Dosing Regimens

*Ciprofloxacin dose should not exceed 1 gram per day in children.

Courtesy of the CDC.

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.

a Cutaneous anthrax with signs of systemic involvement, extensive edema, or lesions on the head or neck require intravenous therapy, and a multidrug approach is recommended. (See previous table)

b Ciprofloxacin or doxycycline should be considered first-line therapy. Amoxicillin 500 mg po TID for adults or 50 mg/kg/day divided every 8 hours for children is an option for completion of therapy after clinical improvement. Oral amoxicillin dose is based on the need to achieve appropriate minimum inhibitory concentration levels.

c Previous guidelines have suggested treating cutaneous anthrax for 7–10 days, but 60 days is recommended in the setting of this attack, given the likelihood of exposure to aerosolized B. anthracis (6).

d The American Academy of Pediatrics recommended treatment of young children with tetracyclines for serious infections (e.g., Rocky Mountain epotted fever).

e Although tetracyclines or ciprofloxacin are not recommended during pregnancy, their use may be indicated for life-threatening illiness. Adverse effects on developing teeth and bones are dose related; therefore, doxycycline might be used for a short time (7–10 days) before 6 months of gestation.

a Can switch to oral form at 750 mg q 12 h when clinically improved.

b Can switch to oral form at 100 mg q 12 h after clinically improved.

Adapted from Plague as a Biological Weapon: Medical and Public Health Management: Inglesby TV, Dennis DT, Henderson DA, et al. JAMA, May 3, 2000; vol. 283, no. 17: 2281–2290 and, Treatment of Biological Warfare Agent Casualities Headquarters Departments of The Army, The Navy and The Air Force and Commandant, Marine Corps http://www.vnh.org

a Oral therapy may be given after the patient is clinically improved.

From Treatment of Biological Warfare Agent Casualties Headquarters Departments of The Army, The Navy and The Air Force And Commandant, Marine Corps. http://www.vnh.org

Adapted from Plague as a Biological Weapon: Medical and Public Health Management: Abstracted from: Inglesby TV, Dennis DT, Henderson DA, et al. JAMA, May 3, 2000; vol. 283, no. 17: 2281–2290.

a Can switch to oral form at 500 mg every 12 hrs when clinically improved.

Adapted from “Consensus Statement: Tularemia as a Biological Weapon: Medical and Public Health Management.” Dennis DT, Inglesby TV, Henderson DA, et al. JAMA, 2001; 285(21):2763–2773.

a Not to exceed 1 g/day.

Adapted from “Consensus Statement: Tularemia as a Biological Weapon: Medical and Public Health Management.” Dennis DT, Inglesby TV, Henderson DA, et al. JAMA, June 6, 2001; vol. 285, no. 21:2763–2773.

a Patients with VHF with unknown pathogen, or pathogen known to be Arenavirus or Bunyavirus.

Adapted from Borio L, Inglesby T, Peters CJ, et al. Hemorrhagic fever viruses as biological weapons: Medical and Public Health Management JAMA, 2002; 287; 2391–2405.

Adapted from Borio L, Inglesby T, Peters CJ, et al. Hemorrhagic fever viruses as biological Weapons: Medical and Public Health Management. JAMA 2002;287:2391–2405.

a For critically ill patients, give intravenous treatment of 4.4 mg/kg every 12 hrs.

a Chronic form requires double antibiotic combination therapy for a minimum of 2 years.

a If osteoarticular involvement, continue treatment for 3 months; if CNS involvement, up to 9 months.

a If the clinical picture seems more severe, oral treatment should include 2 out of the 3 regimens for 1 month followed by monotherapy for an additional 2–5 months. For extrapulmonary suppurative disease, an additional 6–12 months is needed if, with the pulmonic form, abscesses are present with drainage according to the clinical setting.

Adapted from Treatment of Biological Warfare Agent Casualties, Headquarters Departments of The Army, The Navy and The Air Force and Commandant, Marine Corps.

a Use of antibiotics should be clinically warranted.

b Chronic carriers of Salmonella typhi are to be treated for four weeks.

a ORS to replete volume loss is the first priority.

a With more severe cases, dosages may need to be increased and given more often (e.g., 5 mg in adult, or 0.05 mg/kg in children every 2 to 5 min).

b If IV access is not possible, IM administration an option.

Adapted from ATSDR.

a  A 1 mg test dose of physostigmine is sometimes useful if the diagnosis of an anticholinergic agent is uncertain. If the patient’s clinical status improves, full dosing can begin.

Adapted from ATSDR.