a Ciprofloxacin or
doxycycline should be considered an essential part of first-line
therapy for inhalational anthrax.
b Steroids may be considered
as an adjunct therapy for patients with severe edema and for meningitis
based on experience with bacterial meningitis of other etiologies.
c Other agents with in vitro activity include rifampin,
vancomycin, penicillin, ampicillin, chloramphenicol, imipenem, clindamycin,
and clarithromycin. Because of concerns of constitutive and inducible
beta-lactamases in Bacillus anthracis, penicillin
and ampicillin should not be used alone. Consultation with an infectious
disease specialist is advised.
d Initial therapy may be altered
based on clinical course of the patient; one or two antimicrobial agents
(e.g., ciprofloxacin or doxycycline) may be adequate as the patient
improves.
e If meningitis suspected,
doxycycline may be less optimal because of poor central nervous
system penetration.
f Because of the potential
persistence of spores after an aerosol exposure, antimicrobial therapy should
be continued for 60 days.
g If intravenous ciprofloxacin
is not available, oral ciprofloxacin may be acceptable because it
is rapidly and well absorbed from the gastrointestinal tract with
no substantial loss by first-pass metabolism. Maximum serum concentrations
are attained 1–2 hours after oral dosing but may not be
achieved if vomiting or ileus are present.
h In children, ciprofloxacin
dosage should not exceed 1 g/day.
i The American Academy of
Pediatrics recommends treatment of young children with tetracyclines for
serious infections (e.g., Rocky Mountain spotted fever).
j Although tetracyclines
are not recommended during pregnancy, their use may be indicated
for life-threatening illness. Adverse effects on developing teeth
and bones are dose related; therefore, doxycycline might be used
for a short time (7–14 days) before 6 months of gestation.