eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease
Plague: Treatment & Medication
Updated: Nov 24, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- Initial evaluation of patients with plague may begin on an emergent outpatient basis. However, hospitalization is generally required to initiate therapy. Isolation of hospitalized patients varies on type of disease. Standard precautions are indicated for cases of bubonic plague. Droplet precautions are indicated for patients with pneumonic plague and for all patients until pneumonia has been excluded and treatment initiated. In patients with pneumonic plague, isolation should be continued until 48 hours of appropriate antibiotic treatment has been administered.
- Provide supportive medical care as necessary to stabilize and maintain the patient's hemodynamic and respiratory status.
Surgical Care
- Incision and drainage of buboes may be indicated. Material drained from the buboes is infectious until patient is appropriately treated.
Consultations
- Infectious disease specialist
- Intensive care specialist, if hemodynamic or respiratory instability is present
Diet
- No special diet is required.
Activity
- No specific activity restrictions are required.
Medication
Antibiotic agents
Few antibiotics are effective against Y pestis. Each agent is associated with toxicity, but, given the high mortality rate of the disease if untreated, treatment is preferable. New multidrug-resistant strains of Y pestis have been reported in Madagascar.
Streptomycin
Aminoglycoside antibiotic is considered the drug of choice. Disadvantages include an intramuscular route of administration, resistant strains, and high toxicity.
Adult
2 g IM divided bid
Pediatric
15 mg/kg IM q12h
Nephrotoxicity may be increased with aminoglycosides, cephalosporins, penicillins, amphotericin B, and loop diuretics
Documented hypersensitivity; non–dialysis-dependent renal insufficiency
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Some authorities recommend changing from streptomycin to another antibiotic (eg, tetracycline, gentamicin) after 3-5 d to decrease risk of drug-related adverse effects; renal toxicity and ototoxicity; narrow therapeutic index, monitor serum levels; caution with myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission
Gentamicin (Garamycin)
Aminoglycoside used as an alternative to streptomycin and is equally effective.
Adult
Loading dose: 2 mg/kg IV q8h
Maintenance dose: 1-1.5 mg/kg IV q8h
Pediatric
<5 years: 2.5 mg/kg/dose IV q8h
>5 years: 1.5-2.5 mg/kg/dose IV q8h or 6-7.5 mg/kg/d divided q8h, not to exceed 300 mg/d
Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents thus prolonged respiratory depression may occur
Coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)
Documented hypersensitivity; nondialysis-dependent renal insufficiency
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (patient not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment; monitor serum levels
Tetracycline (Sumycin)
Frequently used for prophylaxis as well as treatment. Is usually substituted for streptomycin after a few days of therapy to minimize toxicity. Inhibits bacterial protein synthesis by binding with 30S and, possibly, 50S ribosomal subunits.
Adult
250-500 mg PO q6h
Pediatric
<8 years: Not recommended
>8 years: 25-50 mg/kg/d PO divided qid
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of PO contraceptives causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Doxycycline (Doxy, Vibramycin)
Used as an alternative for tetracycline. Inhibits protein synthesis and thus bacterial growth by binding to 30S and, possibly, 50S ribosomal subunits.
Adult
100 mg IV q12h
Pediatric
<8 years: Not recommended
>8 years: 2-4 mg/kg/d IV divided q12h, not to exceed 200 mg/d
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of PO contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 years) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Chloramphenicol (Chloromycetin)
DOC for plague meningitis. The PO form is not available in the United States, but the IV formulation can be obtained. Binds to 50S bacterial-ribosomal subunits and inhibits bacterial growth by inhibiting protein synthesis.
Adult
50 mg/kg/d IV divided q6h, not to exceed 4 g/d
Pediatric
50-100 mg/kg/d IV divided q6h
Concurrently with barbiturates, chloramphenicol serum levels may decrease while barbiturate levels may increase, causing toxicity; manifestations of hypoglycemia may occur with sulfonylureas; rifampin may reduce serum chloramphenicol levels, presumably through hepatic enzyme induction; may increase effects of anticoagulants; may increase serum hydantoin levels, possibly resulting in toxicity; chloramphenicol levels may be increased or decreased
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Avoid in pregnancy at term or during labor because of potential toxic effects on fetus (gray baby syndrome); serious and fatal blood dyscrasias (aplastic anemia, hypoplastic anemia, thrombocytopenia, granulocytopenia) can occur; evaluate baseline and perform periodic blood studies approximately every 2 d while in therapy; discontinue on appearance of reticulocytopenia, leukopenia, thrombocytopenia, anemia, or findings attributable to chloramphenicol; adjust dose in liver or kidney dysfunction
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Further Reading
Keywords
plague, black death, black plague, bubonic plague, septicemic plague, pneumonic plague, ambulant plague, Yersinia pestis, bioterrorist agent, bioterrorism, bacteremia, pneumonia, septicemia, meningitis, polyarthritis, lung abscess, pharyngitis
