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Because B anthracis (anthrax) has the potential to be used as a biological weapon and can rapidly progress to systemic anthrax with high mortality in those who are infected and untreated, the American Academy of Pediatrics (AAP) offers clinical guidance that can be quickly implemented when needed.

Pediatric Anthrax Clinical Management and an Executive Summary, were published in Pediatrics in May 2014. For background information, see AAP/Centers for Disease Control and Prevention (CDC) Pediatric Anthrax Clinical Management.

Mass B Anthracis Exposure Scenario

In a mass B anthracis release, public authorities will determine the presence and extent of the incident. Information will be made available as soon as possible by the CDC, including real-time information posted on the CDC Anthrax Web page.

Within 48 hours of exposure to B anthracis spores:

  • Public health officials will provide information about points of dispensing locations where antimicrobial prophylaxis will be distributed. Pediatricians will not be the primary point of dispensing.
  • Public health authorities plan to provide a 10-day course of antimicrobial prophylaxis to people likely to have been exposed to spores.

Within 10 days of exposure to B anthracis spores:

  • Public health authorities will further define those who have been exposed and will recommend an additional 50 days of antimicrobial postexposure prophylaxis (PEP), as well as the 3-dose anthrax vaccine, anthrax vaccine adsorbed (AVA [BioThrax, Emergent BioSolutions, Rockville, MD]), series.
  • For children younger than 6 weeks of age (who are not candidates for AVA), antimicrobial prophylaxis should begin immediately, but the vaccine series should be delayed until the child reaches 6 weeks of age.
  • A local adverse event after receiving a previous dose of AVA is not a contraindication to receiving additional doses, although subsequent doses should be administered at an alternate site and closely monitored.
  • Although not strictly contraindicated, AVA should not be coadministered with standard childhood vaccinations during an anthrax event. Immunization of children exposed to aerosolized B anthracis spores with AVA is a priority, above routine immunizations. Routine immunizations should resume 4 weeks after the last AVA dose.

Treatment for Clinical Forms of Anthrax

Anthrax may occur in different forms, any of which may progress to systemic disease. Treatment will vary by clinical manifestation. The CDC Web site provides guidance on diagnostic specimens to obtain for laboratory testing based on various clinical presentations of anthrax.

Cutaneous Anthrax

  • Cutaneous anthrax without systemic involvement that occurs in the context of an anthrax release should be treated with a single oral antimicrobial agent.
  • Unless breastfeeding mothers have untreated cutaneous lesions on their breasts, breastfeeding should continue for infants of mothers who require antimicrobial treatment or prophylaxis or anthrax vaccine.

Inhalation, Gastrointestinal, or other Systemic Disease without Meningeoncephalitis

  • Systemic anthrax infection is generally not considered contagious, and Standard Precautions should be used for routine patient care.
  • Cases should be treated with at least 2 intravenous antimicrobial agents: a bactericidal agent, and a protein synthesis inhibitor, with the provision of oral stepdown therapy for children whose signs and symptoms of systemic infection have resolved.
  • Systemic disease should be treated with 3 intravenous antimicrobial agents with adequate central nervous system penetration, including 2 bactericidal agents and a protein synthesis inhibitor, for at least 2 weeks, and until all clinical signs and symptoms, supported by laboratory and imaging data, document resolution of inflammation associated with the infection.
  • Either Anthrax Immune Globulin or raxibacumab antitoxin is indicated in patients with anthrax systemic disease, particularly children with severe disease, including those with new onset of organ system failure. Dosing guidelines for children will be available on package labels at the time antitoxin is shipped to the site of the exposure.
  • Corticosteroids should be used in children with more severe systemic disease in doses that are consistent with those currently used for meningitis.

Once therapy has been completed for any form of systemic or cutaneous anthrax infection in children involved in an aerosol B anthracis dispersal event, appropriate oral antimicrobial agents should be provided as PEP to complete a full 60 days of therapy.


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