eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease
Tularemia: Treatment & Medication
Updated: Aug 9, 2007
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- Consider the various forms of tularemia in many of the most common emergency department and primary care cases, including cases of conjunctivitis, lymphadenitis, pharyngitis, or pneumonia.
- Start initial supportive care in any unstable patient.
- If tularemia is suspected, obtain serum titers and start antibiotics.
- Postexposure prophylaxis is recommended within 24 hours of airborne exposure using either ciprofloxacin or doxycycline for 2 weeks. It is unlikely that aerosolized exposure to F tularensis is identified within 24 hours, so standard treatment is recommended within 14 days of exposure.
Surgical Care
Drain fluctuant lymph nodes and empyemas.
Consultations
- Consider consulting an infectious diseases specialist for recommendations on commencing antibiotic coverage and any questions involving specific diagnostic studies.
- Consider consultation with a pulmonologist for patients with pulmonary involvement.
- Contact local or federal law enforcement agencies and the Centers for Disease Control and Prevention if multiple cases occur, which would suggest biological or terrorist attack.
Medication
The goal of therapy is eradication of F tularensis with antibiotics.
Antibiotic agents
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens for the clinical presentation. Streptomycin is considered the antimicrobial of choice in treating tularemia. Current research reveals increasing evidence supporting the use of other medications. Although aminoglycosides are currently considered the DOCs and though tetracyclines are acceptable alternatives, increasing research supports the use of fluoroquinolones in the treatment of tularemia. Other antibiotics, such as chloramphenicol, are bacteriostatic and have been associated with a high relapse rate following discontinuation of therapy. Fluoroquinolones may be considered an alternative antibiotic for patients who are unable to tolerate aminoglycosides. This option is of great importance because many practitioners have turned to using the newer fluoroquinolones as their monotherapy of choice in treating community-acquired pneumonia.
Streptomycin sulfate
Considered DOC for tularemia. Aminoglycoside antibiotic recommended when less potentially hazardous therapeutic agents ineffective or contraindicated.
Adult
30-40 mg/kg/d IM divided q12h for 3 d, followed by half dose (15-20 mg/kg/d IM) divided q12h for 7-14 d
Alternate regimen is 7.5-10 mg/kg IM q12h for 7-14 d; not to exceed 2 g/d
Pediatric
30-40 mg/kg/d IM divided q12h for 7-14 d or until patient afebrile; not to exceed 0.75-1 g/d
Nephrotoxic potential may be increased with coadministration of other aminoglycosides, penicillins, cephalosporins, amphotericin b, or 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
Narrow therapeutic index; not intended for long-term therapy; caution in renal failure (not managed with dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; dosage adjustment prn in renal impairment
Gentamicin (Garamycin)
Aminoglycoside used as alternative to streptomycin. Decreased experience with this agent. Dosing regimens numerous and adjusted for CrCl and changes in volume of distribution. May be administered IV or IM. Follow each regimen with a trough level drawn 0.5 h before fourth dose; may draw peak level 0.5 h after 30-min infusion.
Adult
3-5 mg/kg/d IV/IM divided q6-8h
Alternative: 5 mg/kg IV qd
Pediatric
<5 years with normal renal function: 2.5 mg/kg/dose IV/IM q8h
>5 years: 1.5-2.5 mg/kg/dose IV/IM q8h or 6-7.5 mg/kg/d divided q8h; not to exceed 300 mg/d with adjustments for renal function prn
Coadministration with other aminoglycosides, cephalosporins, penicillins, or 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 various degrees may occur (monitor regularly)
Documented hypersensitivity; non–dialysis-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 (not managed with dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; dosage adjustment prn in renal impairment
Tetracycline (Sumycin)
Second DOC. Treatment <2 wk increases risk of relapse. Only potential advantage is ability to cover other coexisting tick-borne pathogens. Should be considered when patients unable to tolerate streptomycin or when renal function is concern. Inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Adult
500 mg PO bid or 250 mg PO qid for 7-14 d
Pediatric
<8 years: Not recommended
>8 years: 25-50 mg/kg/d PO divided qid for 7-14 d
Antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate can decrease tetracycline bioavailability; tetracycline can increase hypoprothrombinemic effects of anticoagulants; monitor PT in patients taking both concurrently; coadministration of tetracycline can decrease pharmacologic 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
Prolonged exposure to sunlight or tanning equipment can cause a photosensitivity reaction; use lower than usual doses in renal impairment; use of tetracycline during tooth development (last one half of pregnancy through 8 y) can cause permanent discoloration of teeth; never administer outdated tetracycline (degradation products of tetracycline highly nephrotoxic and can cause Fanconi-like syndrome)
Chloramphenicol (Chloromycetin)
Insufficient data on use in tularemia. Distant third and possibly fourth choice given growing evidence supporting use of fluoroquinolones. Binds to 50S bacterial-ribosomal subunits and interferes with or inhibits protein synthesis. Effective against gram-negative and gram-positive bacteria.
Adult
50-100 mg/kg/d PO/IV divided q6h; not to exceed 4 g/d
Pediatric
50-75 mg/kg/d PO/IV divided q6h
Taken concurrently with barbiturates, may decrease serum levels and barbiturate clearance, increasing levels or toxicity; clinical manifestations of hypoglycemia may occur when taken concurrently with sulfonylureas; coadministration with rifampin may reduce serum levels, presumably by hepatic enzyme induction; when taken concurrently, may increase effect of anticoagulants; may increase serum hydantoin levels, possibly resulting in toxicity
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus
Precautions
Must not be used to treat trivial infections other than ones indicated or as prophylaxis for bacterial infections; serious and fatal blood dyscrasias (eg, aplastic anemia, hypoplastic anemia, thrombocytopenia, granulocytopenia) can occur; order baseline and periodic blood studies approximately q2d during therapy; discontinue on appearance of reticulocytopenia, leukopenia, thrombocytopenia, anemia, or any other attributable findings; excessive blood levels may result from use of recommended dose in impaired liver or kidney function (decrease dose); caution during pregnancy at term or during labor because of potential toxic effects on fetus (gray syndrome)
Levofloxacin (Levaquin)
May be useful to treat tularemia.
Adult
500 mg PO qd for 7-14 d
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus
Precautions
In prolonged therapy, periodically evaluate function of organ systems (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy; has caused tendon rupture
Ciprofloxacin (Cipro)
Fluoroquinolone that inhibits bacterial DNA synthesis and consequently growth by inhibiting DNA gyrase and topoisomerases, which are required for replication, transcription, and translation of genetic material. Quinolones have broad activity against gram-positive and gram-negative aerobic organisms. No activity against anaerobes. Continue for at least 2 d (7-14 d typical) after signs and symptoms disappear.
Adult
750 mg PO bid or 250-500 mg PO bid
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity; coadministration with steroid combinations after uncomplicated removal of foreign body from cornea
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus
Precautions
May be used in pregnant women if bioterrorism agent suspected
Dosage adjustments (adults)
CrCl (mL/min) <10: 50% of PO or IV dose q12h
Hemodialysis (HD): 0.25-0.5 g PO or 0.2-0.4 g IV q12h
During peritoneal dialysis: 0.25-0.5 g PO or 0.2-0.4 g IV q8h
In prolonged therapy, periodically evaluate function of organ systems (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Not first choice in children because of increased incidence of adverse events (including arthropathy) compared with control subjects; no data for dosage for pediatric patients with renal impairment (ie, CrCl <50 mL/min)
Doxycycline (Vibramycin)
Broad-spectrum, synthetically derived bacteriostatic antibiotic in tetracycline class. Almost completely absorbed, concentrates in bile, and excreted in urine and feces as biologically active metabolite in high concentrations. Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. May block dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Preferred therapy. May eradicate other tick-related copathogens. Should be used for full 14 d to prevent risk of relapse.
Adult
100 mg PO/IV bid
Pediatric
<8 years: Not recommended
>8 years: 2-4 mg/kg/d PO divided bid
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral 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 y) can cause permanent discoloration of teeth; Fanconi-like syndrome may occur with outdated tetracyclines
More on Tularemia |
| Overview: Tularemia |
| Differential Diagnoses & Workup: Tularemia |
 Treatment & Medication: Tularemia |
| Follow-up: Tularemia |
| Multimedia: Tularemia |
| References |
| « Previous Page | Next Page » |
References
Bolgiano EB, Sexton J. Tick-borne illnesses. In: Rosen P, ed. Emergency Medicine: Concepts and Clinical Practice. Vol 3. 4th ed. St Louis, Mo: Mosby; 1998:2612-4.
Bratton RL, Corey R. Tick-borne disease. Am Fam Physician. Jun 15 2005;71(12):2323-30. [Medline].
Cronquist SD. Tularemia: the disease and the weapon. Dermatol Clin. Jul 2004;22(3):313-20, vi-vii. [Medline].
Daya M, Nakamura Y. Pulmonary disease from biological agents: anthrax, plague, Q fever, and tularemia. Crit Care Clin. Oct 2005;21(4):747-63, vii. [Medline].
Faul JL, Doyle RL, Kao PN, Ruoss SJ. Tick-borne pulmonary disease: update on diagnosis and management. Chest. Jul 1999;116(1):222-30. [Medline].
Greenberg SB. Serious waterborne and wilderness infections. Crit Care Clin. Apr 1999;15(2):387-414. [Medline].
Grunow R, Splettstoesser W, McDonald S, et al. Detection of Francisella tularensis in biological specimens using a capture enzyme-linked immunosorbent assay, an immunochromatographic handheld assay, and a PCR. Clin Diagn Lab Immunol. Jan 2000;7(1):86-90. [Medline].
Johansson A, Berglund L, Gothefors L, et al. Ciprofloxacin for treatment of tularemia in children. Pediatr Infect Dis J. May 2000;19(5):449-53. [Medline].
Labayru C, Palop A, Lopez-Urrutia L, et al. [Francisella tularensis: update on microbiological diagnosis after an epidemic outbreak]. Enferm Infecc Microbiol Clin. Nov 1999;17(9):458-62. [Medline].
Limaye AP, Hooper CJ. Treatment of tularemia with fluoroquinolones: two cases and review. Clin Infect Dis. Oct 1999;29(4):922-4. [Medline].
Osterbauer PJ, Dobbs MR. Neurobiological weapons. Neurol Clin. May 2005;23(2):599-621. [Medline].
Schuster GS. Bacterial and protozoal infections. Infect Dis Clin North Am. Dec 1999;13(4):797-816. [Medline].
Senol M, Ozcan A, Karincaoglu Y, et al. Tularemia: a case transmitted from a sheep. Cutis. Jan 1999;63(1):49-51. [Medline].
Smego RA, Castiglia M, Asperilla MO. Lymphocutaneous syndrome. A review of non-sporothrix causes. Medicine (Baltimore). Jan 1999;78(1):38-63. [Medline].
Weber DJ, Isbey S. Tick-borne diseases. In: Emergency Medicine: A Comprehensive Study Guide. 4th ed. New York, NY: McGraw-Hill; 1996:729-30.
Further Reading
Keywords
tularemia, Francisella tularensis, rabbit fever, rabbit skinners' disease, Amblyomma americanum, A americanum, Dermacentor andersoni, D andersoni, Dermacentor variabilis, D variabilis, Chrysops discalis, C discalis
