Further Outpatient Care
Patient may be discharged on oral tetracycline or doxycycline after 48 hours if hemodynamically stable and symptoms are resolving.
Follow up closely for potential relapse.
Further Inpatient Care
Admit patients with plague for antibiotic therapy and isolation.
Inpatient & Outpatient Medications
Antibiotics include streptomycin, tetracycline, doxycycline, and chloramphenicol. Y pestis is often susceptible in vitro to ampicillin, but this antibiotic is rarely effective in vivo. Gentamicin is equally as effective as streptomycin. Antipyretics are useful for patient comfort.
Transfer
Transfer may be required for further hemodynamic and respiratory monitoring and isolation.
Deterrence/Prevention
Plague continues to pose a threat to humans. [26] Identifying the source of infection is vital in preventing outbreaks. If an urban area is involved, rodent control should be undertaken. In rural plague-endemic areas, the public must be instructed to avoid handling sick or dead animals and to avoid places where wild animals live. Pets should be kept free of fleas.
Patients with plague pneumonia should be placed in airborne precautions.
Contacts of pneumonic plague victims should receive antibiotic prophylaxis. Ciprofloxacin or doxycycline is typically used. Trimethoprim-sulfamethoxazole has also been effective for prophylaxis. Contacts of those with bubonic or septicemic plague have no need for prophylaxis.
A number of vaccines are currently under development, including live-attenuated, DNA, and subunit vaccines. A recent review details the new approaches to live-attenuated plague vaccines through construction of attenuated Y pestis strains with specifically defined mutations. [27] Traditionally, live-attenuated plague vaccines have been developed by multiple passages of fully virulent Y pestis. These vaccines raise safety concerns and are not recommended for the general population in the United States.
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Male Xenopsylla cheopis (oriental rat flea) engorged with blood. This flea is the primary vector of plague in most large plague epidemics in Asia, Africa, and South America. Both male and female fleas can transmit the infection. Image courtesy of the Centers for Disease Control and Prevention (CDC).
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Wright stain peripheral blood smear of patient with septicemic plague demonstrating bipolar, safety pin staining of Yersinia pestis. Although Wright stain often demonstrates this characteristic appearance, Giemsa and Wayson stains most consistently highlight this pattern. Courtesy of Jack Poland, PhD, Centers for Disease Control and Prevention (CDC), Fort Collins, CO.
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Inguinal bubo on upper thigh of a person with bubonic plague. Image courtesy of the Centers for Disease Control and Prevention (CDC).
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Yersinia pestis bacteria on fluorescent antibody test. Image courtesy of the Centers for Disease Control and Prevention (CDC).
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Pictured is a flea with a blocked proventriculus, which is equivalent to the gastroesophageal region in a human. In nature, this flea would develop a ravenous hunger because of its inability to digest the fibrinoid mass of blood and bacteria. If this flea were to bite a mammal, the proventriculus would be cleared, and thousands of bacteria would be regurgitated into the bite wound. Courtesy of the United States Army Environmental Hygiene Agency.
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After the femoral lymph nodes, the next most commonly involved regions in plague are the inguinal, axillary, and cervical areas. This child has an erythematous, eroded, crusting, necrotic ulcer at the presumed primary inoculation site in the left upper quadrant. This type of lesion is uncommon in patients with plague. The location of the bubo is primarily a function of the region of the body in which an infected flea inoculates plague bacilli. Courtesy of Jack Poland, PhD, Centers for Disease Control and Prevention (CDC), Fort Collins, Colo.
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Ecchymoses at the base of the neck in a girl with plague. The bandage is over the site of a prior bubo aspirate. These lesions are probably the source of the line from the children's nursery rhyme, "ring around the rosy." Courtesy of Jack Poland, PhD, Centers for Disease Control and Prevention (CDC), Fort Collins, Colo.
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Acral necrosis of the nose, the lips, and the fingers and residual ecchymoses over both forearms in a patient recovering from bubonic plague that disseminated to the blood and the lungs. At one time, the patient's entire body was ecchymotic. Reprinted from Textbook of Military Medicine. Washington, DC, US Department of the Army, Office of the Surgeon General, and Borden Institute. 1997:493. Government publication, no copyright on photos.
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Acral necrosis of the toes and residual ecchymoses over both forearms in a patient recovering from bubonic plague that disseminated to the blood and the lungs. At one time, the patient's entire body was ecchymotic. Reprinted from Textbook of Military Medicine. Washington, DC: US Department of the Army, Office of the Surgeon General, and Borden Institute. 1997:493. Government publication, no copyright on photos.
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Rock squirrel in extremis coughing blood-streaked sputum related to pneumonic plague. Courtesy of Ken Gage, PhD, Centers for Disease Control and Prevention (CDC), Fort Collins, Colo.
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Reported cases of human plague in US 1970-2012. Courtesy of the CDC.
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Worldwide distribution of plague cases 2000-2009. Courtesy of the CDC.
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Human plague cases and deaths in US 2004-2014. Courtesy of the CDC.
Tables
| Antibiotic | Dose | Route of Administration |
|---|---|---|
| Streptomycin | 1 g twice daily | IM |
| Gentamicin | 5 mg/kg once daily, or 2 mg/kg loading dose followed by 1.7 mg/kg every 8 hours | IM or IV |
| Levofloxacin | 500 mg once daily | IV or po |
| Ciprofloxacin | 400 mg every 8-12 hours |
IV |
| 500-750 mg twice daily | po | |
| Doxycycline | 100 mg twice daily or 200 mg once daily | IV or po |
| Moxifloxacin | 400 mg once daily | IV or po |
| Chloramphenicol | 25 mg/kg every 6 hours | IV |
| Antibiotic | Dose | Route of Administration |
|---|---|---|
| Streptomycin | 15 mg/kg twice daily (maximum 2 g/day) | IM |
| Gentamicin | 2.5 mg/kg/dose every 8 hours | IM or IV |
| Levofloxacin | 10 mg/kg/dose (maximum 500 mg/dose) | IV or po |
| Ciprofloxacin | 15 mg/kg/dose every 12 hours (maximum 400 mg/dose) |
IV |
| 20 mg/kg/dose every 12 hours (maximum 500 mg/dose) | po | |
| Doxycycline | Weight < 45 kg: 2.2 mg/kg twice daily (maximum 100 mg/dose) Weight ≥ 45 kg: same as adult dose |
IV or po |
| Chloramphenicol (for children > 2 years) | 25 mg/kg every 6 h (maximum daily dose, 4 g) | IV |
