Doxycycline Calcium

Class: Tetracyclines
Note: This monograph also contains information on Doxycycline Hyclate, Doxycycline Monohydrate
VA Class: AM250
CAS Number: 24390-14-5
Brands: Doryx, Doxy 100, Monodox, Vibramycin, Vibra-Tabs

Introduction

Antibacterial; semisynthetic tetracycline antibiotic derived from oxytetracycline.^{103 111 113 114}

Uses for Doxycycline Calcium

Respiratory Tract Infections

Treatment of respiratory tract infections caused by Mycoplasma pneumoniae.^{111 113 114}

Treatment of respiratory tract infections caused by Haemophilus influenzae, Streptococcus pneumoniae, or Klebsiella.^{111 113 114} Should only be used for treatment of infections caused by these bacteria when in vitro susceptibility tests indicate the organism is susceptible.^{111 113 a}

Empiric treatment of community-acquired pneumonia (CAP) in conjunction with other anti-infectives.^a Tetracyclines provide coverage against C. pneumoniae, M. pneumoniae, H. influenzae, and Legionella, but S. pneumoniae may be resistant.^a Doxycycline is the preferred tetracycline for empiric treatment of CAP.^a

Alternative for treatment of infections caused by Legionella pneumophila†; ¹³⁷ used with or without rifampin.¹³⁷

Acne

Adjunctive treatment of moderate to severe inflammatory acne.^{111 a} Not indicated for treatment of noninflammatory acne.^a

Actinomycosis

Treatment of actinomycosis caused by Actinomyces israelii.^{111 113 137} Alternative to penicillin G;^{111 113 137} oral tetracyclines (usually doxycycline or tetracycline) also used as follow-up after initial parenteral penicillin G.¹⁰⁹

Amebiasis

Adjunct to amebicides for treatment of acute intestinal amebiasis.^{111 113} Tetracyclines not included in current recommendations for treatment of amebiasis caused by Entamoeba.^{109 122}

Anthrax

Postexposure prophylaxis to reduce the incidence or progression of disease following a suspected or confirmed exposure to aerosolized Bacillus anthracis spores (inhalational anthrax).^{102 111 113 141 147} Initial drug of choice for such prophylaxis is ciprofloxacin or doxycycline;^{102 141 147} doxycycline is the preferred tetracycline because of ease of administration and proven efficacy in monkey studies.¹⁰²

Treatment of inhalational anthrax.^{102 111 113 142 143 147 o} Monotherapy may be effective for anthrax that occurs as the result of natural or endemic exposures,^{109 o} but a multiple-drug parenteral regimen (ciprofloxacin or doxycycline and 1 or 2 other anti-infectives predicted to be effective) is recommended for inhalational anthrax that occurs as the result of exposure to anthrax spores in the context of biologic warfare or bioterrorism.^{102 143 147} Although tetracyclines not usually used in children <8 years of age or in pregnant women, the benefits of doxycycline outweigh the risks and CDC and others state doxycycline can be used when necessary for treatment of inhalational anthrax in these individuals.^{102 105 143 147}

Treatment of GI and oropharyngeal anthrax.^{102 143} If occurring in the context of biologic warfare or bioterrorism, use parenteral regimens recommended for inhalational anthrax.^{102 143}

Treatment of cutaneous anthrax.^{102 111 143 147 o} Multiple-drug regimen recommended for initial treatment when there are signs of systemic involvement, extensive edema, or lesions on the head or neck or when cutaneous anthrax occurs in children <2 years of age.^{102 105 143 147 o}

Bartonella Infections

Treatment of bartonellosis caused by Bartonella bacilliformis.^{111 113 160}

Treatment of infections caused by B. henselae† (e.g., cat scratch disease, bacillary angiomatosis, peliosis hepatitis).ⁱ Cat scratch disease generally is self-limited in immunocompetent individuals and may resolve spontaneously in 2–4 months; some clinicians suggest that anti-infective therapy be considered for acutely or severely ill patients with systemic symptoms, particularly those with hepatosplenomegaly or painful lymphadenopathy, and probably is indicated in immunocompromised patients.^{109 j k l} Anti-infectives also are indicated in patients with B. henselae infections who develop bacillary angiomatosis, neuroretinitis, or Parinaud’s oculoglandular syndrome.^{109 j k l} Optimum regimens have not been identified; some clinicians recommend erythromycin, azithromycin, doxycycline, ciprofloxacin, rifampin, co-trimoxazole, gentamicin, or third generation cephalosporins.^{109 i j k l}

Treatment of infections caused by B. quintana†.¹³⁷ Optimum anti-infective regimens have not been identified;^{e f g} various drugs have been used, including doxycycline, erythromycin, azithromycin, chloramphenicol, or cephalosporins.^{137 f g}

A drug of choice for treatment of bartonellosis in HIV-infected adults and adolescents, especially CNS bartonellosis.¹⁶⁰ USPHS/IDSA, CDC, and others suggest that long-term suppression with erythromycin or doxycycline should be considered to prevent recurrence of bartonellosis† in HIV-infected adults and adolescents with relapse or reinfection.^{160 h}

Brucellosis

Treatment of brucellosis;^{103 109 111 113 114 137 147 m} considered a drug of choice.^{109 147} Used in conjunction with other anti-infectives (e.g., streptomycin or gentamicin and/or rifampin),^{103 109 111 113 114 137 147 m} especially for severe infections or when there are complications (e.g., endocarditis, meningitis, osteomyelitis).^{109 147}

Postexposure prophylaxis following a high-risk exposure to Brucella†^{109 147} (e.g., needle-stick injury, inadvertent laboratory exposure, confirmed exposure in the context of biologic warfare or bioterrorism).¹⁴⁷ Postexposure prophylaxis not generally recommended after exposure to endemic brucellosis.^{109 147}

Burkholderia Infections

Treatment of melioidosis† caused by Burkholderia pseudomallei.^{137 147 gg} Although optimum regimens not identified, doxycycline monotherapy may be effective for mild, localized disease without toxicity, and doxycycline in conjunction with co-trimoxazole may be effective for localized disease with toxicity.¹⁴⁷ Severe illness requires an initial parenteral regimen of ceftazidime, imipenem, or meropenem (with or without concomitant co-trimoxazole or doxycycline), followed by a prolonged oral maintenance regimen of doxycycline (in conjunction with co-trimoxazole) or amoxicillin-clavulanate.^{147 gg}

Treatment of glanders† caused by B. mallei.¹³⁷ Experience is limited regarding treatment of human cases; optimum regimens not identified.^{147 gg} Some clinicians suggest streptomycin used in conjunction with tetracycline or chloramphenicol or imipenem monotherapy.¹³⁷ Others suggest that, pending results of in vitro susceptibility tests, regimens used for treatment of melioidosis can be used for initial empiric treatment of glanders.¹⁴⁷

The US Army Medical Research Institute of Infectious Diseases (USAMRIID) and European Commission’s Task Force on Biological and Chemical Agent Threats (BICHAT) state that the same treatment regimens recommended for naturally occurring melioidosis or glanders should be used if these Burkholderia infections occur in the context of biologic warfare or bioterrorism.^{147 gg} These experts suggest that postexposure prophylaxis with doxycycline or co-trimoxazole for ≥10 days can be attempted in such situations, but is of unproven benefit.^{147 gg}

Campylobacter Infections

Treatment of infections caused by Campylobacter fetus.^{103 111 114} Tetracyclines (usually doxycycline) are alternatives,¹⁰⁹ not drugs of choice for C. fetus.¹³⁷

Chancroid

Treatment of chancroid caused by Haemophilus ducreyi.^{103 111 113 114} Not included in CDC recommendations for treatment of chancroid.¹⁰⁷

Chlamydial Infections

Treatment of uncomplicated urethral, endocervical, or rectal infections caused by Chlamydia trachomatis.^{107 108 109 111 114 137} A drug of choice for presumptive treatment of chlamydial infections in patients with gonorrhea.^{107 108}

Treatment of trachoma and inclusion conjunctivitis caused by C. trachomatis.^{109 111 113 114} Consider that anti-infectives may not eliminate C. trachomatis in all cases of chronic trachoma.^{111 113 114}

Treatment of lymphogranuloma venereum (genital, inguinal, or anorectal infections) caused by C. trachomatis.^{103 107 108 111 113 114} Recommended as drug of choice by CDC and others.^{107 108}

Treatment of psittacosis (ornithosis) caused by C. psittaci.^{100 103 109 111 113 114} A drug of choice recommended by CDC.¹⁰⁰

Clostridium Infections

Treatment of infections caused by Clostridium.^{111 113} Tetracyclines are alternatives to metronidazole or penicillin G for adjunctive treatment of C. tetani infections.¹³⁷

Ehrlichiosis

Treatment of human granulocytotropic (or granulocytic) anaplasmosis† (HGA; formerly human granulocytic ehrlichiosis [HGE]) caused by Anaplasma phagocytophilum (formerly Ehrlichia phagocytophila, E. equi, agent of HGE); drug of choice.^{109 137 x z cc}

Treatment of human monocytotropic (or monocytic) ehrlichiosis† (HME) caused by E. chaffeensis; drug of choice.^{109 137 x cc}

Treatment of ehrlichiosis† caused by E. ewingii or E. canis; drug of choice.^{109 137 cc}

Enterobacteriaceae Infections

Treatment of infections caused by susceptible Escherichia coli, Enterobacter aerogenes, Klebsiella, or Shigella.^{111 113} Should only be used for treatment of infections caused by these common gram-negative bacteria when other appropriate anti-infectives are contraindicated or ineffective^a and when in vitro susceptibility tests indicate the organism is susceptible.^{111 113 a}

Fusobacterium Infections

Alternative to penicillin G for treatment of infections caused by Fusobacterium fusiforme (Vincent’s infection).^{111 113}

Gonorrhea and Associated Infections

Alternative for treatment of uncomplicated gonorrhea caused by susceptible Neisseria gonorrhoeae.^{111 113 114} However, tetracyclines are considered inadequate therapy and are not recommended by CDC for treatment of gonorrhea.^{107 b}

Empiric treatment of epididymitis most likely caused by N. gonorrhoeae or C. trachomatis; used in conjunction with IM ceftriaxone.^{107 108}

Granuloma Inguinale (Donovanosis)

Treatment of granuloma inguinale (donovanosis) caused by Calymmatobacterium granulomatis.^{107 111 113 114} CDC recommends doxycycline or co-trimoxazole as drugs of choice.¹⁰⁷

Leptospirosis

Alternative to penicillin G for treatment of leptosporosis†.^{109 137}

Prevention of leptosporosis† in travelers to areas where leptospirosis is endemic or epidemic who are at increased risk (e.g., those who engage in recreational water activities such as whitewater rafting, adventure racing, kayaking).^{123 153}

Can be used for combined prophylaxis in travelers at increased risk of leptospirosis who also require malaria chemoprophylaxis.¹²³

Listeria Infections

Alternative for treatment of listeriosis caused by Listeria monocytogenes.^{111 113} Not usually considered a drug of choice or alternative for these infections.^{109 137}

Lyme Disease

Treatment of early disseminated Lyme disease† associated with erythema migrans, in the absence of neurologic involvement or third-degree AV heart block.^{109 115 116 117 118 119 120 121 136 137 140} IDSA, AAP, and others recommend oral doxycycline or oral amoxicillin as first-line therapy for treatment of early localized or early disseminated Lyme disease when oral therapy is appropriate.^{109 115 116 117 118 119 120 121 136 137 140}

Treatment of uncomplicated Lyme arthritis† without objective evidence of neurologic involvement (e.g., meningitis or radiculopathy).^{109 115 116 117 121 136 140}

Alternative for treatment of neurologic manifestations of Lyme disease† when β-lactams (e.g., ceftriaxone, penicillin G) cannot be used.¹³⁶

Malaria

Prevention (prophylaxis) of malaria caused by Plasmodium falciparum, including chloroquine-resistant strains.^{111 122 123 139 153} Recommended by CDC and others as a drug of choice for prophylaxis in individuals traveling to areas where chloroquine-resistant P. falciparum malaria has been reported;^{122 123} recommended by CDC as an alternative in those traveling to areas where chloroquine-resistant P. falciparum has not been reported and who are unable to take chloroquine or hydroxychloroquine.¹²³

Treatment of uncomplicated malaria† caused by chloroquine-resistant Plasmodium falciparum or chloroquine-resistant P. vivax and when the plasmodial species has not been identified.^{122 158} Used in conjunction with quinine; not effective alone.^{122 158}

CDC and others state treatments of choice for uncomplicated chloroquine-resistant P. falciparum malaria are a regimen of oral quinine in conjunction with oral doxycycline, tetracycline, or clindamycin or a regimen of atovaquone and proguanil.^{122 158} A regimen of quinine and doxycycline (or tetracycline) generally preferred over quinine and clindamycin,¹⁵⁸ except for young children or pregnant women who should not receive tetracyclines.¹⁵⁸ Quinine in conjunction with tetracycline (or doxycycline) also a regimen of choice for chloroquine-resistant P. vivax malaria.^{122 158}

Treatment of severe malaria caused by P. falciparum†; used in conjunction with IV quinidine gluconate initially and then with oral quinine when an oral regimen is tolerated.¹⁵⁸

Presumptive self-treatment of malaria† in travelers who elect not to use prophylaxis, those who require or choose to use a prophylaxis regimen that may not have optimal efficacy, or for long-term travelers receiving effective prophylaxis but who plan to visit very remote areas; used in conjunction with quinine.¹²² Not recommended by CDC for presumptive self-treatment of malaria; CDC recommends the fixed combination of atovaquone and proguanil.¹²³

Active only against the asexual erythrocytic forms of Plasmodium (not exoerythrocytic stages) and cannot prevent delayed primary attacks or relapse of P. ovale or P. vivax malaria or provide a radical cure;^{122 123 158} primaquine usually also indicated to eradicate hypnozoites and prevent relapse in patients exposed to or being treated for P. ovale or P. vivax malaria.^{122 123 158}

Detailed recommendations regarding prevention of malaria available from CDC 24 hours a day from the voice information service (877-394-8747), fax information service (888-232-3299), or Internet at .¹²³

Assistance with diagnosis or treatment of malaria available from CDC Malaria Epidemiology Branch by contacting CDC Malaria Hotline at 770-488-7788 from 8:00 a.m. to 4:30 p.m. Eastern Standard Time or CDC Emergency Operation Center at 770-488-7100 after hours, on weekends, and holidays.¹⁵⁸

Mycobacterial Infections

Alternative for treatment of infections caused by Mycobacterium fortuitum†.¹³⁷

Treatment of cutaneous infections caused by M. marinum†;^{106 137} a drug of choice.¹⁰⁶

Nocardiosis

Alternative to co-trimoxazole for treatment of nocardiosis† caused by Nocardia.^{109 137 a}

Nongonococcal Urethritis

Treatment of nongonococcal urethritis (NGU) caused by Ureaplasma urealyticum, C. trachomatis, or Mycoplasma.^{107 108 111 114 b}

Consider that some cases of recurrent urethritis following doxycycline treatment may be caused by tetracycline-resistant U. urealyticum.¹⁰⁷

Pelvic Inflammatory Disease

Treatment of acute pelvic inflammatory disease (PID); used in conjunction with other anti-infectives.^{107 108} Doxycycline is included in PID regimens to provide coverage against Chlamydia.¹⁰⁷

When a parenteral regimen is indicated for PID, CDC and others recommend IV cefotetan (or cefoxitin) in conjunction with IV or oral doxycycline as a regimen of choice.^{107 108} A regimen of IV ampicillin and sulbactam and IV doxycycline is an alternative^{107 108} since it provides good coverage against C. trachomatis, N. gonorrhoeae, and anaerobes and is effective for tubo-ovarian abscess.¹⁰⁷ Doxycycline also used as follow-up after a parenteral regimen of clindamycin and gentamicin.¹⁰⁷

When an oral regimen is indicated, CDC and others recommend a single IM dose of ceftriaxone or cefoxitin (or other parenteral cephalosporin) followed by oral doxycycline (with or without oral metronidazole) as a regimen of choice.^{107 108} Although experience is limited, oral amoxicillin and clavulanate and oral doxycycline may be an alternative oral regimen.¹⁰⁷

Plague

Treatment of plague caused by Yersinia pestis,^{103 111 113 114 123 137 144 147} including naturally occurring or endemic bubonic, septicemic, or pneumonic plague and plague that occurs following exposure to Y. pestis in the context of biologic warfare or bioterrorism.^{137 144 147} Regimen of choice is streptomycin or gentamicin;^{137 144 147} alternatives are doxycycline, tetracycline, ciprofloxacin, or chloramphenicol.^{144 147} For plague meningitis, some experts recommend that treatment regimen include chloramphenicol.¹⁴⁷

Postexposure prophylaxis following a high-risk exposure to Y. pestis† (e.g., household, hospital, or other close contact with an individual who has pneumonic plague; laboratory exposure to viable Y. pestis; confirmed exposure to plague aerosol in the context of biologic warfare or bioterrorism).^{144 147} Doxycycline may be drug of choice;^{109 144 147} alternatives are tetracycline, ciprofloxacin, or chloramphenicol.¹⁴⁷ Prophylaxis not required for asymptomatic contacts of individuals with bubonic plague, but observe such contacts for 1 week and initiate treatment if symptoms occur.¹⁴⁷

Pleural Effusions

Management of pleural effusions† associated with metastatic tumors.^{126 127 128 132 134 151 152}

Rat-bite Fever

Treatment of rat-bite fever† caused by Streptobacillus moniliformis or Spirillum minus.^{109 137} Tetracyclines (usually doxycycline) are alternatives to penicillin G.^{109 137}

Relapsing Fever

Treatment of relapsing fever caused by Borrelia recurrentis.^{111 113 137} A drug of choice.¹³⁷

Rickettsial Infections

Treatment of rickettsial infections including Rocky Mountain spotted fever (RMSF), typhus fever and the typhus group, Q fever, rickettsialpox, and tick fevers caused by Rickettsiae.^{103 109 111 112 113 114 147 cc} Drug of choice for treatment of most rickettsial infections.^{109 112 147 a cc}

Syphilis

Alternative to penicillin G benzathine for treatment of primary, secondary, latent, or tertiary syphilis (not neurosyphilis) in nonpregnant adults and adolescents hypersensitive to penicillins, including HIV-infected patients.^{107 108 109 111 113 160} Use tetracyclines only if compliance and follow-up can be ensured since efficacy not well documented.^{107 160}

Tularemia

Treatment of tularemia caused by Francisella tularensis,^{103 111 113 114 137 145 147} including naturally occurring or endemic tularemia or tularemia that occurs following exposure to F. tularensis in the context of biologic warfare or bioterrorism.^{137 145 147} Drugs of choice are streptomycin or gentamicin; alternatives are tetracyclines (usually doxycycline), ciprofloxacin, or chloramphenicol.^{137 145 147} Risk of relapse and primary treatment failure may be higher with the alternatives.¹⁴⁵

Postexposure prophylaxis of tularemia† following a high-risk laboratory exposure to F. tularensis (e.g., spill, centrifuge accident, needlestick injury) or in individuals exposed to the organism in the context of biologic warfare or bioterrorism.^{145 147} Drugs of choice are doxycycline, tetracycline, or ciprofloxacin.^{145 147} Postexposure prophylaxis usually not recommended after exposure to natural or endemic tularemia (e.g., tick bite, rabbit or other animal exposure) and is unnecessary in close contacts of tularemia patients since human-to-human transmission does not occur.¹⁴⁷

Preexposure prophylaxis of tularemia†.¹⁴⁷ Based on results of in vitro susceptibility data, use of doxycycline or ciprofloxacin before exposure possibly may protect against tularemia in the context of biologic warfare or bioterrorism.¹⁴⁷

Vibrio Infections

Treatment of cholera caused by Vibrio cholerae.^{109 110 111 137 p} A drug of choice; used as an adjunct to fluid and electrolyte replacement in moderate to severe disease.^{109 110 137 p}

Treatment of severe V. parahaemolyticus† infection when anti-infective therapy is indicated in addition to supportive care.^p

Treatment of infections caused by V. vulnificus†.^{137 p p} Optimum anti-infective therapy has not been identified; a tetracycline or third generation cephalosporin (e.g., cefotaxime, ceftazidime) is recommended.^{137 p q} Because the case fatality rate associated with V. vulnificus is high, initiate anti-infective therapy promptly if indicated.^q

Yaws

Alternative to penicillin G for treatment of yaws caused by Treponema pertenue.^{111 137}

Yersinia Infections

Treatment of plague caused by Yersinia pestis.^{103 111 113 114 137 144 147} (See Plague under Uses.)

Treatment of GI infections caused by Yersinia enterocolitica† or Y. pseudotuberculosis†.^{110 p} These infections usually are self-limited, but IDSA, AAP, and others recommend anti-infectives for severe infections or when septicemia or other invasive disease occurs.^{109 110 p} Some suggest the role of oral anti-infectives in management of enterocolitis, pseudoappendicitis syndrome, or mesenteric adenitis caused by Yersinia needs further evaluation.¹⁰⁹

Prophylaxis in Sexual Assault Victims

Empiric anti-infective prophylaxis in sexual assault victims†; used in conjunction with a drug effective for gonorrhea (IM ceftriaxone) and a drug effective for bacterial vaginosis and trichomoniasis (oral metronidazole).^{107 108}

Doxycycline Calcium Dosage and Administration

Administration

Administer orally^{101 103 114 111} or by slow IV infusion.¹¹³ Also has been administered by intrapleural infusion.^{126 127 128 132 134 151 152}

Do not administer IM or sub-Q.¹¹³

IV route recommended only when oral therapy is not indicated or feasible; oral should replace IV as soon as possible.¹¹³ Prolonged IV administration may result in thrombophlebitis; avoid extravasation.¹¹³

Oral Administration

Administer capsules and tablets with adequate amounts of fluid to reduce the risk of esophageal irritation and ulceration.^{103 114 111 123} Probably should not be given at bedtime or to patients with esophageal obstruction or compression.^{123 b}

Administer with food or milk to minimize nausea and vomiting and if gastric irritation occurs;^{103 114 111} absorption not markedly influenced by simultaneous ingestion of food or milk.^{103 114 111 146 148 150}

When used for prevention of malaria, CDC recommends taking the drug in the evening (but not at bedtime), avoiding prolonged, direct exposure to the sun, and use of sunscreens that absorb long-wave UVA radiation to minimize the risk of photosensitivity.¹²³

Reconstitution

Reconstitute doxycycline monohydrate powder for oral suspension at the time of dispensing according to manufacturer’s directions to provide a suspension containing 25 mg/5 mL.¹¹¹

Doxycycline calcium oral suspension is administered as provided without further dilution and contains 50 mg/5 mL.¹¹¹

If necessary because the commercial powder for oral suspension and oral suspension are not available, doxycycline film-coated tablets can be ground and mixed with food or drinks.^{155 156} Ground doxycycline tablets are most palatable when mixed with chocolate pudding, regular or low-fat chocolate milk, simple syrup with sour apple flavor, apple juice with table sugar, or low-fat milk; the bitterness of the drug is not masked with grape or strawberry jellies or cherry yogurt.¹⁵⁵

IV Infusion

For solution and drug compatibility information, see Compatibility under Stability.

Reconstitution

Reconstitute vial containing 100 or 200 mg with 10 or 20 mL, respectively, of sterile water for injection or a compatible IV infusion solution (see Compatibility under Stability) to provide a solution containing 10 mg/mL.¹¹³

Dilution

Reconstituted solution must be further diluted prior to administration.¹¹³ Each 100 mg should be diluted in 100 mL to 1 L of compatible IV infusion solution (see Compatibility under Stability) to provide solutions containing approximately 0.1–1 mg/mL.¹¹³ Concentrations <0.1 mg/mL or >1 mg/mL are not recommended.¹¹³

Rate of Administration

Administer by slow IV infusion, usually over 1–4 hours (depending on the dose).¹¹³ The minimum recommended time to infuse 100 mg in a solution containing 0.5 mg/mL is 1 hour.¹¹³

Intrapleural Administration

Reconstitution and Dilution

Dilute 500 mg of doxycycline with 25–30 mL of 0.9% sodium chloride injection.^{126 127 128 132 134 151 152}

Intrapleural Administration Technique

Prior to intrapleural instillation of doxycycline solution, drain the pleural cavity by thoracentesis (needle aspiration) or via a thoracostomy tube by gravity or suction (i.e., closed chest tube drainage).^{127 128 130 131 133}

Efficacy of the procedure may be reduced if fluid drainage from the chest tube is >100 mL/24 hours when doxycycline is introduced into the pleural cavity.^{130 131 133}

Instill diluted doxycycline solution into the pleural space through a thoracostomy tube; clamp tube and subsequently remove the fluid.^{126 127 128 132 134 151 152}

Dosage

Available as doxycycline calcium,¹¹¹ doxycycline hyclate,^{103 111 113} and doxycycline monohydrate;^{111 114} dosage expressed in terms of doxycycline.^{103 111 113 114}

Pediatric Patients

General Pediatric Dosage

Oral

Children >8 years of age weighing ≤45 kg: 4.4 mg/kg in 2 divided doses on day 1 followed by 2.2 mg/kg daily in 1 or 2 divided doses.^{103 111 114} For severe infections, up to 4.4 mg/kg daily.^{103 111 114}

Children >8 years of age weighing >45 kg: 100 mg every 12 hours on day 1 followed by 100 mg daily in 1 or 2 divided doses.^{103 111 114} For more severe infections, 100 mg every 12 hours.^{103 111 114}

IV

Children >8 years of age weighing ≤45 kg: 4.4 mg/kg in 1 or 2 divided doses on day 1 followed by 2.2–4.4 mg/kg daily in 1 or 2 infusions.¹¹³

Children >8 years of age weighing >45 kg: 200 mg on day 1 in 1 or 2 infusions followed by 100–200 mg daily.¹¹³

Anthrax

Postexposure Prophylaxis Following Exposure in the Context of Biologic Warfare or Bioterrorism

Oral

Children ≤8 years of age† or weighing <45 kg: 2.2 mg/kg (up to 100 mg) twice daily given for ≥60 days.^{141 147 c} Because of concerns regarding long-term doxycycline use in infants and children, consider changing (after 10–14 days) to amoxicillin to complete the prophylaxis regimen if penicillin susceptibility is confirmed.^{102 104 141 147}

Children >8 years of age weighing ≥45 kg: 100 mg twice daily given for ≥60 days.^{104 141 147 c}

Optimum duration of postexposure prophylaxis after an inhalation exposure to B. anthracis spores is unclear,^{147 ff} but prolonged postexposure prophylaxis usually required.^{102 147} A duration of 60 days may be adequate for a low-dose exposure, but a duration >4 months may be necessary to reduce the risk following a high-dose exposure.^ff CDC and US Working Group on Civilian Biodefense recommend that postexposure prophylaxis following a confirmed exposure (including in laboratory workers with confirmed exposures to B. anthracis cultures) be continued for 60 days.^{102 147} The US Army Medical Research Institute of Infectious Diseases (USAMRIID) recommends that postexposure prophylaxis be continued for at least 60 days in individuals who are not fully immunized against anthrax and when anthrax vaccine is unavailable or cannot be used for postexposure vaccination.¹⁴⁷

Treatment of Inhalational, GI, or Oropharyngeal Anthrax

Oral

Children ≤8 years of age† or weighing <45 kg: 2.2 mg/kg twice daily (up to 200 mg daily).^{102 147 c}

Children >8 years of age weighing ≥45 kg: 100 mg twice daily.^{102 c} Some experts recommend an initial 200-mg dose, then 100 mg every 12 hours.¹⁴⁷

Initial parenteral regimen preferred; use oral regimen for initial treatment only when a parenteral regimen is not available (e.g., when there are supply or logistic problems because large numbers of individuals require treatment in a mass casualty setting).^{102 147} Continue for total duration of ≥60 days if inhalational anthrax occurred as the result of exposure to anthrax spores in the context of biologic warfare or bioterrorism.^{102 143 147} Because of concerns regarding long-term doxycycline use in infants and children, consider changing (after 10–14 days) to amoxicillin to complete the treatment regimen in children <8 years of age if penicillin susceptibility is confirmed.¹⁰⁵

IV, then Oral

Children ≤8 years of age† or weighing <45 kg: 2.2 mg/kg (up to 100 mg) twice daily.