Tularemia Treatment & Management

Updated: Jan 12, 2023
  • Author: Kerry O Cleveland, MD; Chief Editor: John L Brusch, MD, FACP  more...
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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.


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.


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]


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.



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.



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]