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Prevention of anthrax

Kenneth H Wilson, MD
Section Editor
Daniel J Sexton, MD
Deputy Editor
Anna R Thorner, MD


The incidence of anthrax in humans has decreased during the past century, and it is now very rare in developed countries including the United States. However, anthrax remains a concern in the developed world because of its potential as an agent of bioterrorism.

The prevention of anthrax will be reviewed here. The microbiology, pathogenesis, epidemiology, clinical manifestations, diagnosis, and treatment of anthrax are discussed separately. (See "Microbiology, pathogenesis, and epidemiology of anthrax" and "Clinical manifestations and diagnosis of anthrax" and "Treatment of anthrax".)


Inhalation anthrax — Individuals exposed to aerosolized Bacillus anthracis are considered to be at risk for inhalation anthrax. Postexposure prophylaxis (PEP) for inhalation anthrax involves antimicrobial agents and vaccination. The recommendations presented here are in agreement with the recommendations of the United States Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics [1-3].

PEP of asymptomatic individuals should start as soon as possible following exposure and ideally within 48 hours because its effectiveness decreases with delay in administration [1,2]. Clinicians should seek advice from public health officials to determine which individuals should receive PEP [2]. When selecting a PEP regimen, the production of toxin, the potential for antimicrobial drug resistance, the frequent occurrence of meningitis, and the presence of latent spores must be taken into account [1]. Individuals exposed to aerosolized B. anthracis are presumed to be at prolonged risk for inhalation anthrax from ungerminated spores retained in their lungs following the initial exposure. The presence of B. anthracis spores requires prolonged antimicrobial prophylaxis (for 60 days).

Individuals with an indication for PEP for inhalation anthrax should receive both [1]:


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Literature review current through: Sep 2016. | This topic last updated: Apr 15, 2016.
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  1. Hendricks KA, Wright ME, Shadomy SV, et al. Centers for disease control and prevention expert panel meetings on prevention and treatment of anthrax in adults. Emerg Infect Dis 2014; 20.
  2. Bradley JS, Peacock G, Krug SE, et al. Pediatric anthrax clinical management. Pediatrics 2014; 133:e1411.
  3. Meaney-Delman D, Zotti ME, Creanga AA, et al. Special considerations for prophylaxis for and treatment of anthrax in pregnant and postpartum women. Emerg Infect Dis 2014; 20.
  4. Lightfoot N, Scott R, Turnbull B. Antimicrobial susceptibility of Bacillus anthracis. Salisbury Med Bull Suppl 1990; 68:95.
  5. Doğanay M, Aydin N. Antimicrobial susceptibility of Bacillus anthracis. Scand J Infect Dis 1991; 23:333.
  6. Turnbull PC, Sirianni NM, LeBron CI, et al. MICs of selected antibiotics for Bacillus anthracis, Bacillus cereus, Bacillus thuringiensis, and Bacillus mycoides from a range of clinical and environmental sources as determined by the Etest. J Clin Microbiol 2004; 42:3626.
  7. Luna VA, King DS, Gulledge J, et al. Susceptibility of Bacillus anthracis, Bacillus cereus, Bacillus mycoides, Bacillus pseudomycoides and Bacillus thuringiensis to 24 antimicrobials using Sensititre automated microbroth dilution and Etest agar gradient diffusion methods. J Antimicrob Chemother 2007; 60:555.
  8. Bakici MZ, Elaldi N, Bakir M, et al. Antimicrobial susceptibility of Bacillus anthracis in an endemic area. Scand J Infect Dis 2002; 34:564.
  9. Food and Drug Administration. Information for Healthcare Professionals: Fluoroquinolone Antimicrobial Drugs. 2008.
  10. Shepard CW, Soriano-Gabarro M, Zell ER, et al. Antimicrobial postexposure prophylaxis for anthrax: adverse events and adherence. Emerg Infect Dis 2002; 8:1124.
  11. Tierney BC, Martin SW, Franzke LH, et al. Serious adverse events among participants in the Centers for Disease Control and Prevention's Anthrax Vaccine and Antimicrobial Availability Program for persons at risk for bioterrorism-related inhalational anthrax. Clin Infect Dis 2003; 37:905.
  12. GOCHENOUR WS Jr, GLEISER CA, TIGERTT WD. Observations on penicillin prophylaxis of experimental inhalation anthrax in the monkey. J Hyg (Lond) 1962; 60:29.
  13. Friedlander AM, Welkos SL, Pitt ML, et al. Postexposure prophylaxis against experimental inhalation anthrax. J Infect Dis 1993; 167:1239.
  14. Vietri NJ, Purcell BK, Lawler JV, et al. Short-course postexposure antibiotic prophylaxis combined with vaccination protects against experimental inhalational anthrax. Proc Natl Acad Sci U S A 2006; 103:7813.
  15. US Food and Drug Administration. FDA news release: FDA approves vaccine for use after known or suspected anthrax exposure. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm474027.htm (Accessed on November 25, 2015).
  16. Wright JG, Quinn CP, Shadomy S, et al. Use of anthrax vaccine in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009. MMWR Recomm Rep 2010; 59:1.
  17. US Food and Drug Administration. FDA News Release. FDA approves raxibacumab to treat inhalational anthrax. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm332341.htm (Accessed on January 02, 2013).
  18. US Food and Drug Adminisration. FDA News Release. FDA approves new treatment for inhalation anthrax. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm491470.htm (Accessed on April 04, 2016).
  19. Anti-Infective Drugs Advisory Committee Meeting - 02 November 2012. Human Genome Sciences, Inc. Briefing Document, Raxibacumab - Treatment of Inhalational Anthrax. BLA 125349. http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/Anti-InfectiveDrugsAdvisoryCommittee/UCM326185.pdf (Accessed on January 03, 2013).
  20. Raxibacumab prescribing information. http://www.accessdata.fda.gov/drugsatfda_docs/label/2012/125349s000lbl.pdf (Accessed on January 03, 2013).
  21. Nabel GJ. Protecting against future shock--inhalational anthrax. N Engl J Med 2009; 361:191.
  22. Migone TS, Subramanian GM, Zhong J, et al. Raxibacumab for the treatment of inhalational anthrax. N Engl J Med 2009; 361:135.
  23. Peterson JW, Comer JE, Noffsinger DM, et al. Human monoclonal anti-protective antigen antibody completely protects rabbits and is synergistic with ciprofloxacin in protecting mice and guinea pigs against inhalation anthrax. Infect Immun 2006; 74:1016.
  24. ANTHIM (obiltoxaximab) injection, for intravenous use - Highlights of prescribing information. http://www.anthim.com/download/pdf/ANTHIM-prescribing-information.pdf (Accessed on April 04, 2016).
  25. Kobiler D, Gozes Y, Rosenberg H, et al. Efficiency of protection of guinea pigs against infection with Bacillus anthracis spores by passive immunization. Infect Immun 2002; 70:544.
  26. HENDERSON DW, PEACOCK S, BELTON FC. Observations on the prophylaxis of experimental pulmonary anthrax in the monkey. J Hyg (Lond) 1956; 54:28.
  27. Food and Drug Administration. Biothrax Product Approval Information. 2008. http://www.fda.gov/cber/approvltr/biothrax121108L.htm (Accessed on February 13, 2009).
  28. Brachman PS, Gold H, Plotkin SA, et al. Field Evaluation of a Human Anthrax Vaccine. Am J Public Health Nations Health 1962; 52:632.
  29. Marano N, Plikaytis BD, Martin SW, et al. Effects of a reduced dose schedule and intramuscular administration of anthrax vaccine adsorbed on immunogenicity and safety at 7 months: a randomized trial. JAMA 2008; 300:1532.
  30. Centers for Disease Control And Prevention. Summary Report of the Meeting of the Advisory Committee on Immunization Practices (ACIP), October 22-23. Atlanta, GA 2008.
  31. Wiesen AR, Littell CT. Relationship between prepregnancy anthrax vaccination and pregnancy and birth outcomes among US Army women. JAMA 2002; 287:1556.
  32. Ryan MA, Smith TC, Sevick CJ, et al. Birth defects among infants born to women who received anthrax vaccine in pregnancy. Am J Epidemiol 2008; 168:434.
  33. Turnbull PC. Current status of immunization against anthrax: old vaccines may be here to stay for a while. Curr Opin Infect Dis 2000; 13:113.
  34. Shlyakhov EN, Rubinstein E. Human live anthrax vaccine in the former USSR. Vaccine 1994; 12:727.
  35. Donegan S, Bellamy R, Gamble CL. Vaccines for preventing anthrax. Cochrane Database Syst Rev 2009; :CD006403.
  36. McBride BW, Mogg A, Telfer JL, et al. Protective efficacy of a recombinant protective antigen against Bacillus anthracis challenge and assessment of immunological markers. Vaccine 1998; 16:810.
  37. Miller J, McBride BW, Manchee RJ, et al. Production and purification of recombinant protective antigen and protective efficacy against Bacillus anthracis. Lett Appl Microbiol 1998; 26:56.
  38. Ivins BE, Pitt ML, Fellows PF, et al. Comparative efficacy of experimental anthrax vaccine candidates against inhalation anthrax in rhesus macaques. Vaccine 1998; 16:1141.
  39. Gorse GJ, Keitel W, Keyserling H, et al. Immunogenicity and tolerance of ascending doses of a recombinant protective antigen (rPA102) anthrax vaccine: a randomized, double-blinded, controlled, multicenter trial. Vaccine 2006; 24:5950.
  40. Campbell JD, Clement KH, Wasserman SS, et al. Safety, reactogenicity and immunogenicity of a recombinant protective antigen anthrax vaccine given to healthy adults. Hum Vaccin 2007; 3:205.
  41. Centers for Disease Control and Prevention. Bioterrorism readiness plan: a template for healthcare facilities. http://www.cdc.gov/ncidod/dhqp/pdf/bt/13apr99APIC-CDCBioterrorism (Accessed on October 06, 2009).