CBRNE - Plague Medication

Updated: Apr 18, 2017
  • Author: Susan E Dufel, MD, FACEP; Chief Editor: Duane C Caneva, MD, MSc  more...
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Medication Summary

Medical management of plague can involve a myriad of supportive medications, including crystalloids, colloids, medications used for intubation, vasopressor agents, and antiulcer and antipyretic agents. This section describes only antibiotic management of plague. Early administration of antibiotics is essential after samples for diagnostic purposes have been obtained.

For both prophylaxis and treatment, antibiotics shown to be effective against plague include gentamicin and doxycycline. Fluoroquinolones are recommended, despite the lack of studies in humans. [23, 24]

Two cases of mutiple-antibiotic resistant Yersinia pestis were discovered in Madagascar in 1995 and were presumed to be the result of horizontal gene transfer in the flea midgut. This discovery has raised the concern for the possibility of a natural or engineered antibiotic-resistant strain that could be used for biological attacks. [25]



Class Summary

Antibiotics that cover Yersinia pestis should be empirically given to any patient with predisposing risk factors and signs and symptoms of the plague. Treatment duration should be 10 days. In severe cases, a two-drug regimen should be used. Antibiotic regimens for postexposure prophylaxis should be considered for close contacts of infected patients. Agents and dosages are covered below.


Aminoglycoside antibiotic for gram-negative coverage. Drug of choice (DOC) with consideration of use as secondary agent.


Alternative DOC in combination with consideration of use with a secondary agent. Drug often not commercially available. Treatment usually limited to 5 d due to toxicity concerns. Continuation of secondary agent for full 10 d recommended.


DOC to be used as secondary agent in plague meningitis (better CNS penetration), profound hypotension, and pleural and/or pericardial involvement. May be considered as secondary agent. DOC for pregnant patients. Binds to 50S bacterial ribosomal subunits and inhibits bacterial growth. Effective against gram-negative and gram-positive bacteria.

Doxycycline (Doryx, Vibramycin, Monodox, Morgidox, Adoxa, Oracea)

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

May be considered as secondary agent or for postexposure prophylaxis.

Levofloxacin (Levaquin)

Second-generation quinolone. Acts by interfering with DNA gyrase in bacterial cells. Bactericidal. Fluoroquinolone antibiotic indicated for treatment or prophylaxis following exposure of Yersinia pestis (plague).

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. Has no activity against anaerobes.

Animal studies have shown effectiveness against the plague. Can be considered as a secondary agent or as an agent for postexposure prophylaxis.


Treats susceptible bacterial infections of both gram-positive and gram-negative organisms as well as mycoplasmal, chlamydial, and rickettsial infections; inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunits of susceptible bacteria; use with either streptomycin or gentamicin. Consider as a secondary agent or for postexposure prophylaxis.

Trimethoprim/sulfamethoxazole (Bactrim, Bactrim DS, Sulfatrim Pediatric)

DOC for prophylaxis of pregnant women and children < 8 y; inhibits bacterial synthesis of dihydrofolic acid by competing with PABA, inhibiting folic acid synthesis and resulting in the inhibition of bacterial growth.

Moxifloxacin (Avelox)

This fluoroquinolone is indicated in adults for the treatment of plague, including pneumonic and septicemic plague, caused by susceptible isolates of Yersinia pestis; it is also indicated for prophylaxis of plague in adults.