Anthrax: implementation guidance for clinicians

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2
Contents
Contents .................................................................................................................................................. 3
Acknowledgements ................................................................................................................................ 4
Introduction ............................................................................................................................................ 5
Methods .................................................................................................................................................. 5
Clinical approach .................................................................................................................................... 7
Infection prevention and control (IPC) .................................................................................................. 8
Laboratory testing .................................................................................................................................. 8
Antibiotic treatment ............................................................................................................................... 9
Uncomplicated cutaneous anthrax ............................................................................................... 9
Systemic anthrax .......................................................................................................................... 10
Anthrax meningitis or meningoencephalitis ............................................................................... 11
Post-exposure prophylaxis................................................................................................................... 12
Images ................................................................................................................................................... 13
References ............................................................................................................................................ 17
Annex A: Anthrax summary poster ....................................................................................................... 18

3
Acknowledgements
The World Health Organization (WHO) gratefully acknowledges the contributions and collaborative
efforts of all those involved in this publication.

This publication was developed by the WHO Technical Team within the Health Emergencies
Programme: Jamie Rylance (Safe and Scalable Care Unit) and Nicolò Binello (Emerging Zoonoses
and High Impact Epidemics Unit) under the leadership of Janet Diaz (Safe and Scalable Care Unit).

WHO sincerely acknowledges the panel of external experts who contributed to this effort: Daniela
Garone (Médecins sans Frontières, Brussels, Belgium), John Frean (National Institute for
Communicable Diseases, Sandringham, South Africa), Cristina Galvan (Hospital Universitario de
Móstoles, Madrid, Spain), Richard Kojan (ALIMA, Paris, France), Ziad Memish (Alfaisal University,
Riyadh, Kingdom of Saudia Arabia), Alam Ahmed Nawsher (Institute of Epidemiology, Disease
Control & Research, Dhaka, Bangladesh), Priscilla Rupali (Christian Medical College, Vellore, India)
and James Joseph Sejvar (University of Pittsburgh, Pittsburgh, United States of America).

WHO extends its thanks to colleagues across WHO headquarters and regional offices: Mercedes
Bonet Semenas (WHO headquarters, Geneva, Switzerland), Samuel Chong (WHO regional office for
the Western Pacific region), Rashidatu Fouad (WHO regional office for Africa), Benedikt Huttner
(WHO headquarters, Geneva, Switzerland), Chiori Kodama (WHO regional office for the Eastern
Mediterranean), Madison Moon (WHO headquarters, Geneva, Switzerland), Lorenzo Pezzoli (WHO
headquarters, Geneva, Switzerland), Dina Pfeifer (WHO regional office for Europe), Angel Rodriguez
(Pan-American Health Organization, Washington DC, United States), Wilson Were (WHO
headquarters, Geneva, Switzerland), Pushpa Ranjan Wijesinghe (WHO regional office for South-
East Asia).

4
Introduction
Anthrax is a zoonosis caused by Bacillus anthracis, a Gram-positive, spore-forming bacterium.
Occasionally transmitted to humans, B. anthracis is considered to be predominantly a pathogen of
grazing herbivores, both livestock and wildlife. Transmission occurs via bacterial spores, which can
remain viable for long periods in soil, animal tissues, and animal-derived products. Within the host,
spores germinate into vegetative forms, producing toxins that contribute to severe, often life-
threatening illness.
In animals, infection generally results from ingestion of contaminated feed or water. Humans
acquire the disease accidentally through direct contact with infected animals or contaminated
animal products; person-to-person transmission is very rare. Specifically, the spores of B. anthracis
can enter the human body via four primary routes: transcutaneous inoculation (accounting for up
to 95% of cases), ingestion, inhalation, and direct injection – each associated with distinct clinical
syndromes (Table 1). Regardless of the portal of entry, infection has the potential to progress to
disseminated disease, including sepsis, meningitis or meningoencephalitis. The incubation period
usually ranges from 2 to 7 days, although longer durations may occur, particularly following
inhalational exposure.

This document was developed as a practical summary of the WHO guideline Anthrax in humans and
animals.2 In response to recent reported human cases in Africa and South-East Asia, and in Africa,
this field guide was developed and adapted from the guideline to provide clear and succinct
clinical advice tailored for resource-limited and emergency settings. Specifically, the field guide is
intended for frontline health care professionals who manage patients with suspected or confirmed
anthrax or individuals exposed to B. anthracis during an outbreak. The content focuses exclusively
on naturally occurring anthrax in humans. Intentional release or bioterrorism-related exposure is
addressed in other WHO guidance documents.1 Similarly, this document does not provide
guidance on the use of monoclonal antibodies (e.g. raxibacumab, obiltoxaximab) or anthrax
immunoglobin (derived from human plasma).

Methods
To support the recommendations with current data, antimicrobial resistance rates of B. anthracis
were reviewed using findings from a recent systematic review.3 Technical experts from relevant
departments at WHO headquarters and regional offices were consulted to ensure the document
reflects multidisciplinary expertise and aligns with current standards and practices.
A panel of external experts was established to review, validate and provide technical input into the
draft document. The group comprised a diverse group of individuals with relevant experience in
clinical practice and infectious diseases and was selected with careful consideration of gender and
geographical balance.
In accordance with WHO procedures for declarations of interests (DOIs), all members of the panel
were asked to declare in writing any competing interests (academic, financial or other) at the time
of the invitation to participate in the case definition development process. The standard WHO DOI
forms were completed, signed by each expert and sent electronically to the WHO Technical Team.
There were no conflicts of interest.

5
Table 1. Anthrax clinical syndromes

Syndrome Cutaneous anthrax Gastrointestinal anthrax Inhalational anthrax Injection-related anthrax Anthrax meningoencephalitis

Transmission Direct contact (via skin Ingestion of contaminated Inhalation of aerosolized Injection of contaminated Clinical syndrome of disseminated
abrasions or hair follicles) with undercooked meat. spores (e.g. industrial dusts). drugs (intravenous or disease, predominantly occurring
infected animals, blood and transcutaneous) secondary to another form of
other animal tissues, parts or anthrax (left).
products (e.g. hides, wool, hair,
bone), or contaminated soil. *

Symptoms and Itchy, painless papule, Gastrointestinal form Flu-like symptoms (e.g. fever, Skin blistering and necrosis Fever and signs of meningeal
signs becoming a larger vesicle or Nausea, vomiting, abdominal cough, myalgia), followed by with oedema at injection site. irritation (including neck stiffness),
blister, then evolving into a pain, sometimes associated severe respiratory distress Eschar less common than headache, altered mental status,
necrotic ulcer with a black, with diarrhoea. (dyspnea, hypoxemia) and cutaneous form. impaired consciousness, seizures,
depressed central crust Gastrointestinal haemorrhage shock. Fever, fatigue, nausea, and/or focal neurological deficits.
(eschar), see Figure 1Figure and/or ascites in severe cases. Imaging (chest X-ray): vomiting, and/or abdominal
2Figure 5. Oropharyngeal form mediastinal widening (due to pain in some cases.
Oedema and regional haemorrhagic mediastinitis)
Oedematous or necrotic
lymphadenopathy often and/or pleural effusion.
oropharyngeal lesions often
associated with the skin lesion. accompanied by sore throat,
Predominant localization on dysphagia, neck oedema, and
exposed areas (e.g. hands, cervical lymphadenopathy.
forearms, neck, face).
Fever, headache, and/or
malaise in a minority of cases.

Specimen for Intact vesicle or blister fluid, Peripheral blood and Peripheral blood and Skin lesion fluid. Cerebrospinal fluid (often bloody;
diagnosis ulcer (base), and/or eschar specimens from affected site specimens from affected site high protein and low glucose
(below edges), see Figure (e.g. ascitic fluid, (e.g. pleural fluid). concentration).
2, Figure 3, Figure 4 oropharyngeal lesion).

Treatment One or two antibiotics Two antibiotics and antitoxin.‡ Two antibiotics and antitoxin.‡ Two antibiotics, surgical Two antibiotics with adequate
(depending on clinical debridement and antitoxin.‡ blood-brain barrier penetration
presentation). and antitoxin. ‡

Prognosis With early treatment, good Variable prognosis, depending Very severe illness with very Severe illness with high Very severe illness with very high
prognosis. on organ involvement. high mortality mortality. mortality.

* Direct person-to-person transmission is very rare and only occurs from skin lesions of an infected individual.
‡
Monoclonal antibodies (e.g. raxibacumab, obiltoxaximab) or anthrax immunoglobin (derived from human plasma) are outside the scope of this guidance.
Clinical approach
1. Suspect anthrax in individuals with a consistent clinical syndrome and relevant history of
exposure.
2. Maintain safety and implement adequate infection prevention and control (IPC) measures
(below).
3. Assess and treat based on the Airway, Breathing, Circulation (“ABC”) approach, and triage
according to standard practice.
4. Ascertain the potential source of infection, and consider occupational exposure as an
important risk factor (to infected animals, their blood or other parts or products).
5. Identify the most likely clinical syndrome and check for manifestations of disseminated
disease, including sepsis, meningitis or meningoencephalitis. Consider differentials, including
those in Table 2.
6. Where possible, confirm the microbiological diagnosis by obtaining and testing appropriate
specimens from affected sites or peripheral blood according to the clinical presentation.
7. Initiate empiric antibiotic treatment as soon as possible and adjust regimen based on
antimicrobial susceptibility testing results (where available and feasible).
8. Consider the need for adjuvant antitoxin, provide monitored supportive care and ensure early
treatment of complications (e.g. septic shock).
9. Notify the relevant public health authorities according to national guidelines.

Table 2. Differential diagnosis of anthrax.

Diseases which may present with syndromes similar to anthrax

Cutaneous anthrax Focal skin infections (e.g. Cutaneous diphtheria

(suggested particularly by furuncle, erysipelas) Contagious ecthyma
ulceration, eschar and/or oedema) Ecthyma gangrenosum Spider bites
Rickettsial diseases (e.g. scrub Vasculitis
typhus, spotted rickettsial fevers)
Tularaemia (ulceroglandular
form)
Rat bite fever

Gastrointestinal anthrax Bacterial food poisoning Acute pharyngotonsillitis

Acute diarrheal diseases Oropharyngeal abscess
Acute abdomen of any cause Respiratory diphtheria
(oropharyngeal lesions)

Inhalation anthrax Severe acute respiratory illness of any cause

Anthrax meningoencephalitis Acute or subacute meningitis or meningoencephalitis of any cause

Cerebrovascular accident
Infection prevention and control (IPC)
• Standard precautions with risk assessment for appropriate personal protective equipment
(PPE) should be used when caring for all patients with any type of suspected or confirmed
anthrax.4
▪ Contact precautions are additionally required while a patient has any skin lesion
discharging fluid, pus, or blood.4
▪ Perform a risk assessment with respect to isolation: place patient in a single
room / isolation if there is a cutaneous draining lesion.
▪ Any PPE used when caring for a patient with a skin lesion should be disposed as infectious
waste.
• Any cloths used to clean discharge from a skin lesion in the patient care environment, and
all linens, used bandaging, masks, and dressings from skin lesions should be disposed as
infectious waste.5
• Hand washing must always be performed with soap and water immediately after a patient care
interaction. Alcohol-based handrub or 0.05% chlorine solution sanitizers should not be used
due to their lack of effectiveness against spores.6

Laboratory testing
• Specimens should be collected from appropriate clinical sites based on the presentation,
including skin lesions (vesicular or blister fluid, swab from ulcer base, tissue underneath eschar
edges), peripheral blood, ascitic fluid, oropharyngeal lesions, pleural fluid, cerebrospinal fluid,
and/or any other affected site. Specimens should ideally be taken before starting treatment,
but do not delay antibiotic administration.
• The diagnosis of anthrax is confirmed by the growth of B. anthracis on culture of a clinical
specimen. A positive molecular test (PCR) on a clinical specimen also supports the diagnosis.
• In resource-limited settings, a rapid diagnosis can be established by direct microscopy, which
can demonstrate the presence of Gram-positive bacilli with a characteristic boxcar-shaped
morphology (see Figure 6).

8
Antibiotic treatment
Single antibiotic therapy is recommended for uncomplicated cutaneous lesions. For more severe
disease, combination treatment with at least two highly bioavailable agents is required.
Carbapenems are not included in this guide as first-line treatment options in accordance with the
AWaRe (Access, Watch, Reserve) antibiotic classification framework and due to limitations in
availability and accessibility in resource-limited settings.

Uncomplicated cutaneous anthrax

Oral monotherapy is recommended for cases of uncomplicated cutaneous anthrax.
In areas where penicillin susceptibility among B. anthracis isolates is not known, oral doxycycline
or ciprofloxacin should be used (Table 3). In outbreaks where penicillin susceptibility is known, oral
amoxicillin or penicillin V could be used instead. Empiric therapy for pregnant and lactating
women is the same as for nonpregnant adults.
Where feasible, antibiotic therapy should be reviewed and adjusted based on antibiotic
susceptibility testing results as soon as they are available.
Overall, treatment duration should be extended for at least 7 days or until the patient is clinically
stable, whichever is longer. Clear clinical improvement should always be documented prior to
therapy discontinuation.

Table 3. Empiric antibiotic therapy for uncomplicated cutaneous anthrax

Empiric antibiotic therapy Adults Children

In areas or outbreaks with unknown penicillin susceptibility, use oral doxycycline or ciprofloxacin

Doxycycline 100 mg q12h PO 2 mg/kg q12h PO (max 100 mg q12h)

Ciprofloxacin 500 mg q12h PO 15 mg/kg q12h PO (max 500 mg q12h)

In outbreaks with known penicillin susceptibility, consider oral amoxicillin or penicillin V

Amoxycillin 1 g q8h PO 25 mg/kg q8h PO (max 1 g q8h)

Penicillin V (phenoxymethyl-penicillin) 500 mg q6h PO 15 mg/kg q6h PO (max 500 mg q6h)

IV: intravenous administration; PO = oral administration

9
Systemic anthrax
Systemic anthrax is defined as any of the following: 1) Cutaneous anthrax with systemic illness,
sepsis and/or extensive oedema (hereafter referred to as severe cutaneous anthrax); 2)
Gastrointestinal anthrax; 3) Inhalation anthrax; 4) Injection-related anthrax; 5) B. anthracis
bacteraemia.
In the presence of any of these scenarios, empiric combination therapy with two antibiotics is
recommended. The first agent should be selected from ciprofloxacin, ampicillin, or penicillin G,
based on local penicillin susceptibility patterns (Table 4). The second agent should be chosen
according to the clinical presentation: intravenous clindamycin for inhalation or injection-related
anthrax, oral clindamycin for severe cutaneous anthrax, or intravenous gentamicin for
gastrointestinal anthrax.
Where feasible, antibiotic therapy should be reviewed and adjusted based on antibiotic
susceptibility testing results as soon as they are available.
Overall, treatment duration should be extended for at least 14 days or until the patient is clinically
stable, whichever is longer. For severe cutaneous anthrax, when symptoms cease and temperature
normalizes, monotherapy can be considered. Clear clinical improvement should always be
documented prior to therapy discontinuation.

Table 4. Empiric antibiotic therapy for systemic anthrax

Adults Children

Choose one of the following agents: ciprofloxacin, ampicillin IV or penicillin G

In areas or outbreaks with unknown penicillin susceptibility

Ciprofloxacin 400 mg q12h IV 10 mg/kg q12h IV (max 400 mg q12h)

750mg q12h PO 15 mg/kg q12h PO (max 500 mg q12h)

In outbreaks with known penicillin susceptibility

Ampicillin 2 g q6h IV 50 mg/kg q6h IV (max 2 g q6h)

Penicillin G (benzylpenicillin) 4 MU q4h IV 67 000 U/kg q4h IV (max 4 MU q4h)

Add clindamycin (IV for inhalation or injection-related anthrax or PO/IV for severe cutaneous anthrax) or
gentamycin (gastrointestinal anthrax)

Clindamycin 900 mg q8h IV 13.3 mg q8h IV (max 900 mg q8h)

600 mg q8h PO 10 mg/kg q8h (max 600 mg q8h)

Gentamicin 3 mg/kg q24h IV 3 mg/kg q24h IV

IV: intravenous administration; PO = oral administration

10
Anthrax meningitis or meningoencephalitis
In the presence of anthrax meningitis or meningoencephalitis, empiric combination therapy with
two antibiotics with adequate central nervous system penetration is recommended. Intravenous
administration should be preferred.7 The first agent should be selected from ciprofloxacin,
ampicillin, or penicillin G, based on local penicillin susceptibility patterns (Table 5). The second
agent of choice is rifampicin or vancomycin.
Where feasible, antibiotic therapy should be reviewed and adjusted based on antibiotic
susceptibility testing results as soon as they are available.
Overall, treatment duration should be extended for at least 21 days or until the patient is clinically
stable, whichever is longer. Clear clinical improvement should always be documented prior to
therapy discontinuation.

Table 5. Empiric antibiotic therapy for anthrax meningitis or meningoencephalitis

Adults Children

Choose one of the following agents: ciprofloxacin, ampicillin IV or penicillin G

In areas or outbreaks with unknown penicillin susceptibility

Ciprofloxacin 400 mg q12h IV 10 mg/kg q12h IV (max 400 mg q12h)

750mg q12h PO 15 mg/kg q12h PO (max 500 mg q12h)

In areas with known penicillin susceptibility

Ampicillin 2 g q6h IV 50 mg/kg q6h IV (max 2 g q6h)

Penicillin G (benzylpenicillin) 4 MU q4h IV 67 000 U/kg q4h IV (max 4 MU q4h)

Add rifampicin or vancomycin

Rifampicin 600 mg q12h IV or PO 10 mg/kg q12h IV or PO (max

300 mg q12h)

Vancomycin 1 g q12h IV 20 mg/kg q8h IV

IV: intravenous administration; PO = oral administration

11
Post-exposure prophylaxis
Individuals with documented or suspected aerosolized exposure to B. anthracis should receive
vaccination and a protracted course of oral antibiotic prophylaxis (42 to 60 days).
Individuals with documented or suspected gastrointestinal exposure may receive a short course of
oral antibiotic prophylaxis (10 days), especially in the presence of substantial exposure
(e.g., consumption of meat from an undercooked contaminated carcass).
Post-exposure should be started as soon as possible and ideally within 48 hours. The choice of
antibiotic regimen can be chosen between doxycycline and ciprofloxacin (Table 6). Notably,
protracted courses of doxycycline are contraindicated in children aged less than 8 years due to the
risk of bone deposition and tooth staining.

Table 6. Post-exposure prophylaxis for anthrax (only for inhalation and gastrointestinal
exposures)

Adults Children

Choose one of the following agents: doxycycline or ciprofloxacin

Doxycycline 100 mg q12h PO 2 mg/kg q12h PO (max 100 mg q12h)

Ciprofloxacin 500 mg q12h PO 15 mg/kg q12h PO (max 500 mg q12h)

PO = oral administration

12
Images
The following may be useful in identifying anthrax disease, and are included for reference.

Figure 1 Black coloured lesion on the forearm of a patient with cutaneous anthrax.

https://phil.cdc.gov/Details.aspx?pid=2033
Photo credit: CDC/ Dr James H. Steele

Figure 2 Black coloured lesion (eschar) with marginal erythema on the neck of a patient with
cutaneous anthrax.

https://phil.cdc.gov/Details.aspx?pid=1934
Photo credit: CDC

13
Figure 3 Clusters of boils / blistering on the hand and wrist of a patient with cutaneous
anthrax.

https://phil.cdc.gov/Details.aspx?pid=20869
Photo credit: CDC/ O.T. Chambers

Figure 4 Cutaneous anthrax lesion of the right hand dorsal surface.

https://phil.cdc.gov/Details.aspx?pid=20334
Photo credit: CDC/ F. Marc LaForce, M.D.

14
Figure 5 Series of 3 images from the same patient representing cutaneous anthrax lesions at
day 5 (A), day 7 (B), and day 12 (C) of development.

A
(day 5)

https://phil.cdc.gov/Details.aspx?pid=1800
Photo credit: CDC

B
(day 7)

https://phil.cdc.gov/Details.aspx?pid=1801
Photo credit: CDC

C
(day 12)

https://phil.cdc.gov/Details.aspx?pid=1799
Photo credit: CDC/ Arthur E. Kaye

15
Figure 6 Chains of Gram-positive, rod-shaped, Bacillus anthracis bacteria
(“boxcar” appearance).

https://phil.cdc.gov/Details.aspx?pid=2105
Photo credit: CDC/ Dr. James Feeley

16
References
1. World Health Organisation. Public health response to biological and chemical weapons: WHO
guidance: World Health Organization; 2004.
https://iris.who.int/bitstream/handle/10665/42611/9241546158.pdf

2. World Health Organization. Anthrax in humans and animals: World Health Organization; 2008.
https://iris.who.int/bitstream/handle/10665/97503/9789241547536_eng.pdf

3. Maxson T, Kongphet-Tran T, Mongkolrattanothai T, et al. Systematic Review of In Vitro

Antimicrobial Susceptibility Testing for Bacillus anthracis, 1947-2019. Clinical infectious
diseases : an official publication of the Infectious Diseases Society of America 2022; 75(Suppl
3): S373-s8.

4. World Health Organisation. Transmission-based precautions for the prevention and control of
infections: aide memoire. 2022. https://iris.who.int/bitstream/handle/10665/356853/WHO-
UHL-IHS-IPC-2022.2-eng.pdf

5. World Health Organisation. Safe management of wastes from health-care activities: World
Health Organization; 2014.
https://iris.who.int/bitstream/handle/10665/85349/9789241548564_eng.pdf

6. World Health Organization. WHO guidelines on hand hygiene in health care: World Health
Organization, 2009.
https://iris.who.int/bitstream/handle/10665/44102/9789241597906_eng.pdf

7. World Health Organization. WHO guidelines on meningitis diagnosis, treatment and care.
2025. https://iris.who.int/bitstream/handle/10665/381006/9789240108042-eng.pdf

17
Annex A: Anthrax summary poster

18
Anthrax: a guide for treating patients
Cutaneous anthrax (95% of cases): most commonly on
exposed areas: hands, forearms, neck, face.
Infection transmission Direct contact with infected
animals or animal Itchy swelling +/- blistering
Zoonotic source (herbivores) products or infected becoming a painless necrotic
of Bacillus anthracis bacteria soils, through cuts or ulcer with depressed central
abrasions on the skin crust (eschar)

Surrounding oedema
Ingestion of
contaminated Regional
undercooked lymphadenopathy
food.

Gastrointestinal anthrax: Nausea, vomiting, abdominal pain +/-

Inhalation of aerosolized bacterial spores during industrial
exposure or bioterrorism is much less common. Presents as diarrhea. Gastrointestinal hemorrhage and ascites in severe cases.
flu-like illness (fever, myalgia, cough), followed by severe Oropharyngeal form less common but more severe (sore throat,
respiratory distress (dyspnea, hypoxemia). oedema, dysphagia, cervical lymphadenopathy)

Maintain safety General approach to the patient

Standard precautions with risk 1. Maintain safety (Infection Prevention and Control)
assessment for all patient contacts ? Dissemination
2. Assess and treat Airway, Breathing, Circulation, Disability
! meningitis ! sepsis
Hand washing: soap + water (ABCD) and triage according to standard practice
(alcohol-based hand rub and
0.05% chlorine solution are 3. Confirm the type of disease, and check for clinical
not effective against spores) signs of disseminated disease
(including sepsis and meningitis)
4. Take sample for From:
Apply contact precautions microbiological Vesicle/blister fluid, ulcer, PCR and/or culture with
and cover skin lesions which confirmation eschar (below edges) antibiotic sensitivity testing
ooze or discharge pus, blood, Blood Direct microscopy
or fluid Site-specific specimen Gram-positive bacilli with
(e.g. ascitic fluid, CSF) “boxcar-shaped” morphology
Dispose as infectious waste all used CSF: High opening pressure
5. Initiate empiric antibiotic immediately  white blood cell count (> 100/mm3)
bandaging and dressings from skin
 glucose (< 2.2 mmol/L [40 mg/dL]
lesions and cloths used for 6. Provide monitored supportive care and initiate or <40% blood levels)
cleaning environmental spillage early treatment for complications e.g. sepsis  protein (> 45mg/dL)

* Ensure clear clinical improvement

Antibiotic regimens before stopping antibiotics.

Uncomplicated cutaneous Systemic anthrax Anthrax meningitis

one antibiotic orally combined antibiotic therapy combined antibiotic therapy
for at least 7 days* for at least 14 days* for at least 21 days*
Medication Adults Children Medication Adults Children Medication Adults Children
doxycycline 100 mg q12h PO 2 mg/kg q12h PO ciprofloxacin‡ 400 mg q12h 10 mg/kg q12h IV ciprofloxacin‡ 400 mg q12h IV 10 mg/kg q12h IV
ONE max 100 mg / dose ONE IV max 400 mg / dose ONE max 400 mg / dose
OF ciprofloxacin‡ 500 mg q12h PO 15 mg/kg q12h PO OF 750 mg q12h PO 15 mg/kg q12h IV OF 750mg q12h PO 15 mg/kg q12h PO
max 500 mg / dose max 500 mg / dose
max 500 mg / dose
Only in outbreaks with known bacterial susceptibility, Only in outbreaks with known bacterial susceptibility,
Only in outbreaks with known bacterial susceptibility,
consider using intravenous penicillin. consider using intravenous penicillin.
consider using an oral penicillin.
amoxycillin † 1 g q8h PO 25 mg/kg q8h PO ampicillin † 2 g q6h IV 50 mg/kg q6h IV ampicillin † 2 g q6h IV 50 mg/kg q6h IV
max 2 g / dose max 2 g / dose
maximum 1g / dose
penicillin V † 500 mg q6h PO 15 mg/kg q6h PO penicillin G † 4 MU q4h IV 67 000 U/kg q4h IV penicillin G † 4 MU q4h IV 67 000 U/kg q4h IV
benzylpenicillin max 4MU / dose benzylpenicillin max 4 MU / dose
phenoxymethyl maximum 500 mg /
penicillin dose
clindamycin 900 mg q8h 13.3 mg q8h IV AND rifampicin 600 mg q12h 10 mg/kg q12h
AND (inhalation) IV max 900 mg / dose ONE IV or PO IV or PO
* adjust therapy based on sensitivity testing. ONE 600 mg q8h 10 mg q8h PO OF max 300 mg/dose
(cutaneous)
† only in outbreaks with known penicillin susceptibility OF PO max 600 mg / dose
vancomycin 1 g q12h IV 20 mg/kg q8h IV
‡ ciprofloxacin may be used for anthrax treatment in
pregnant women and children. gentamicin 3 mg / kg q24h 3 mg/kg q24h IV
(gastrointestinal) IV
Anthrax meningitis is a clinical syndrome of
disseminated disease, predominantly occurring
Post-exposure prophylaxis Systemic anthrax is defined as any of: secondary to another form of anthrax.
For cutaneous exposure: none 1) Cutaneous anthrax with systemic illness, sepsis It presents with fever and signs of meningeal
For consumption of meat known to be contaminated, and/or extensive oedema;
consider 10 days of oral ciprofloxacin or doxycycline.
irritation (e.g. neck stiffness), headache, altered
2) Gastrointestinal anthrax; mental status, impaired consciousness, seizures
For aerosolised anthrax spores, give ciprofloxacin or
doxycycline for 60 days. In these cases, avoid doxycycline
3) Inhalation anthrax; and/or focal neurological deficits.
in children and pregnant women. 4) Injection-related anthrax;
5) Bacillus anthracis bacteremia. Version 1.0
August 2025

Standard precautions for the prevention and control of infections. WHO 2022. https://iris.who.int/bitstream/handle/10665/356855/WHO-UHL-IHS-IPC-2022.1-eng.pdf
References Basic Emergency Care. WHO 2018. https://iris.who.int/bitstream/handle/10665/275635/9789241513081-eng.pdf
Guidelines for the Surveillance and Control of Anthrax in Humans and Animals. WHO 2008. https://iris.who.int/bitstream/handle/10665/59516/WHO_EMC_ZDI_98.6.pdf