Pediatric Plague Guidelines

Updated: Aug 16, 2021
  • Author: Vinod K Dhawan, MD, FACP, FRCPC, FIDSA; Chief Editor: Russell W Steele, MD  more...
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Guidelines Summary

In 2021, the Centers for Disease Control and Prevention (CDC) published clinical practice guidelines on the treatment of plague. [23, 25] These are some of the highlights of the guidelines.

Plague is treatable with antimicrobials and supportive care. Early recognition and administration of effective antimicrobials are key to saving lives. Persons exposed to Yersinia pestis can avoid illness if given effective antimicrobial prophylaxis.

Aminoglycosides and fluoroquinolones are the mainstays of treatment for plague. Tetracyclines, chloramphenicol, and trimethoprim-sulfamethoxazole might also be suitable treatment, depending on the type of disease and the age and pregnancy status of the patient. Dual therapy with distinct classes of antimicrobials is recommended in the case of a bioterrorist attack with Y pestis engineered for resistance to treatment.

FDA-approved antimicrobials for plague include streptomycin, ciprofloxacin, levofloxacin, moxifloxacin, and doxycycline. Although not approved for plague, gentamicin, chloramphenicol, and trimethoprim-sulfamethoxazole are considered effective.

Bubonic and pharyngeal plague

Gentamicin or streptomycin is a first-line agent for bubonic plague; they must be given parenterally and are associated with nephrotoxicity and ototoxicity. Alternative first-line agents include high-dose ciprofloxacin, levofloxacin, moxifloxacin, and doxycycline, administered intravenously or orally. Consider dual therapy and drainage for patients with large buboes. Treatment is for 10-14 days.

Pneumonic and septicemic plague

For naturally occurring pneumonic plague, the CDC recommends levofloxacin or moxifloxacin. Because plague is life threatening, doxycycline is not considered contraindicated in children and has not been shown to cause tooth staining, unlike other tetracyclines, which should be avoided if possible. For children aged 3 mo to 17 yr, moxifloxacin is recommended as an alternative antimicrobial, rather than a first-line agent, because of lack of FDA approval for use in children and because of higher reported rates of prolonged QTc interval than seen with other fluoroquinolones.

Plazomicin is not recommended as an alternative antimicrobial for children 1 mo to 17 yr because there are no published data on use and dosage in pediatric patients.

Plague meningitis

Moxifloxacin and levofloxacin should be effective for plague meningitis because they have been shown to have robust activity against Y pestis and excellent CNS penetration. Quinolones, however, can cause seizures. When possible, dual therapy with chloramphenicol and moxifloxacin or levofloxacin should be used as initial treatment in patients with plague and signs of meningitis, such as nuchal rigidity. If chloramphenicol is not available, a non-fluoroquinolone first-line antimicrobial or an alternative antimicrobial for septicemic plague can be used.

For patients who develop secondary plague meningitis while already receiving antimicrobial therapy, chloramphenicol should be added to the existing antimicrobial treatment regimen for plague. Moxifloxacin or levofloxacin can be added to the treatment regimen instead of chloramphenicol if it is not available or if the clinician prefers not to use chloramphenicol in young children because of potential adverse effects. After chloramphenicol, moxifloxacin, or levofloxacin is added, the entire regimen of antimicrobials should be continued for an additional 10 days.

Treatment of plague in neonates

The CDC recommends that treatment should be started without delay for symptomatic neonates who have been infected with Y pestis. First-line antimicrobial options for neonates with pneumonic or septicemic plague are gentamicin, ciprofloxacin, levofloxacin, and streptomycin. For neonates with bubonic or pharyngeal plague, first-line options are gentamicin, ciprofloxacin, levofloxacin, streptomycin, and doxycycline. Administration via the intravenous route is recommended to ensure that the full dose is successfully given.

All neonates who are exposed postnatally to Y pestis should receive postexposure prophylaxis. Prophylaxis also should be considered for asymptomatic neonates whose mothers had untreated Y pestis infection during the last 7 days of pregnancy.

Infection control

Caretakers should wear a mask in addition to taking standard precautions, as well as wear eye protection and a face shield if splashing is likely.