Table 5.23.

Recommended therapy and prophylaxis in children for diseases associated with bioterrorism

Disease	Therapy or prophylaxis	Treatmenta, agent and dosage
Smallpox	Therapy	Supportive care
	Prophylaxis	Vaccination may be effective if given with the first several days after exposure
Plague	Therapy	Gentamicin 2.5 mg/kg IV q8 h or Streptomycin 15 mg/kg IM q12 h (max 2 g/day, although only available for compassionate usage and in limited supply) or Doxycycline 2.2 mg/kg IV q12 h (max 200 mg/day) or Ciprofloxacinb 15 mg/kg IV q12 h or Levofloxacin 10–15 mg/kg IV q24 h or Chloramphenicolc 25 mg/kg q6 h (max 4 g/day)
	Prophylaxis	Doxycycline 2.2 mg/kg PO q12 h or Ciprofloxacinb 20 mg/kg PO q12 h
Tularemia	Therapy	Same as for plague
	Prophylaxis	Same as for plague
Botulism	Therapy	Supportive care, antitoxin and/or botulism immune globulin may halt progression of symptoms but are unlikely to reverse them
	Prophylaxis	None
Viral hemorrhagic fevers	Therapy	Supportive care, ribavirin may be beneficial in select casesd
	Prophylaxis	None

Used with permission from Society of Critical Care Medicine

References: (Berger and Burns 2012; Cieslak and Henretig 2016; Markenson and Redlener 2007; Pittman et al. 2018; USAMRIID 2014)

^aIn a mass casualty setting, parenteral therapy might not be possible. In such cases, oral therapy (with analogous agents) may need to be used

^bOfloxacin (and possibly other quinolones) may be acceptable alternatives to ciprofloxacin or levofloxacin; however, they are not approved for use in children

^cConcentration should be maintained between 5 and 20 μg/mL. Some experts have recommended that chloramphenicol be used to treat patients with plague meningitis, because chloramphenicol penetrates the blood-brain barrier. Use in children younger than 2 may be associated with adverse reactions but might be warranted for serious infections

^dRibavirin is recommended for arenavirus or bunyavirus infections and may be indicated for a viral hemorrhagic fever of an unknown etiology although not FDA approved for these indications. For intravenous therapy use a loading dose: 30 kg IV once (max dose, 2 g), then 16 mg/kg IV q6 h for 4 days (max dose, 1 g), and then 8 mg/kg IV q8 h for 6 days (max dose, 500 mg). In a mass casualty setting, it may be necessary to use oral therapy. For oral therapy, use a loading dose of 30 mg/kg PO once, then 15 mg/kg/day PO in 2 divided doses for 10 days