Yersinia infection

Pre-exposure prophylaxis

• Pre-exposure prophylaxis is not considered necessary for healthcare workers who care for patients with pneumonic plague, as long as standard and droplet precautions can be maintained. Pre-exposure prophylaxis may be warranted in situations where there are mask shortages, patient overcrowding, poor ventilation, or other crisis situations, provided there is a sufficient supply of antibiotics available.[2]Nelson CA, Meaney-Delman D, Fleck-Derderian S, et al. Antimicrobial treatment and prophylaxis of plague: recommendations for naturally acquired infections and bioterrorism response. MMWR Recomm Rep. 2021 Jul 16;70(3):1-27. https://www.cdc.gov/mmwr/volumes/70/rr/rr7003a1.htm http://www.ncbi.nlm.nih.gov/pubmed/34264565?tool=bestpractice.com  

• The Centers for Disease Control and Prevention (CDC) recommends an oral fluoroquinolone (ciprofloxacin, levofloxacin) or a tetracycline antibiotic (doxycycline) as first-line options in nonpregnant adults and children. Moxifloxacin is also a first-line option for adults. Other drugs from these two classes are suitable alternatives, as well as trimethoprim/sulfamethoxazole, although the use of these drugs for prophylaxis may be off-label. A fluoroquinolone is the first-line option for pregnant women; however, the same drugs as used for nonpregnant adults may be used as alternatives.[2]Nelson CA, Meaney-Delman D, Fleck-Derderian S, et al. Antimicrobial treatment and prophylaxis of plague: recommendations for naturally acquired infections and bioterrorism response. MMWR Recomm Rep. 2021 Jul 16;70(3):1-27. https://www.cdc.gov/mmwr/volumes/70/rr/rr7003a1.htm http://www.ncbi.nlm.nih.gov/pubmed/34264565?tool=bestpractice.com The World Health Organization supports the use of ciprofloxacin, doxycycline (or tetracycline), and trimethoprim/sulfamethoxazole as first-line options for pre-exposure prophylaxis.[1]World Health Organization. WHO guidelines for plague management. May 2021 [internet publication]. https://www.who.int/publications/i/item/who-guidelines-for-plague-management Consult local protocols for antibiotic choice and dose. 

• Prophylaxis can be discontinued 48 hours after the last perceived exposure, although there are no data on the optimal duration.[2]Nelson CA, Meaney-Delman D, Fleck-Derderian S, et al. Antimicrobial treatment and prophylaxis of plague: recommendations for naturally acquired infections and bioterrorism response. MMWR Recomm Rep. 2021 Jul 16;70(3):1-27. https://www.cdc.gov/mmwr/volumes/70/rr/rr7003a1.htm http://www.ncbi.nlm.nih.gov/pubmed/34264565?tool=bestpractice.com  

• Patients who become symptomatic while receiving prophylaxis should be advised to visit their doctor to be reviewed and should start parenteral antibiotic treatment. See the Management section.

Vaccines

• A vaccine for plague is no longer available in the US due to a lack of efficacy for pneumonic plague, but novel vaccines are in development or available for experimental use.[2]Nelson CA, Meaney-Delman D, Fleck-Derderian S, et al. Antimicrobial treatment and prophylaxis of plague: recommendations for naturally acquired infections and bioterrorism response. MMWR Recomm Rep. 2021 Jul 16;70(3):1-27. https://www.cdc.gov/mmwr/volumes/70/rr/rr7003a1.htm http://www.ncbi.nlm.nih.gov/pubmed/34264565?tool=bestpractice.com  

Prevention of flea bites

• Flea bites may be prevented by applying suitable insect repellents. Rat populations in urban areas can be controlled by extermination and rat-proofing buildings, but control of wild populations is impractical and eradicating plague is impossible. Flea control is an important adjunct to rat control because fleas deprived of their natural food source are more likely to bite people. In an outbreak situation, flea control should be part of the environmental control measures used before rat extermination is considered.

Postexposure prophylaxis

• Consider postexposure prophylaxis for people who had close sustained contact (i.e., <6 feet [<2 meters]) with a patient with pneumonic plague and who were not wearing adequate personal protective equipment. Postexposure prophylaxis may also be considered for laboratory workers accidentally exposed to infectious materials and people who had close or direct contact with infected animals (e.g., pet owners, veterinary staff, hunters). Postexposure prophylaxis is not required in healthcare workers who follow standard and droplet precautions while caring for patients with pneumonic plague.[2]Nelson CA, Meaney-Delman D, Fleck-Derderian S, et al. Antimicrobial treatment and prophylaxis of plague: recommendations for naturally acquired infections and bioterrorism response. MMWR Recomm Rep. 2021 Jul 16;70(3):1-27. https://www.cdc.gov/mmwr/volumes/70/rr/rr7003a1.htm http://www.ncbi.nlm.nih.gov/pubmed/34264565?tool=bestpractice.com

• Rapid postexposure prophylaxis is recommended for exposed people in the event of an intentional release. Antibiotic monotherapy is recommended, with targeting of the drug choice as indicated if engineered resistance is detected.[2]Nelson CA, Meaney-Delman D, Fleck-Derderian S, et al. Antimicrobial treatment and prophylaxis of plague: recommendations for naturally acquired infections and bioterrorism response. MMWR Recomm Rep. 2021 Jul 16;70(3):1-27. https://www.cdc.gov/mmwr/volumes/70/rr/rr7003a1.htm http://www.ncbi.nlm.nih.gov/pubmed/34264565?tool=bestpractice.com

• The CDC recommends an oral fluoroquinolone (ciprofloxacin, levofloxacin) or a tetracycline antibiotic (doxycycline) as are considered the first-line options in nonpregnant adults and children. Moxifloxacin is also a first-line option for adults. Other drugs from these two classes are suitable alternatives, as well as trimethoprim/sulfamethoxazole, although the use of these drugs for prophylaxis may be off-label. A fluoroquinolone is the first-line option for pregnant women; however, the same drugs as used for nonpregnant adults may be used as alternatives.[2]Nelson CA, Meaney-Delman D, Fleck-Derderian S, et al. Antimicrobial treatment and prophylaxis of plague: recommendations for naturally acquired infections and bioterrorism response. MMWR Recomm Rep. 2021 Jul 16;70(3):1-27. https://www.cdc.gov/mmwr/volumes/70/rr/rr7003a1.htm http://www.ncbi.nlm.nih.gov/pubmed/34264565?tool=bestpractice.com The WHO supports the use of ciprofloxacin, doxycycline, or trimethoprim/sulfamethoxazole as first-line options for postexposure prophylaxis.[1]World Health Organization. WHO guidelines for plague management. May 2021 [internet publication]. https://www.who.int/publications/i/item/who-guidelines-for-plague-management Consult local protocols for antibiotic choice and dose.

• Treatment duration is 7 days.[2]Nelson CA, Meaney-Delman D, Fleck-Derderian S, et al. Antimicrobial treatment and prophylaxis of plague: recommendations for naturally acquired infections and bioterrorism response. MMWR Recomm Rep. 2021 Jul 16;70(3):1-27. https://www.cdc.gov/mmwr/volumes/70/rr/rr7003a1.htm http://www.ncbi.nlm.nih.gov/pubmed/34264565?tool=bestpractice.com

• Patients who become symptomatic while receiving prophylaxis should be advised to visit their doctor to be reviewed and should start parenteral antibiotic treatment. See the Management section.