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.
Hospitalization and administration of parenteral antibiotics are required for patients with suspected tularemia that presents with systemic inflammatory response syndrome (SIRS), with bacteremia, 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.[15] In other countries, the choice of agent depends on local guidance and availability of these drugs. 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.[17]
Fluoroquinolones (e.g., ciprofloxacin) seem to be effective in milder cases of tularemia, although experience with their use is limited. The CDC recommends ciprofloxacin as a suitable agent for nonsevere cases of tularemia.[15][20]
Parenteral therapy with an aminoglycoside should be administered to any patient judged with serious enough infection to necessitate hospitalization. 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 nonsevere cases of tularemia.[15] 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.[15][17] Relapse may occur and should be treated with an additional 7 to 14 days of therapy.
Although there is little experience to provide guidance, tularemic meningitis should be treated with a combination of ciprofloxacin and an aminoglycoside. Treatment should be considered in consultation with an infectious disease specialist.[15]
Pregnant patients are not treated differently from nonpregnant 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.[21][22]
Surgical drainage
Surgical drainage of enlarged nodes in ulceroglandular tularemia is frequently required for symptomatic relief.[1]
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