Sections

Tularemia

Treatment

Approach Considerations

Medical care in tularemia primarily is directed toward antibiotic eradication of F tularensis. Symptomatic and supportive care is applied for accompanying conditions (eg, osteomyelitis, pericarditis, peritonitis) in patients with tularemia, as clinically indicated.

Updated (2014) guidelines on the diagnosis and treatment of tularemia have been published by the Infectious Diseases Society of America (IDSA) (see Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America).^[64]

Inpatient care

Treatment for patients with tularemia includes supportive and general medical care for manifestations that require hospitalization (eg, ARDS, pneumonia, lung abscess, renal insufficiency).

Surgical care

Surgical care is not needed in tularemia management unless an ulcerative lesion develops a superinfection and requires debridement or drainage is required for empyema or a fluctuant lymph node.

Consultations

Consider consultation with an infectious diseases specialist to help determine the diagnosis and treatment plan. In patients with pneumonia or ARDS, assistance from a pulmonologist may be necessary.

Reporting

Tularemia is a reportable disease in the United States. Contact your local public health department if you suspect a case of tularemia. Contact local or federal law enforcement agencies and the Centers for Disease Control and Prevention if multiple cases occur, which would suggest biologic or terrorist attack.

Antibiotic Therapy

Streptomycin is considered the drug of choice (DOC) to treat tularemia. Less experience has been reported with other aminoglycosides; gentamicin and amikacin are effective, have been used successfully, and generally are more available.

While chloramphenicol and tetracycline are clinically useful, relapse rates of up to 50% have been reported in patients treated with these agents.

Case reports indicate a potential role for erythromycin and fluoroquinolones (ciprofloxacin, levofloxacin); however, clinical experience and in vitro data supporting their use are limited.

F tularensis is naturally resistant to penicillins and first-generation cephalosporins. Ceftriaxone, a third-generation cephalosporin, has been examined in the treatment of tularemia and, although it was found to have good in vitro MICs (minimal inhibitory concentrations), a number of therapeutic failures occurred.^{[69, 70]}

Prophylaxis

Postexposure prophylaxis is recommended within 24 hours of airborne exposure to F tularensis using either ciprofloxacin or doxycycline for 2 weeks. It is unlikely that aerosolized exposure to F tularensis will be identified within 24 hours, so standard treatment is recommended within 14 days of exposure.

Vaccination

No tularemia vaccine is available. A vaccine based on a live strain of the bacterium previously was available but is no longer produced because of concerns about unknown attenuation, safety, and production.

Prevention

Tick bites can be prevented by avoiding tick-infested areas, wearing trousers and long-sleeved shirts, and using tick repellants and by frequent inspection of the body and clothing for evidence of ticks. Ticks should be promptly removed by grasping the tick near the mouthparts and pulling upward. Care should be taken to not squeeze the body, because tick secretions may be infectious.

Exposure to dead or wild mammals should be avoided, if possible. When exposure is necessary (eg, skinning or eviscerating a rabbit carcass), gloves should be worn, especially if abrasions are on the hands. Hands should be washed thoroughly afterwards.

Surgical Care

Surgical or needle drainage of suppurated fluctuant nodes may be necessary.^[71]Recurrent suppuration of lymph nodes despite treatment has been described in patients with prior receipt of immunosuppressive medications.^[72]

Medication

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Media Gallery

Eschar on thumb and under thumbnail at the site of a rabbit bite in a patient with tularemia.
Axillary bubo in a patient with tularemia.
Ulceroglandular type of tularemia on the face. Courtesy of Dr Hon Pak.
Ulceroglandular tularemia on an extremity. Courtesy of Dr Hon Pak.
Ulceroglandular type of tularemia on the hand. Courtesy of Dr Hon Pak.

of 5

Author

Kerry O Cleveland, MD Professor of Medicine, University of Tennessee College of Medicine; Consulting Staff, Department of Internal Medicine, Division of Infectious Diseases, Methodist Healthcare of Memphis

Kerry O Cleveland, MD is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America, Society for Healthcare Epidemiology of America

Disclosure: Nothing to disclose.

Coauthor(s)

Michael Gelfand, MD, FACP Chief, Professor, Department of Internal Medicine, Division of Infectious Diseases, Methodist Healthcare of Memphis, University of Tennessee Health Science Center College of Medicine

Michael Gelfand, MD, FACP is a member of the following medical societies: American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, Southern Medical Association

Disclosure: Nothing to disclose.

Chief Editor

John L Brusch, MD, FACP Corresponding Faculty Member, Harvard Medical School

John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

Gregory J Raugi, MD, PhD Professor, Department of Internal Medicine, Division of Dermatology, University of Washington at Seattle School of Medicine; Chief, Dermatology Section, Primary and Specialty Care Service, Veterans Administration Medical Center of Seattle

Gregory J Raugi, MD, PhD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Acknowledgements

Richard B Brown, MD, FACP Chief, Division of Infectious Diseases, Baystate Medical Center; Professor, Department of Internal Medicine, Tufts University School of Medicine

Richard B Brown, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians, American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, and Massachusetts Medical Society

Disclosure: Nothing to disclose.

Dan Danzl, MD Chair, Department of Emergency Medicine, Professor, University of Louisville Hospital

Dan Danzl, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Kentucky Medical Association, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Jonathan A Edlow, MD Associate Professor of Medicine, Department of Emergency Medicine, Harvard Medical School; Vice Chairman, Department of Emergency Medicine, Beth Israel Deaconess Medical Center

Jonathan A Edlow, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Jon Mark Hirshon, MD, MPH Associate Professor, Department of Emergency Medicine, University of Maryland School of Medicine

Jon Mark Hirshon, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Public Health Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Kelly Maurelus, MD Resident Physician, Department of Emergency Medicine, Kings County Hospital, State University of New York Downstate

Kelly Maurelus, MD, is a member of the following medical societies: American Medical Student Association/Foundation and Student National Medical Association

Disclosure: Nothing to disclose.

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM Professor of Emergency Medicine, Education Officer, Department of Emergency Medicine, Hospital of the University of Pennsylvania; Director of Education and Research, PENN Travel Medicine; Medical Director, Fast Track, Department of Emergency Medicine

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

William H Shoff, MD, DTM&H Director, PENN Travel Medicine; Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine

William H Shoff, MD, DTM&H is a member of the following medical societies: American College of Physicians, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Richard H Sinert, DO Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Russell W Steele, MD Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Robert W Tolan Jr, MD Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: Novartis Honoraria Speaking and teaching

Mark R Wallace, MD, FACP, FIDSA Clinical Professor of Medicine, Florida State University College of Medicine; Head of Infectious Disease Fellowship Program, Orlando Regional Medical Center

Mark R Wallace, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Tropical Medicine and Hygiene, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.