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Emergency Preparedness:
Anthrax

Anthrax Drugs of Choice

Drugs-of-choice are chosen by the following criteria:
   Proven Effectiveness
   Availability and cost to the general public
   Side effects

Doxycycline

a) According to the study published in the JID 1993;167:1239-42, Doxycycline was successfully used as a post exposure prophylaxis against Inhalation Anthrax.  While taking Doxycycline, 9 out of 10 test subjects survived a lethal challenge of Inhalation Anthrax and displayed no symptoms.

b) Doxycycline is available to the general public as a prescription drug or as an over-the-counter animal antibiotic.   At approximately $65.00 per 500ct of 100mg tablets (wholesale), Doxycycline's cost is well within the reach of most households. 

c)  Doxycycline is less of a calcium binder than the other Tetracyclines and produces fewer side effects including less discoloration of the teeth in children.   Unlike the other Tetracyclines, it can be taken with milk.      

Ciprofloxacin

a) According to the study published in the JID 1993;167:1239-42, Ciprofloxacin was successfully used as a post exposure prophylaxis against Inhalation Anthrax.  Of the test subjects, 8 out of 9 survived a lethal challenge of Inhalation Anthrax while taking Ciprofloxacin.   One subject died of unknown causes and was excluded from the statistical analysis.

b) Ciprofloxacin is available only by prescription and not in the over-the-counter animal antibiotic market.  As a prescription drug, Cirpofloxacin costs (wholesale) about $400.00 per 100ct of 500mg tabs. 

c) Because of side effects, humans under the age of 19 years are usually not given Ciprofloxacin. 

Tetracycline and Oxytetracycline

a)  Tetracycline and Oxytetracycline were not used in the 1993 Anthrax study.  However, the Tetracyclines have been successfully used and are recommended as a Prophylaxis against numerous diseases as well as treatment for cutaneous Anthrax.  Considering that all Tetracyclines--including Doxycycline--act upon the  30s ribosome then extrapolation would indicate their usage if Doxy and Cipro were not available. b) Both Tetracycline and Oxytetracycline are available as a prescription drug and an over-the-counter animal antibiotic. 

c) Tetracycline and Oxytetracycline are calcium binders and will damage the teeth of children.  They will also affect the bones of the unborn and cause discoloration of the first and second buds (teeth) after the birth.  The bone deformities will return to normal after the drug is stopped. 

Penicillin

a) Penicillin was used in the Anthrax study, but only had a 70% success rate as a prophylaxis.

b) Penicillin is available as a prescription drug and an over-the-counter animal antibiotic.

c) Other than Anaphylactic Shock, Penicillin has few side effects.

Dose and Doseage

Sec I   Dose is a unit (example--500mg)

Sec II  Dosage is the Dose X the Frequency X the Duration  (example--500mg every 12 hours for 60 days - or more days if directed by authorities.)   

Sec I  Dose: Military guidelines for the daily dose total for Doxycycline (against Anthrax) is 200mg (100mg twice a day).   However, you will note that our Charts recommend the Daily Dose Total for Doxycycline against Anthrax is 300mg.  We chose this schedule for the following reasons.

      1) The general population does not have access to the Anthrax vaccine or the Plague vaccine.

      2) Unlike the military, the general population is not as healthy and does not have as strong an immune system.

      3) We also feel that until otherwise confirmed, an Anthrax event could be State sponsored and quite possibly be both Anthrax and Plague or other combinations of Biologicals.  

      4) Also, unlike the military, secondary infections may also be present in the civilian population such as venereal diseases. Prophylaxis against Inhalation Anthrax may fail if the antibiotic is also fighting a disease like gonorrhea.

II  Dosage: Different antibiotics sometimes require different frequency of dose.   For instance Doxycycline should be taken at least BID (twice a day).  Other Tetracyclines call for a 4 times a day schedule.  This is because it is important to keep a steady blood-level of the antibiotic in the patient. 

If the peak and trough levels vary too greatly then the blood level is not constant enough for a particular antibiotic to be efficient.  When dosing, it is important to consider the daily dose total as well as the frequency. 

Example: Doxycycline 3 times a day or 2 times a day is acceptable as long as the daily dose total is accurate.  However, Oxytetracycline 2 times a day is not acceptable.  Oxytetracycline must have a frequency of at least 4 times a day.

      Duration:  As borne out by the military studies, duration for Anthrax prophylaxis must be for 60 days (or more days if directed by authorities)IF the vaccine is not available.  

***END***

Source: This is an official CDC Health Update [edited]
Distributed via Health Alert Network


Recommendations for Post-Exposure Prophylaxis for _B. anthracis_ in Florida
---------
These recommendations are based on the susceptibility pattern of the _B. anthracis_ isolate from the Florida inhalation anthrax case.

Adults
--------
Adult males & non-pregnant females (ages 18-65 yrs)
Ciprofloxacin 500 mg orally twice a day for 60 days (or more days if directed by authorities).
OR
Doxycycline 100 mg orally twice a day for 60 days (or more days if directed by authorities).
OR
Amoxicillin 500 mg orally 3 times a day for 60 days (or more days if directed by authorities).

*Drug-drug interactions and individual patient allergies should be considered when selecting an antibiotic for prophylaxis.

Pregnant adult females
Amoxicillin 500 mg orally 3 times a day for 60 days (or more days if directed by authorities).
* If allergic to amoxicillin or penicillin, consultation with a physician is required as ciprofloxacin or doxycycline may be indicated.

Adults age 65 yrs & over
Doxycycline 100 mg orally twice a day for 60 days (or more days if directed by authorities).
OR
Ciprofloxacin 500 mg orally twice a day for 60 days (or more days if directed by authorities).
OR
Amoxicillin 500 mg orally 3 times a day for 60 days (or more days if directed by authorities).

*Drug-drug interactions and individual patient allergies should be considered when selecting an antibiotic for prophylaxis.

** In older adults, the potential CNS side effects of ciprofloxacin should also be considered when selecting an antibiotic for prophylaxis.

Children
-----------
Antibiotics for children are listed in order of preference:
Children 9 yrs & over Amoxicillin 500 mg orally 3 times a day for 60 days (or more days if directed by authorities).
OR
Ciprofloxacin 500 mg orally twice a day for 60 days (or more days if directed by authorities).
OR
Doxycycline 100 mg orally twice a day for 60 days (or more days if directed by authorities).

*Drug-drug interactions and individual patient allergies should be considered when selecting an antibiotic for prophylaxis. Amoxicillin is preferred for children. If allergic to amoxicillin or penicillin, consultation with a physician is required, as ciprofloxacin or doxycycline may be indicated.

Children less than 9 yrs
Amoxicillin 80 mg/kg/day orally, divided into 3 doses a day for 60 days (or more days if directed by authorities).
OR
Ciprofloxacin 10-15 mg/kg/day orally, divided into 2 doses a day for 60 days (or more days if directed by authorities).
OR
Doxycycline 5 mg/kg/day orally, divided into 2 doses a day for 60 days (or more days if directed by authorities).

* Drug-drug interactions and individual patient allergies should be considered when selecting an antibiotic for prophylaxis. Amoxicillin is preferred for children. If allergic to amoxicillin or penicillin, consultation with a physician is required, as ciprofloxacin or doxycycline may be indicated.

* Reminder: symptoms of inhalational anthrax include fever, muscle aches, and fatigue that rapidly progress to severe systemic illness. Workers and visitors associate with the AMI work site in Florida who develop such symptoms should be thoroughly evaluated to exclude anthrax and be reported
to the state health department.

FOR ADDITIONAL INFORMATION
CALL CDC ATLANTA, USA
(404) 639-2807


 
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