Medical Care
Plague is a treatable disease, but clinicians must have a high index of suspicion and initiate appropriate antibiotics at the earliest possible time. [21] Initial evaluation of patients with plague may begin on an emergent outpatient basis. However, hospitalization is generally required to initiate therapy. Isolation of hospitalized patients varies based on the type of disease. Standard precautions are indicated for cases of bubonic plague. Droplet precautions are indicated for patients with pneumonic plague and for all patients until pneumonia has been excluded and treatment initiated. In patients with pneumonic plague, isolation should be continued until 48 hours of appropriate antibiotic treatment has been administered. Aggressive supportive medical care as necessary to stabilize and maintain the patient's hemodynamic and respiratory status.
Currently recommended antibiotic treatment for plague is summarized in the tables below. Gentamicin and fluoroquinolones are typically first-line treatments in the United States. Duration of treatment is 10 to 14 days, or until 2 days after fever subsides. Oral therapy may be substituted once the patient improves.
Recommended antibiotic treatment for plague in adults (Source: CDC, Atlanta, GA) [22]
Table. (Open Table in a new window)
| 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 |
Recommended antibiotic treatment for plague in Children* (Source: CDC, Atlanta, GA) [22]
Table. (Open Table in a new window)
| 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 |
* All recommended antibiotics for plague have relative contraindications for use in children and; however, use is justified in life-threatening situations.
Additionally, updated guidelines on the diagnosis and treatment of bubonic plague 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). [23]
Provide supportive medical care as necessary to stabilize and maintain the patient's hemodynamic and respiratory status.
Updated (2014) guidelines on the diagnosis and treatment of bubonic plague 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). [23]
Surgical Care
Incision and drainage of buboes may be indicated. Material drained from the buboes is infectious until patient is appropriately treated.
Consultations
Consultations may include the following:
-
Infectious disease specialist
-
Intensive care specialist, if hemodynamic or respiratory instability is present
Diet
No special diet is required.
Activity
No specific activity restrictions are required.
Prevention
Persons engaging in outdoor activities in areas where plague is endemic should wear long pants when possible and use insect repellent on clothing and skin. Persons also should avoid direct contact with ill or dead animals and never feed squirrels, chipmunks, or other rodents. In addition, pet owners should regularly use flea control products on their pets and consult a veterinarian if their pet is ill. Rodent habitat can be reduced around the home by removing brush, clutter, and potential rodent food sources such as garbage or pet food.
-
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).
-
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.
-
Inguinal bubo on upper thigh of a person with bubonic plague. Image courtesy of the Centers for Disease Control and Prevention (CDC).
-
Yersinia pestis bacteria on fluorescent antibody test. Image courtesy of the Centers for Disease Control and Prevention (CDC).
-
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.
-
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.
-
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.
-
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.
-
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.
-
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.
-
Reported cases of human plague in US 1970-2012. Courtesy of the CDC.
-
Worldwide distribution of plague cases 2000-2009. Courtesy of the CDC.
-
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 |
