| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ciprofloxacin]] 500 mg PO q12h'''''<BR> OR <BR> ▸ '''''[[Levofloxacin]] 750 mg PO q24h'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]] 400 mg PO q24h'''''<BR> OR <BR> ▸ '''''[[Doxycycline]] 100 mg PO q12h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Streptomycin]] 2 g/day IM q12h'''''<BR> OR <BR> ▸ '''''[[Gentamicin]] 3 mg/Kg/day IM or IV q8h'''''<BR> OR <BR> ▸ '''''[[Tetracycline]] 2 g/day PO q6h'''''<BR> OR <BR> ▸ '''''[[Chloramphenicol]] 50 mg/Kg/day PO or IV q6h'''''<BR> OR <BR> ▸ '''''[[Doxycycline]] 200 mg/day PO q12h or q24h'''''<BR> OR <BR> ▸ '''''[[Oxytetracycline]] 250 - 300 mg/day PO or IM q8h, q12h or q24h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Levofloxacin]] 750 mg IV q24h'''''<BR> OR <BR> ▸ '''''[[Meropenem]] 2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Penicillin G]] 4 MU IV q4h'''''<BR> OR <BR> ▸ '''''[[Ampicillin]] 3 g IV q6h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G]] 4 MU IV q4h'''''<BR> OR <BR> ▸ '''''[[Ampicillin]] 3 g IV q6h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Levofloxacin]] 750 mg IV q24h'''''<BR> OR <BR> ▸ '''''[[Meropenem]] 2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Penicillin G]] 4 MU IV q4h'''''<BR> OR <BR> ▸ '''''[[Ampicillin]] 3 g IV q6h'''''
According to treatment experts, a patient diagnosed with suspected plague should be hospitalized and medically isolated. Laboratory tests should be done, including blood cultures for plague bacteria and microscopic examination of lymph gland, blood, and sputum samples. Antibiotic treatment should begin as soon as possible after laboratory specimens are taken. Effective antibiotics are streptomycin, gentamicin (used when streptomycin is not available), tetracyclines and chloramphenicol. (used for critically ill patients, or rarely for suspected neuro-involvement)
Medical Therapy
When a diagnosis of human plague is suspected on clinical and epidemiological grounds, appropriate specimens for diagnosis should be obtained immediately and the patient should be started on specific antimicrobial therapy without waiting for a definitive answer from the laboratory.[1][2]
Suspect plague patients with evidence of pneumonia should be placed in isolation, and managed under respiratory droplet precautions.[3]
Specific Therapy
Aminoglycosides
Streptomycin is the most effective antibiotic against Yersinia pestis and the drug of choice for treatment of plague, particularly the pneumonic form. Therapeutic effect may be expected with 30 mg/kg/day (up to a total of 2 g/day) in divided doses given intramuscularly, to be continued for a full course of 10 days of therapy or until 3 days after the temperature has returned to normal.[1][4][5][6][7]
Gentamicin has been found to be effective in animal studies, and is used to treat human plague patients.[1]
Chloramphenicol
Chloramphenicol is a suitable alternative to aminoglycosides in the treatment of bubonic or septicaemic plague and is the drug of choice for treatment of patients with Yersinia pestis invasion of tissue spaces into which other drugs pass poorly or not at all (such as plague meningitis, pleuritis, or endophthalmitis. Dosage should be 50 mg/kg/day administered in divided doses either parenterally or, if tolerated, orally for 10 days. Chloramphenicol may be used adjunctively with aminoglycosides.[1]
Tetracyclines
This group of antibiotics is bacteriostatic but effective in the primary treatment of patients with uncomplicated plague. An oral loading dose of 15 mg/kg tetracycline (not to exceed 1 g total) should be followed by 25-50 mg/kg/day (up to a total of 2 g/day) for 10 days. Tetracyclines may also be used adjunctively with other antibiotics.[1]
Sulfonamides
Sulfonamides have been used extensively in plague treatment and prevention: however, some studies have shown higher mortality, increased complications, and longer duration of fever as compared with the use of streptomycin, chloramphenicol or tetracyclineantibiotics. Sulfadiazine is given as a loading dose of 2-4 g followed by a dose of 1 g every 4-6 hours for a period of 10 days. In children, the oral loading dose is 75 mg/kg, followed by 150 mg/kg/day orally in six divided doses. The combination drug trimethoprim-sulfamethoxazole has been used both in treatment and prevention of plague.[1]
Other cases of antibiotics, such as penicillins, cephalosporins, and macrolides have been shown to be ineffective or of variable effect in treatment of plague and they should not be used for this purpose.[1]
▸ Ciprofloxacin 30 mg/kg/day PO q12h, max: 500 mg/dose OR ▸ Levofloxacin 16 mg/kg/day PO q12h, max: 250 mg/dose (<50 kg) OR ▸ Levofloxacin 500 mg PO q24h (≥50 kg) OR ▸ Doxycycline 4.4 mg/kg/day PO q12h, max: 100 mg/dose (<45 kg) OR ▸ Doxycycline 100 mg/dose PO q12h (≥45 kg)
Alternative Regimen
▸ Clindamycin 30 mg/kg/day PO q8h, max: 600 mg/dose OR ▸ Penicillin VK 50–75 mg/kg/day PO q6–8h OR ▸ Amoxicillin 75 mg/kg/day PO q8h, max: 1 g/dose
Systemic Anthrax with Meningitis, Pediatric Patients
Preferred Regimen
▸ Ciprofloxacin 30 mg/kg/day IV q8h, max: 400 mg/dose OR ▸ Levofloxacin 20 mg/kg/day IV q12h, max: 250 mg/dose (<50 kg) OR ▸ Levofloxacin 500 mg IV q24h (≥50 kg) OR ▸ Meropenem 60 mg/kg/day IV q12h, max: 2 g/dose OR ▸ Imipenem/Cilastatin 100 mg/kg/day IV q6h, max: 1 g/dose OR ▸ Vancomycin 60 mg/kg/day IV q8h
PLUS
▸ Clindamycin 30 mg/kg/day PO q8h, max: 600 mg/dose OR ▸ Linezolid 30 mg/kg/day IV q8h, max: 1 g/dose (<12 yr) OR ▸ Linezolid 30 mg/kg/day IV q12h, max: 600 mg/dose (≥12 yr) OR ▸ Doxycycline 4.4 mg/kg/day IV q12h, max: 100 mg/dose (<45 kg) OR ▸ Doxycycline 200 mg IV x1 then 100 mg IV q12h, max: 200 mg/dose (≥45 kg) OR ▸ Rifampin 20 mg/kg/day IV q12h, max: 300 mg/dose
Alternative Regimen
▸ Penicillin G 0.4 MU/kg/day IV q4h, max: 4 MU/dose OR ▸ Ampicillin 200 mg/kg/day IV q6h, max: 900 mg/dose
PLUS
▸ Clindamycin 30 mg/kg/day PO q8h, max: 600 mg/dose OR ▸ Linezolid 30 mg/kg/day IV q8h, max: 1 g/dose (<12 yr) OR ▸ Linezolid 30 mg/kg/day IV q12h, max: 600 mg/dose (≥12 yr) OR ▸ Doxycycline 4.4 mg/kg/day IV q12h, max: 100 mg/dose (<45 kg) OR ▸ Doxycycline 200 mg IV x1 then 100 mg IV q12h, max: 200 mg/dose (≥45 kg) OR ▸ Rifampin 20 mg/kg/day IV q12h, max: 300 mg/dose
An aminoglycoside judiciously administered is effective and safe for both mother and fetus, and in children. Because of its safety, intravenous or intramuscular administration, and ability to have blood concentrations monitored, gentamicin is the preferred antibiotic for treating plague in pregnancy.[9]
↑Meyer, K. F.; Quan, S. F.; McCrumb, F. R.; Larson, A. (1952). "EFFECTIVE TREATMENT OF PLAGUE". Annals of the New York Academy of Sciences. 55 (6): 1228–1274. doi:10.1111/j.1749-6632.1952.tb22687.x. ISSN0077-8923.
↑Wheeler, Arthur P.; Bernard, Gordon R. (1999). "Treating Patients with Severe Sepsis". New England Journal of Medicine. 340 (3): 207–214. doi:10.1056/NEJM199901213400307. ISSN0028-4793.