Prophylaxis and Treatment of Anthrax in Pregnant Women

Abstract

Objective To review the safety and pharmacokinetics of antibiotics recommended for anthrax post-exposure prophylaxis and treatment in pregnant women. Data Sources Articles were identified in the PUBMED database from inception through December 2012 by searching the keywords ([“pregnancy]” and [generic antibiotic name]). Additionally, hand searches of references from REPROTOX, TERIS, review articles and Briggs’ Drugs in Pregnancy and Lactation were performed. Methods of Study Selection Articles included in the review contain primary data related to the safety and pharmacokinetics among pregnant women of five antibiotics recommended for anthrax post-exposure prophylaxis and treatment (ciprofloxacin, levofloxacin, moxifloxacin, doxycycline, amoxicillin), and of nine additional antibiotics recommended as part of the treatment regimen (penicillin, ampicillin, linezolid, clindamycin, meropenem, doripenem, rifampin, chloramphenicol, or vancomycin). Tabulation, Integration and Results The PUBMED search identified 3850 articles for review. Reference hand searching yielded nine additional articles. In total, 112 articles met the inclusion criteria. Conclusions Overall, safety and pharmacokinetic information is limited for these antibiotics. Although small increases in risks for certain anomalies have been observed with some antibiotics recommended for prophylaxis and treatment of anthrax, the absolute risk of these antibiotics appears low. Given the high morbidity and mortality associated with anthrax, antibiotics should be dosed appropriately to ensure that antibiotic levels can be achieved and sustained. Dosing adjustments may be necessary for the beta lactam antibiotics and the fluoroquinolones to achieve therapeutic levels in pregnant women. Data indicate that the beta lactam antibiotics, the fluoroquinolones, and, to a lesser extent, clindamycin enter the fetal compartment, an important consideration in the treatment of anthrax, as these antibiotics may provide additional fetal benefit in the 2nd and 3rd trimesters of pregnancy. Additional well designed safety and pharmacokinetic studies are needed.

Diagnosis and Management of Tickborne Rickettsial Diseases: Rocky Mountain Spotted Fever and Other Spotted Fever Group Rickettsioses, Ehrlichioses, and Anaplasmosis — United States

“…A recent systematic review reported no evidence of teratogenicity associated with doxycycline use during pregnancy; however, limited data and a lack of controlled studies were limitations (216). No reports of maternal hepatic toxicity associated with doxycycline use have been published (215)(216)(217). Rarely, fatty liver of pregnancy has occurred in patients who received high-dose intravenous tetracycline (215,218); however, the dosages administered in these cases exceeded what is recommended for the treatment of tickborne rickettsial disease.…”

“…Doxycycline has been used successfully to treat tickborne rickettsial diseases in several pregnant women without adverse effects to the mother; however, follow-up to address adverse effects to the fetus was limited (142,197). Chloramphenicol is a potential alternative treatment for RMSF during pregnancy; however, care must be used when administering the drug late during the third trimester of pregnancy because of the theoretical risk for gray baby syndrome (193,217).…”

Special Considerations for Prophylaxis for and Treatment of Anthrax in Pregnant and Postpartum Women

“…In preparation for the meeting, 2 systematic reviews were conducted; the first summarized the worldwide experience of 20 cases of anthrax in P/PP/L women ( 4 ), and the second evaluated the safety and pharmacokinetics of 14 antibiotics recommended for anthrax prophylaxis and treatment ( 5 ). Before the meeting, the CDC convened 5 workgroups: vaccines, antibiotic prophylaxis and treatment, other treatments and clinical considerations, health care planning, and communications.…”

Transfer of vaginal chloramphenicol to circulating blood in pregnant women and its relationship with their maternal background and neonatal health

“…In reproduction test in rats, 300 mg/kg of chloramphenicol for 4 weeks was found to potentially cause miscarriage and premature birth [21]. Chloramphenicol is recognized as Class C in the United States FDA pregnancy category [22]. In the present study, pregnant women with gestational ages ranging from 16 to 36 weeks were exposed to by 100 mg of transvaginal chloramphenicol per day for 7 days.…”

“…Second, this study did not determine the concentration of chloramphenicol in the umbilical cord blood. Maternal chloramphenicol readily crosses the placenta [22]. However, the maternal plasma concentration of chloramphenicol after trans-vaginal treatment was one one-thousandth that of the therapeutic concentration in oral and intravenous treatments.…”