TABLE 10. Empiric* treatment regimens for pregnant or lactating persons†,§ aged >18 years with cutaneous anthrax without signs and symptoms of meningitis, by descending order of preference — CDC recommendations, 2023.
| Treatment (listed drugs joined by “or” are considered equivalent) | Dosage |
|---|---|
|
First-line antimicrobial drug
| |
| Doxycycline¶,** |
100 mg every 12 hours orally |
| or | |
| Ciprofloxacin¶ |
500 mg every 12 hours orally |
| or | |
| Levofloxacin¶ |
750 mg every 24 hours orally |
| PCN-S only: | |
| Amoxicillin††,§§ |
1 g every 8 hours orally |
| or | |
| Penicillin VK†† |
500 mg every 6 hours orally |
|
Alternative antimicrobial drug¶¶
| |
| Amoxicillin/clavulanate†† |
16:1 formulation (1 g/62.5 mg) in 2 tablets every 12 hours orally |
| or | |
| Amoxicillin/clavulanate†† |
7:1 formulation (875/125 mg) every 12 hours orally |
| Moxifloxacin**,†† |
400 mg every 24 hours orally |
| Ofloxacin†† |
400 mg every 12 hours orally |
| Clindamycin†† |
600 mg every 8 hours orally |
| Omadacycline†† |
450 mg every 24 hours orally x 2 days, then 300 mg every 24 hours orally |
| Linezolid†† |
600 mg every 12 hours orally |
| Clarithromycin††,*** |
500 mg every 12 hours orally (only initiate after at least 3 days of treatment with any of the other antimicrobial drugs listed) |
| Dalbavancin†† |
1 g x 1 dose IV, then 500 mg weekly IV |
| Imipenem/cilastatin†† |
1 g every 6 hours IV |
| or | |
| Meropenem†† |
2 g every 8 hours IV |
| Vancomycin†† |
15 mg/kg every 12 hours IV over a period of 1–2 hours (target AUC24 of 400–600 µg x h/mL [preferred]; if AUC24 is not available, maintain serum trough concentrations of 15–20 µg/mL) |
|
Antitoxin (only to be used if antimicrobial drugs are not available or not appropriate; listed antitoxins joined by “or” are considered equivalent)
| |
| Raxibacumab††† |
40 mg/kg in a single dose IV |
| or | |
| Obiltoxaximab††† |
16 mg/kg in a single dose IV |
| AIGIV§§§ | 420 units IV |
Abbreviations: AIGIV = anthrax immunoglobulin intravenous; AUC24 = area under the concentration-time curve from 0 to 24 hours; FDA = Food and Drug Administration; IV = intravenous; PCN-S = penicillin-susceptible strains; PEPAbx = antimicrobial postexposure prophylaxis for anthrax.
* Definitive therapy should be directed by antibiotic susceptibility test results, when available.
† For pregnant adolescents, refer to pediatric guidelines for weight-based dosing (see Table 13).
§ Dosing recommended for pregnant persons regardless of trimester.
¶ Approved by FDA for anthrax PEPAbx, treatment, or both, but specific uses (e.g., doses, dosing schedules, and patient populations) recommended in this report might differ from the FDA-approved labeling.
** If liquid formulations are not available for adults who cannot swallow pills, instructions are available for preparing oral suspensions of moxifloxacin (Source: Hutchinson DJ, Johnson CE, Klein KC. Stability of extemporaneously prepared moxifloxacin oral suspensions. Am J Health Syst Pharm 2009;66:665–7.121) and doxycycline (Source: CDC. In an anthrax emergency: how to prepare doxycycline hyclate for children and adults who cannot swallow pills. Atlanta, GA: US Department of Health and Human Services, CDC; 2020. https://www.cdc.gov/anthrax/public-health/doxy-crushing-instruction-pamphlet.html).
†† Not approved by FDA for anthrax PEPAbx or treatment.
§§ Ampicillin 500 mg every 6 hours orally can be used as an alternative to amoxicillin, if available.
¶¶ Alternative selections are for patients who have contraindications to or cannot tolerate first-line antimicrobial drugs or if first-line antimicrobial drugs are not available.
*** Clarithromycin is unlikely to be effective if the patient has bacteremia, thus a different antimicrobial drug must be used initially to clear bacteremia.
††† Premedicate with IV or oral diphenhydramine within 1 hour before administration. Hypersensitivity and anaphylaxis have been reported after raxibacumab and obiltoxaximab administration.
§§§ An 840-unit dose of AIGIV can be considered for severe cases.