | |
| Doripenem 500 mg every 8 h | ||
| OR | OR | |
| For penicillin-susceptible strains | For penicillin-susceptible strains | |
| Penicillin G 4 million units every 4 h | Penicillin G 4 million units every 4 h | |
| OR | OR | |
| Ampicillin 3 g every 6 h | Ampicillin 3 g every 6 h | |
| PLUS |
PLUS |
|
| Protein synthesis inhibitor | Protein synthesis inhibitor | |
| Clindamycin 900 mg every 8 h | Linezolid§ 600 mg every 12 h | |
| OR | OR | |
| Linezolid§ 600 mg every 12 h | Clindamycin 900 mg every 8 h | |
| OR | OR | |
| Doxycycline¶ 200 mg initially, then 100 mg every 12 h | Rifampin# 600 mg every 12 h | |
| OR | OR | |
| Rifampin# 600 mg every 12 h |
Chloramphenicol** 1 g every 6–8 h |
|
| Duration of therapy for 10–14 d or until clinical criteria for stability are met. Patient exposed to aerosolized spores will require prophylaxis to complete an antimicrobial course of up to 60 d from onset of illness (see postexposure prophylaxis in [[ANCHOR###T1###Table 1###Anchor]]) | Duration of therapy for 2–3 weeks or greater, until clinical criteria for stability are met. Patients exposed to aerosolized spores will require prophylaxis to complete an antimicrobial course of up to 60 d from onset of illness (see postexposure prophylaxis in [[ANCHOR###T1###Table 1###Anchor]]) |
*Bold type indicates preferred agent. Nonbolded type indicates alternative selections, which are listed in order of preference for therapy for patients who cannot tolerate first-line therapy or if first-line therapy is unavailable. †Severe anthrax includes anthrax meningitis, inhalation, injection, and gastrointestinal anthrax; and cutaneous anthrax with systemic involvement, extensive edema, or lesions of the head or neck. ‡Increased risk for seizures associated with imipenem/cilastatin therapy. §Linezolid should be used with caution in patients with thrombocytopenia because it might exacerbate it. Linezolid use for >14 d carries additional risk for hematopoietic toxicity. ¶A single 10–14 d course of doxycycline is not routinely associated with tooth-staining. #**Rifampin is not a protein synthesis inhibitor, it may also be used in combination therapy based on in vitro synergy. **Should only be used if other options are not available, due to toxicity concerns.