Anthrax prevention

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]

Prevention of anthrax infection can be achieved with post-exposure prophylaxis antibiotics and vaccination. The US Advisory Committee on Immunization Practices recommended 60 days of antibiotic drug prophylaxis for immediate protection and a 3-dose series of Anthrax Vaccine Adsorbed (AVA) for long-term protection. Postexposure prophylaxis of asymptomatic persons should start as soon as possible after exposure because its effectiveness decreases with delay in implementation. Everyone exposed to aerosolized B. anthracis spores should receive a full 60 days of post-exposure prophylaxis antimicrobial drugs, whether they are unvaccinated, partially vaccinated, or fully vaccinated. Protective measures should also be implemented to prevent the transmission of the disease.^[1]

Well-timed and effective postexposure prophylaxis can potentially save thousands of lives. Postexposure prophylaxis of asymptomatic persons should start as soon as possible after exposure because its effectiveness decreases with delay in implementation. Initial symptoms may resemble a common cold, including sore throat, mild fever, myalgia, and malaise. After a few days, the symptoms may progress to severe breathing problems shock, and ultimately death.^[2] After exposure to anthrax, it is recommended 60 days of antibiotic drug prophylaxis for immediate protection and a 3-dose series of Anthrax Vaccine Adsorbed (AVA) for long-term protection.^[1]

To ensure adequate and continued protection, everyone exposed to aerosolized Bacillus anthracis spores should receive a full 60 days of postexposure prophylaxis antibiotic drugs, whether they are unvaccinated, partially vaccinated, or fully vaccinated.^[2]

Ciprofloxacin, levofloxacin, and doxycycline are FDA-approved for the antibiotic drug portion of postexposure prophylaxis for inhalation anthrax in adults ≥18 years of age.

No safety data are available for levofloxacin use beyond 30 days; thus, oral ciprofloxacin and doxycycline are recommended as first-line antibiotic drugs for postexposure prophylaxis. Alternative antibiotic drugs that might be used for postexposure prophylaxis, if first-line agents are not tolerated or are unavailable, include:^[2]

• Levofloxacin and moxifloxacin
• Amoxicillin and penicillin V Potassium if the isolate is penicillin susceptible
• Clindamycin

Despite the existence of a vaccine licensed to prevent anthrax, it is not typically available for the general public. It protects against cutaneous and inhalation anthrax. There is evidence of seroconversion after 3 doses of Anthrax Vaccine Adsorbed (AVA). The vaccine should be administered subcutaneously at diagnosis, and 2 and 4 weeks later.^[1] AVA is not FDA-approved for postexposure prophylaxis and could be made available under an Investigational New Drug protocol or an Emergency Use Authorization in a declared emergency.

Anthrax vaccine is indicated for the following risk groups of adults:^[3]

• Laboratory workers who work with anthrax
• People who handle animals or animal products
• Members of the United States military

• Bacillus anthracis, postexposure prophylaxis

• 1. For adults^[4]

• 1.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown

• Preferred regimen (1): Ciprofloxacin 500 mg IV q12h
• Preferred regimen (2): Doxycycline 100 mg IV q12h
• Preferred regimen (3): Levofloxacin 750 mg IV q24h
• Preferred regimen (4): Moxifloxacin 400 mg IV q24h
• Preferred regimen (5): Clindamycin 600 mg IV q8h

• 1.2 Alternatives for penicillin-susceptible strain

• Preferred regimen (1): Amoxicillin 1 g IV q8h
• Preferred regimen (2): Penicillin VK 500 mg IV q6h

• 2. For children = 1 month^[5]

• 2.1 For penicillin-resistant strains or prior to susceptibility testing

• Preferred regimen (1): Ciprofloxacin 30 mg/kg/day, PO, bid (not to exceed 500 mg/dose)
• Preferred regimen (2):

• If patients body weight < 45 kg: Doxycycline 4.4 mg/kg/day, PO, bid (not to exceed 100 mg/dose)
• If patients body weight > 45 kg: Doxycycline 100 mg/dose, PO, bid

• Preferred regimen (3): Clindamycin 30 mg/kg/day, PO, tid (not to exceed 900 mg/dose)
• Preferred regimen (4):

• If patients body weight < 50 kg: Levofloxacin 16 mg/kg/day, PO, bid (not to exceed 250 mg/dose)
• If patients body weight > 50 kg: Levofloxacin 500 mg, PO, qd

• 2.2 For penicillin-susceptible strains

• Preferred regimen (1): Amoxicillin 75 mg/kg/day, PO, tid (not to exceed 1 g/dose)
• Preferred regimen (2): Penicillin VK 50-75 mg/kg/day, PO, id or tid
• Note: Duration of Therapy is 60 days after exposure

• 3. For children < 1 month

• 3.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown

• 3.1.1 For 32–34 weeks gestational age

• 3.1.1.1 For < 1 week of Age

• Preferred regimen (1): Ciprofloxacin 20 mg/kg/day, PO, bid
• Preferred regimen (2): Clindamycin 10 mg/kg/day, PO, bid

• 3.1.1.2 For 1–4 week of age

• Preferred regimen (1): Ciprofloxacin 20 mg/kg/day, PO,bid
• Preferred regimen (2): Clindamycin 15 mg/kg/day, PO, tid

• 3.1.2 For 34–37 week gestational age

• 3.1.2.1 For < 1 week of age

• Preferred regimen (1): Ciprofloxacin 20 mg/kg/day, PO, bid
• Preferred regimen (2): Clindamycin 15 mg/kg/day, PO, tid

• 3.1.2.2 'For 1–4 week of age

• Preferred regimen (1): Ciprofloxacin 20 mg/kg/day, PO, bid
• Preferred regimen (2): Clindamycin 20 mg/kg/day, PO, id

• 3.1.3 Term newborn infant

• 3.1.3.1 For < 1 week of age

• Preferred regimen (1): Ciprofloxacin 30 mg/kg/day, PO, bid
• Preferred regimen (2): Doxycycline 4.4 mg/kg/day, PO, bid (Loading dose 4.4 mg/kg)
• Preferred regimen (3): Clindamycin 15 mg/kg/day, PO, tid

• 3.1.3.2 For 1–4 week of Age

• Preferred regimen (1): Ciprofloxacin 30 mg/kg/day, PO, bid
• Preferred regimen (2): Doxycycline 4.4 mg/kg/day, PO, bid (Loading dose 4.4 mg/kg)
• Preferred regimen (3): Clindamycin 20 mg/kg/day, PO, qid

• 3.2 Alternatives for penicillin-susceptible strains

• 3.2.1 For 32–34 weeks gestational age

• 3.2.1.1 For < 1 week of age

• Alternative regimen (1): Amoxicillin 50 mg/kg/day, PO, bid
• Alternative regimen (2): Penicillin Vk 50 mg/kg/day, PO, bid

• 3.2.1.2 For 1–4 week of age

• Alternative regimen (1): Amoxicillin 75 mg/kg/day, PO, tid
• Alternative regimen (2): Penicillin Vk 75 mg/kg/day, PO, tid

• 3.2.2 For 34–37 week gestational age

• 3.2.2.1 For < 1 week of age

• Alternative regimen (1): Amoxicillin 50 mg/kg/day, PO, bid
• Alternative regimen (2): Penicillin Vk 50 mg/kg/day, PO, bid

• 3.2.2.2 For 1–4 week of age

• Alternative regimen (1): Amoxicillin 75 mg/kg/day, PO, tid
• Alternative regimen (2): Penicillin Vk 75 mg/kg/day, PO, tid

• 3.2.3 Term newborn infant

• 3.2.3.1 For < 1 week of age

• Alternative regimen (1): Amoxicillin 75 mg/kg/day, PO, tid
• Alternative regimen (2): Penicillin Vk 75 mg/kg/day, PO, tid

• 3.2.3.2 For 1–4 week of age

• Alternative regimen (1): Amoxicillin 75 mg/kg/day, PO, tid
• Alternative regimen (2): Penicillin Vk 75 mg/kg/day, PO, id or tid
• Note: Duration of therapy is 60 days from exposure

In order to prevent infection and transmission of the virus, several measures should be implemented, particularly when handling victims of anthrax infection, including:

• All possibly contaminated bedding or clothing of infected patients should be isolated in double plastic bags and treated as possible biohazard waste.
• If a person is suspected of having died from anthrax, every precaution should be taken to avoid skin contact with the potentially contaminated body. The body should be put in strict quarantine, sealed in an airtight body bag and then cremated. No embalming or autopsy should be attempted without a fully equipped biohazard laboratory and trained, knowledgeable personnel.
• Full isolation of the body is important to prevent possible contamination of others. Protective, impermeable clothing and equipment such as rubber gloves, rubber apron, and rubber boots with no perforations should be used when handling the body. No skin, especially if it has any wounds or scratches, should be exposed. Disposable personal protective equipment is preferable, but if not available, decontamination can be achieved by autoclaving.
• Anyone working with anthrax in a suspected or confirmed victim should wear respiratory equipment capable of filtering this size of particle or smaller.^[6]

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