Plague Medication

Updated: Aug 13, 2021
  • Author: Venkat R Minnaganti, MD, FACP; Chief Editor: Michael Stuart Bronze, MD  more...
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Medication Summary

Untreated plague can progress to a fulminant illness with a high risk of mortality. Thus, early and appropriate antibiotic treatment is essential.

Historically, streptomycin (15 mg/kg, up to 1 g intramuscularly every 12 h) has been the drug of choice [34] ; however, in the United States, supplies of streptomycin are scarce.

An in vitro comparison [37] and a murine model [38] demonstrated that gentamicin (5 mg/kg intravenously or intramuscularly once daily) is comparable to or superior than streptomycin. Gentamicin has been used successfully in the treatment of human plague, [18] is inexpensive, and can be dosed once daily.

Doxycycline (as dosed for anthrax) is a recommended alternative in patients who cannot take aminoglycosides or in the event of a mass casualty scenario, making parenteral therapy unachievable. [34]

Because chloramphenicol attains high CSF concentrations, [34] it has been used to treat meningeal plague, although no studies have been conducted for substantiation. [39]  Chloramphenicol may be challenging to obtain.

Studies in murine models have shown that fluoroquinolones demonstrate efficacy similar to that of the aminoglycosides. [38] Fluoroquinolones are a reasonable alternative therapy. [39]

The FDA has approved levofloxacin and moxifloxacin for the treatment of plague. These have also been approved for use as prophylaxis following exposure to Yersinia pestis.

Trimethoprim-sulfamethoxazole has been used to treat bubonic plague; however, it is not considered first-line therapy.

Beta-lactam antibiotics and macrolides should not be used.

Patients with advanced plague have a presentation of typical gram-negative sepsis and need antibiotic treatment for 10-14 days, along with other supportive measures. [39]



Class Summary

Therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting. Antibiotic selection should be guided by blood culture sensitivity whenever feasible.

Levofloxacin (Levaquin)

Levofloxacin is the L-isomer of the racemate, ofloxacin, a quinolone antimicrobial agent. The antibacterial activity of ofloxacin resides primarily in the L-isomer. It inhibits bacterial topoisomerase IV and DNA gyrase (topoisomerases type II), enzymes required for DNA replication, transcription, repair, and recombination. It is indicated for treatment and prophylaxis of plague, including pneumonic and septicemic plague, caused by Yersinia pestis in adults and pediatric patients, aged 6 months or older.

Moxifloxacin (Avelox)

Moxifloxacin is a fluoroquinolone antibiotic that inhibits A subunits of DNA gyrase (topoisomerase type II) and topoisomerase IV, resulting in inhibition of bacterial DNA replication and transcription. It is indicated in adults for treatment and prophylaxis of pneumonic or septicemic plague caused by Yersinia pestis.


Aminoglycoside antibiotic recommended when less potentially hazardous therapeutic agents are ineffective or contraindicated.

Gentamicin (Garamycin)

Aminoglycoside antibiotic for gram-negative coverage.

Doxycycline (Bio-Tab, Doryx, Doxy, Vibramycin, Vibra-Tabs

Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.

Chloramphenicol (Chloromycetin)

Binds to 50S bacterial ribosomal subunits and inhibits bacterial growth by inhibiting protein synthesis. Effective against gram-negative and gram-positive bacteria.

Ciprofloxacin (Cipro, Cipro XR, ProQuin XR)