APPENDIX 5

Oral Follow-up Combination Therapy for Severe Anthrax (for Children 1 Month of Age and Older)

1. A bactericidal antimicrobial
a. For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
Ciprofloxacin, 30 mg/kg/day, by mouth (PO), divided every 12 h (not to exceed 500 mg/dose)
OR
Levofloxacin <50 kg: 16 mg/kg/day, PO, divided every 12 h (not to exceed 250 mg/dose) ≥50 kg: 500 mg, PO, given every 24 h
OR
b. Alternatives for penicillin-susceptible strains
Amoxicillin, 75 mg/kg/day, PO, divided every 8 h (not to exceed 1 g/dose)
OR
Penicillin VK, 50–75 mg/kg/day, PO, divided every 6 to 8 h
PLUS
2. A protein synthesis inhibitor
Clindamycina 30 mg/kg/day, PO, divided every 8 h (not to exceed 600 mg/dose)
OR
Doxycyclineb <45 kg: 4.4 mg/kg/day, PO, divided every 12 h (not exceed 100 mg/dose) ≥45 kg: 100 mg, PO, given every 12 h
OR
Linezolidc (non-CNS infection dose):
<12 y old: 30 mg/kg/day, PO, divided every 8 h
≥12 y old: 30 mg/kg/day, PO, divided every 12 h
(not to exceed 600 mg/dose)
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 (see Appendix 1).
  • Severe anthrax includes inhalation anthrax; injection, gastrointestinal, or cutaneous anthrax with systemic involvement, extensive edema, or lesions of the head or neck.

  • Bold font: preferred antimicrobial agent.

  • Normal font: alternative selections are listed in order of preference for therapy for patients who cannot take first-line therapy or if first-line therapy is unavailable.

  • Doses are provided for children with normal renal and hepatic function. Doses may vary for those with some degree of organ failure.

  • a Based on in vitro susceptibility data rather than studies of clinical efficacy.

  • b A single 14-day course of doxycycline is not routinely associated with tooth staining.

  • c Linezolid should be used with caution in patients with thrombocytopenia, as it may exacerbate it. Linezolid use for >14 days carries additional hematopoietic toxicity.