COMMENTARY

Anthrax in Children: Prevention and Treatment

John S. Bradley, MD; Georgina Peacock, MD, MPH; Steven E. Krug, MD

Disclosures

May 27, 2014

Editorial Collaboration

Medscape &

Anthrax Treatment

Anthrax occurs in different clinical forms, any of which can progress to systemic disease. Treatment will vary by clinical manifestation. Children may require larger doses per kilogram of body weight and more frequent dosing of certain antimicrobial agents. Children with active cutaneous or systemic infection should complete antimicrobial treatment and then transition to oral postexposure prophylaxis for the remainder of the 60 days as prophylaxis for inhalation anthrax.

Cutaneous anthrax without systemic involvement

Treat with a single oral antimicrobial.

Ciprofloxacin is preferred, or if the strain is susceptible to penicillin, amoxicillin should be used.

Inhalation, gastrointestinal, or other systemic disease without meningoencephalitis. Treat with at least 2 intravenous antimicrobials: a bactericidal agent and a protein synthesis inhibitor.

Ciprofloxacin is the preferred bactericidal agent, or if the strain is susceptible, penicillin may be used.

Clindamycin is the preferred protein synthesis inhibitor.

Systemic disease with possible or confirmed meningoencephalitis. Treat with antimicrobial agents and antitoxin.

Treat with 3 intravenous antimicrobial agents with adequate central nervous system penetration, including 2 bactericidal agents and a protein synthesis inhibitor.

   - Ciprofloxacin is the preferred bactericidal agent.

   - Meropenem or, if susceptible, penicillin as a secondary bactericidal agent.

   - Linezolid is the preferred protein synthesis inhibitor.

Treat with antitoxin (either anthrax immune globulin or raxibacumab antitoxin).

Severe systemic disease. Treat with antitoxin (either anthrax immune globulin or raxibacumab antitoxin). Children with severe systemic disease and meningoencephalitis should also receive corticosteroids.

Diagnosis and Critical Care

For suspected inhalation anthrax, a chest radiograph should be performed to assess for a widened mediastinum, pleural effusions, and/or pulmonary infiltrates. Children who show signs and symptoms of systemic anthrax should undergo lumbar puncture when possible because of the high rates of subsequent meningoencephalitis. For children who are too unstable for lumbar puncture, central nervous system imaging by CT with contrast, or MRI with contrast, should be able to document meningeal enhancement characteristics of infection and identify hemorrhagic parenchymal lesions characteristic of anthrax meningoencephalitis.

As a result of the potential for sudden decompensation, children who are hospitalized and treated for anthrax should receive careful hemodynamic monitoring, including continuous pulse oximetry and cardiorespiratory monitoring for at least 24 to 48 hours, even if initial findings are reassuring. Prompt and continuous pleural fluid drainage by chest and/or peritoneal tube is critical in patients with inhalation anthrax. Patients may also require mechanical ventilation because of respiratory distress or imminent shock.

Web Resources

Pediatric Anthrax Clinical Management

Pediatric Anthrax Clinical Management: Executive Summary

CDC: Anthrax

AAP Pediatric Preparedness Resource Kit

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