TABLE 16. Empiric* treatment regimens for preterm and full-term neonates 32–44 weeks’ postmenstrual age (gestational age plus chronologic age) with cutaneous anthrax without signs and symptoms of meningitis, by descending order of preference — CDC recommendations, 2023.
| Treatment | 32 to <34 weeks’ gestational age |
34 to <37 weeks’ gestational age |
Full-term infant |
|||
|---|---|---|---|---|---|---|
| 0 to <1 week |
1–4 weeks |
0 to <1 week |
1–4 weeks |
0 to <1 week |
1–4 weeks |
|
| Dosage | Dosage | Dosage | Dosage | Dosage | Dosage | |
|
First-line antimicrobial drug
| ||||||
| Ciprofloxacin† |
10 mg/kg every 12 hours orally |
10 mg/kg every 12 hours orally |
10 mg/kg every 12 hours orally |
10 mg/kg every 12 hours orally |
15 mg/kg every 12 hours orally |
15 mg/kg every 12 hours orally |
| PCN-S only§: | ||||||
| Amoxicillin¶,** |
25 mg/kg every 12 hours orally |
25 mg/kg every 8 hours orally |
25 mg/kg every 8 hours orally |
25 mg/kg every 8 hours orally |
25 mg/kg every 8 hours orally |
25 mg/kg every 8 hours orally |
| Penicillin VK¶ |
25 mg/kg every 12 hours orally |
25 mg/kg every 8 hours orally |
25 mg/kg every 12 hours orally |
25 mg/kg every 8 hours orally |
25 mg/kg every 8 hours orally |
25 mg/kg every 6 hours orally |
| Amoxicillin/clavulanate¶ |
25 mg amoxicillin/kg every 12 hours orally |
25 mg amoxicillin/kg every 8 hours orally |
25 mg amoxicillin/kg every 12 hours orally |
25 mg amoxicillin/kg every 8 hours orally |
25 mg amoxicillin/kg every 8 hours orally |
25 mg amoxicillin/kg every 8 hours orally |
| Doxycycline†,†† |
5 mg/kg every 12 hours orally |
5 mg/kg every 12 hours orally |
5 mg/kg every 12 hours orally |
5 mg/kg every 12 hours orally |
5 mg/kg x 1 dose orally, then 2.5 mg/kg every 12 hours orally |
5 mg/kg x 1 dose orally, then 2.5 mg/kg every 12 hours orally |
| Clindamycin¶ |
7 mg/kg every 8 hours orally |
7 mg/kg every 8 hours orally |
7 mg/kg every 8 hours orally |
7 mg/kg every 8 hours orally |
9 mg/kg every 8 hours orally |
9 mg/kg every 8 hours orally |
| Levofloxacin† |
10 mg/kg every 12 hours orally |
10 mg/kg every 8 hours orally |
10 mg/kg every 12 hours orally |
10 mg/kg every 8 hours orally |
10 mg/kg every 12 hours orally |
10 mg/kg every 8 hours orally |
|
Alternative antimicrobial drug§§
| ||||||
| Moxifloxacin††,¶¶ |
10 mg/kg every 24 hours orally |
10 mg/kg every 24 hours orally |
10 mg/kg every 24 hours orally |
10 mg/kg every 24 hours orally |
10 mg/kg every 24 hours orally |
10 mg/kg every 24 hours orally |
| Linezolid¶ |
10 mg/kg every 12 hours IV |
10 mg/kg every 8 hours IV |
10 mg/kg every 12 hours IV |
10 mg/kg every 8 hours IV |
10 mg/kg every 12 hours IV |
10 mg/kg every 8 hours IV |
| Meropenem¶ |
13.3 mg/kg every 8 hours IV |
20 mg/kg every 8 hours IV |
20 mg/kg every 8 hours IV |
20 mg/kg every 8 hours IV |
20 mg/kg every 8 hours IV |
20 mg/kg every 8 hours IV |
| Vancomycin¶,*** |
20 mg/kg loading dose IV, then 15 mg/kg every 12 hours IV |
20 mg/kg loading dose IV, then 15 mg/kg every 12 hours IV |
20 mg/kg loading dose IV, then 15 mg/kg every 8 hours IV |
20 mg/kg loading dose IV, then 15 mg/kg every 8 hours IV |
20 mg/kg loading dose IV, then 15 mg/kg every 8 hours IV |
20 mg/kg loading dose IV, then 15 mg/kg every 8 hours IV |
| Administer over a period of 1–2 hours. After dose 3 of vancomycin, adjust dosages to target AUC24 of 400 µg x h/mL [preferred]; if AUC24 is not available, maintain trough concentrations of 10–15 µg/mL. Check concentrations earlier if renal function is impaired. During the first 7–10 days, serum creatinine represents maternal concentration. | ||||||
| Omadacycline¶¶,††† |
NA |
NA |
NA |
5.5 mg/kg loading dose IV x 1, then 3.85 mg/kg every 24 hours IV |
5.5 mg/kg loading dose IV x 1, then 3.85 mg/kg every 24 hours IV |
5.5 mg/kg loading dose IV x 1, then 3.85 mg/kg every 24 hours IV |
| Dalbavancin¶ |
NA |
NA |
NA |
NA |
NA |
22.5 mg/kg x 1 dose IV |
|
Antitoxin (only to be used if antimicrobial drugs are not available or not appropriate; listed antitoxins joined by “or” are considered equivalent)
| ||||||
| Raxibacumab§§§ |
55 mg/kg as a single dose IV |
55 mg/kg as a single dose IV |
55 mg/kg as a single dose IV |
55 mg/kg as a single dose IV |
55 mg/kg as a single dose IV |
55 mg/kg as a single dose IV |
| or | ||||||
| Obiltoxaximab§§§ |
16 mg/kg as a single dose IV |
16 mg/kg as a single dose IV |
16 mg/kg as a single dose IV |
16 mg/kg as a single dose IV |
16 mg/kg as a single dose IV |
16 mg/kg as a single dose IV |
| AIGIV | 1 vial (approximately 60 units) as a single dose IV | 1 vial (approximately 60 units) as a single dose IV | 1 vial (approximately 60 units) as a single dose IV | 1 vial (approximately 60 units) as a single dose IV | 1 vial (approximately 60 units) as a single dose IV | 1 vial (approximately 60 units) as a single dose IV |
Source: Bradley JS, Nelson JD, eds. Nelson’s pediatric antimicrobial therapy. 29th ed. Itasca, IL: American Academy of Pediatrics; 2023.
Abbreviations: FDA = Food and Drug Administration; IV = intravenous; NA = not applicable; PCN-S = penicillin-susceptible strains; PEPAbx = antimicrobial postexposure prophylaxis for anthrax.
* Definitive therapy should be directed by antibiotic susceptibility test results, when available.
† 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.
§ Up to 10% of naturally occurring strains of anthrax are resistant to penicillin and amoxicillin; bioterror strains might be engineered to generate resistance to multiple antibiotics. Susceptibility results reported from CDC within 48–72 hours of initial isolation of anthrax.
¶ Not approved by FDA for anthrax PEPAbx or treatment.
** Ampicillin can be used as an alternative to amoxicillin, if available.
†† 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).
§§ 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.
¶¶ Not approved by FDA for any pediatric indications. Not approved by FDA for anthrax PEPAbx or treatment.
*** Allergic reactions are rare in neonates, but neonates can release histamine that causes hypotension after rapid infusions of vancomycin; thus, it can be safest to pretreat with an antihistamine.
††† The use of tetracycline-class antibiotics during tooth development (i.e., last half of pregnancy, infancy, and childhood up to age 8 years) might cause permanent discoloration of the teeth (yellow, gray, or brown) and enamel hypoplasia. This adverse effect appears to occur less often with doxycycline but might occur more with longer durations of therapy.
§§§ Premedicate with IV or oral diphenhydramine within 1 hour before administration. Hypersensitivity and anaphylaxis have been reported after raxibacumab and obiltoxaximab administration.