Approach
Antibiotic treatment with agents active against Francisella tularensis is the mainstay of therapy in all patients, regardless of the clinical manifestation. Surgical drainage of enlarged nodes may also be required. Standard isolation practices should be followed.
Hospitalisation and administration of parenteral antibiotics are required for patients with suspected tularaemia that presents with systemic inflammatory response syndrome (SIRS), with bacteraemia, or in typhoidal/pneumonic forms.
Antibiotic therapy
The gold standard for therapy is an aminoglycoside. The Centers for Disease Control and Prevention (CDC) recommend gentamicin as the drug of choice based on experience and efficacy, particularly for severe cases.[16] The World Health Organization (WHO) recommends gentamicin as the drug of choice as it is more widely available, with streptomycin as an alternative if it is available.[18] The choice of agent ultimately depends on local guidance and availability of these drugs.
Fluoroquinolones (e.g., ciprofloxacin) seem to be effective in milder cases of tularaemia, although experience with their use is limited. The CDC recommends ciprofloxacin as a suitable agent for non-severe cases of tularaemia.[16][21]
Parenteral therapy with an aminoglycoside should be administered to any patient judged with serious enough infection to necessitate hospitalisation. Oral therapy with a fluoroquinolone is only advised for outpatient treatment of milder cases.[1][6]
Tetracyclines and chloramphenicol are bacteriostatic only, and relapses have occurred after cessation of therapy. Doxycycline is a less-preferred agent than a fluoroquinolone or aminoglycoside. However, the CDC recommends doxycycline as a suitable agent for non-severe cases of tularaemia.[16] Chloramphenicol is no longer recommended due to its adverse effect profile.
A treatment course of at least 10 days is recommended for aminoglycosides. Ciprofloxacin should be given for 10-14 days. Tetracyclines are bacteriostatic and longer treatment courses of 14-21 days are required. In more severe infection, the treatment period may be longer and depends on the clinical response.[16][18] Relapse may occur and should be treated with an additional 7 to 14 days of therapy.
Although there is little experience to provide guidance, tularaemic meningitis should be treated with a combination of ciprofloxacin and an aminoglycoside. Treatment should be considered in consultation with an infectious disease specialist.[16]
Pregnant patients are not treated differently from non-pregnant patients as the benefits outweigh the risks associated with use of these drugs in pregnancy.
Children are treated the same as adults. Although repeated courses of tetracycline were associated with staining of permanent teeth in young children, no evidence suggests that short courses of doxycycline causes any such tooth staining or weakening of the tooth enamel in children <8 years of age.[22][23]
Surgical drainage
Surgical drainage of enlarged nodes in ulceroglandular tularaemia is frequently required for symptomatic relief.[1]
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