Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

tularaemia without meningitis

1st line – aminoglycoside or ciprofloxacin

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ACUTE
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tularaemia without meningitis
1st line – 

aminoglycoside or ciprofloxacin

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]​​

Treatment course: at least 10 days (aminoglycosides); 10-14 days (ciprofloxacin); longer courses may be required in severe infection depending on the clinical response. Relapse may occur and should be treated with an additional 7 to 14 days of therapy.

Primary options

gentamicin: children: 2.5 mg/kg intravenously/intramuscularly every 8 hours; adults: 5 mg/kg intravenously/intramuscularly every 24 hours

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Secondary options

ciprofloxacin: children: 15 mg/kg intravenously/orally every 12 hours, maximum 800 mg/day; adults: 400 mg intravenously every 12 hours, or 500 mg orally twice daily

OR

streptomycin: children: 15 mg/kg intramuscularly every 12 hours, maximum 2 g/day; adults: 1 g intramuscularly every 12 hours

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2nd line – doxycycline

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ACUTE
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tularaemia without meningitis
2nd line – 

doxycycline

Doxycycline is a less-preferred therapy than aminoglycosides or fluoroquinolones because it is bacteriostatic for tularaemia, with relapse a potential problem after cessation of therapy. However, the CDC recommends doxycycline as a suitable agent for non-severe cases of tularaemia.[16]​​

Treatment course: 14-21 days. Relapse may occur and should be treated with an additional 7 to 14 days of therapy.

Primary options

doxycycline: children: 2.2 mg/kg intravenously/orally every 12 hours, maximum 200 mg/day; adults: 100 mg intravenously/orally every 12 hours

Consider – surgical drainage

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ACUTE
|
tularaemia without meningitis
|
ulceroglandular form
Consider – 

surgical drainage

Additional treatment recommended for SOME patients in selected patient group

Surgical drainage of enlarged nodes in ulceroglandular tularaemia is frequently required for symptomatic relief.[1]​​

tularaemic meningitis

1st line – ciprofloxacin plus an aminoglycoside

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ACUTE
|
tularaemic meningitis
1st line – 

ciprofloxacin plus an aminoglycoside

Although there is little experience to provide guidance, tularaemic meningitis should be treated with a combination of ciprofloxacin and an aminoglycoside (e.g., gentamicin, streptomycin). The Centers for Disease Control and Prevention and World Health Organization (WHO) recommend gentamicin first-line for the treatment of severe tularaemia.[16][18]​​​ The WHO recommends streptomycin as an alternative.​[18]​​

Treatment should be considered in consultation with an infectious disease specialist.[16]

Treatment course: at least 10-14 days, but depends on the clinical response.

Primary options

ciprofloxacin: children: 15 mg/kg intravenously/orally every 12 hours, maximum 800 mg/day; adults: 400 mg intravenously every 12 hours, or 500 mg orally twice daily

and

gentamicin: children: 2.5 mg/kg intravenously/intramuscularly every 8 hours; adults: 5 mg/kg intravenously/intramuscularly every 24 hours

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Secondary options

ciprofloxacin: children: 15 mg/kg intravenously/orally every 12 hours, maximum 800 mg/day; adults: 400 mg intravenously every 12 hours, or 500 mg orally twice daily

and

streptomycin: children: 15 mg/kg intramuscularly every 12 hours, maximum 2 g/day; adults: 1 g intramuscularly every 12 hours

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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