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November 16, 2001 / 50(45)
Notice to Readers: Update: Interim Recommendations for Antimicrobial
Prophylaxis for Children and Breastfeeding Mothers and Treatment of Children
Ciprofloxacin or doxycycline is recommended for antimicrobial prophylaxis and treatment of
adults and children with Bacillus anthracis infection associated with the recent bioterrorist
attacks in the United States. Amoxicillin is an option for antimicrobial prophylaxis for children
and pregnant women and to complete treatment of cutaneous disease when B. anthracis is
susceptible to penicillin, as is the case in the recent attacks (1--3). Use of ciprofloxacin or
doxycycline might be associated with adverse effects in children (4,5), and liquid formulations
of these drugs are not widely available. This notice provides further information about
prophylaxis and treatment of children and breastfeeding mothers, including the use of
Ciprofloxacin, doxycycline, and penicillin G procaine have been effective as antimicrobial
prophylaxis for inhalational B. anthracis infection in nonhuman primates and are approved for
this use in humans by the Food and Drug Administration (FDA) (5,6). Amoxicillin has not been
studied in animal models and is not approved by FDA for the prophylaxis or treatment of
anthrax. Other data indicate that B. anthracis strains produce a cephalosporinase and suggest
that the strains contain an inducible beta-lactamase that might decrease the effectiveness of
penicillins, especially when a large number of organisms is present (2). In addition, penicillin
achieves low intracellular concentrations that might be detrimental to its ability to kill
germinating spores in macrophages.
Because of these concerns, penicillins (including amoxicillin) are not recommended for initial
treatment of anthrax, but are likely to be effective for antimicrobial prophylaxis following
exposure to B. anthracis, a setting where relatively few organisms are expected to be present.
Therefore, amoxicillin* may be used for the 60-day antimicrobial prophylaxis in infants and
children when the isolate involved in the exposure is determined to be susceptible to penicillin.
Isolates of B. anthracis implicated in the recent bioterrorist attacks are susceptible to
ciprofloxacin, doxycycline, and penicillin (2).
Initial treatment of infants and children with inhalational or systemic (including gastrointestinal
or oropharyngeal) anthrax should consist of intravenous ciprofloxacin† or doxycyline§, plus one
or two additional antimicrobial¶ agents. If meningitis is suspected, ciprofloxacin might be more
effective than doxycycline because of better central nervous system penetration (2). Experience
with fluoroquinolones other than ciprofloxacin in children is limited.
Ciprofloxacin or doxycycline should be the initial treatment of localized cutaneous anthrax in
infants and children. Intravenous therapy with multiple antimicrobial agents is recommended
for cutaneous anthrax with systemic involvement, extensive edema, or lesions on the head or
neck (2). Whether infants and young children are at increased risk for systemic dissemination of
cutaneous infection is not known; a 7-month-old patient infected during the recent bioterrorism
attacks developed systemic illness after onset of cutaneous anthrax (7). For young children (e.g.
aged <2 years), initial therapy of cutaneous anthrax should be intravenous, and combination
therapy with additional antimicrobials should be considered.
After clinical improvement following intravenous treatment for inhalational or cutaneous
anthrax, oral therapy with one or two antimicrobial agents (including either ciprofloxacin or
doxycycline) may be used to complete the first 14--21 days of treatment for inhalational anthrax
or the first 7--10 days for uncomplicated cutaneous anthrax. The optimal oral treatment regimen
is unknown; some adults with inhalational anthrax as a result of the recent bioterrorist attacks
are receiving ciprofloxacin and rifampin. For both inhalational and cutaneous anthrax in the
setting of this bioterrorist attack, antimicrobial therapy should be continued for 60 days because
of the likelihood of exposure to aerosolized B. anthracis and the need to protect against
persistent spores that might germinate in the respiratory tract. Because of potential adverse
effects of prolonged use of ciprofloxacin or doxycycline in children, amoxicillin is an option for
completion of the remaining 60 days of therapy for persons infected in these bioterrorist attacks.
Because of its known safety for infants, amoxicillin is an option for antimicrobial prophylaxis in
breastfeeding mothers when B. anthracis is known to be penicillin-susceptible and no
contraindication to maternal amoxicillin use is indicated. The American Academy of Pediatrics
also considers ciprofloxacin and tetracyclines (which include doxycycline) to be usually
compatible with breastfeeding because the amount of either drug absorbed by infants is small,
but little is known about the safety of long-term use (8). Mothers concerned about the use of
ciprofloxacin or doxycycline for antimicrobial prophylaxis should consider expressing and then
discarding breast milk so that breastfeeding can be resumed when antimicrobial prophylaxis is
completed. Decisions about antimicrobial choice and continuation of breastfeeding should be
made by the mother and her and the infant's health-care providers. Consideration should be
given to antimicrobial efficacy, safety for the infant, and the benefits of breastfeeding.
Health-care providers prescribing antimicrobial drugs for the prophylaxis or treatment of
anthrax should be aware of their adverse effects and consult with an infectious disease specialist
as needed. Additional information about recognition, prophylaxis, and treatment of anthrax
infection is available at <>.
CDC. Update: investigation of anthrax associated with intentional exposure and interim public
health guidelines, October 2001. MMWR 2001;50:889--93.
CDC. Update: investigation of bioterrorism-related anthrax and interim guidelines for exposure
management and antimicrobial therapy, October 2001. MMWR 2001;50:909--19.
CDC. Updated recommendations for antimicrobial prophylaxis among asymptomatic pregnant
women after exposure to Bacillus anthracis. MMWR 2001;50:960.
Bayer Corporation. Ciprofloxacin®. In: Physicians desk reference. Montvale, New Jersey:
Medical Economics Company, 2000:678--83.
Food and Drug Administration. Prescription drug products; Doxycycline and Penicillin G
Procaine administration for inhalational anthrax (post-exposure). Federal Register
Friedlander AM, Welkos SL, Pitt MLM, et al. Postexposure prophylaxis against experimental
inhalation anthrax. J Infect Dis 1993;167:1239--43.
Roche KJ, Chang MW, Lazarus H. Cutaneous anthrax infection: images in clinical medicine. N
Engl J Med 2001. Available at <>. Accessed November 6, 2001.
American Academy of Pediatrics Committee on Drugs. The transfer of drugs and other
chemicals into human milk. Pediatrics. 2001;108:776--89.
* The recommended dose of amoxicillin is 80 mg/kg/day orally divided every 8 hours
(maximum 500 mg/dose).
† The recommended dose of ciprofloxacin is 10 mg/kg/dose every 12 hours intravenously
(maximum 400 mg/dose) or 15 mg/kg/dose every 12 hours orally (maximum 500 mg/dose).
§ The recommended dose of doxycycline is 2.2 mg/kg/dose every 12 hours intravenously or
orally (maximum 100 mg/dose).
¶ Options for additional drugs, based on in vitro sensitivity testing of isolates in the recent
attacks, include rifampin, vancomycin, penicillin, ampicillin, chloramphenicol, imipenem,
clindamycin, and clarithromycin (2).
Use of trade names and commercial sources is for identification only and does not imply
endorsement by the U.S. Department of Health and Human Services.
References to non-CDC sites on the Internet are provided as a service to MMWR readers and
do not constitute or imply endorsement of these organizations or their programs by CDC or the
U.S. Department of Health and Human Services. CDC is not responsible for the content of
pages found at these sites.
Disclaimer All MMWR HTML versions of articles are electronic conversions from ASCII text
into HTML. This conversion may have resulted in character translation or format errors in the
HTML version. Users should not rely on this HTML document, but are referred to the
electronic PDF version and/or the original MMWR paper copy for the official text, figures, and
tables. An original paper copy of this issue can be obtained from the Superintendent of
Documents, U.S. Government Printing Office (GPO), Washington, DC 20402-9371; telephone:
(202) 512-1800. Contact GPO for current prices.
**Questions or messages regarding errors in formatting should be addressed to
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Morbidity and Mortality Weekly Report
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Department of Health and Human Services This page last reviewed 11/16/2001  


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