Consensus statement ularemia, a bacterial zoono

TREATMENT

Contained Casualty Situation

Adults. In a contained casualty situa- tion, in which logistics permit indi- vidual medical management, the work- ing group recommends parenteral antimicrobial therapy for tularemia (TABLE 2). Streptomycin is the drug of choice.49,74,90,91 Gentamicin, which is more widely available and may be used intravenously, is an acceptable al- ternative.49,74,90-93 Treatment with aminoglycosides should be continued for 10 days. Tetracyclines and chlor- amphenicol are also used to treat tula- remia49,74,90; however, relapses and pri- mary treatment failures occur at a higher rate with these bacteriostatic agents than with aminoglycosides, and they should be given for at least 14 days to reduce chance of relapse.27,74,90 Fluo- roquinolones, which have intracellu- lar activity, are promising candidates for treating tularemia. Ciprofloxacin, which is not labeled for use in tulare- mia, has been shown to be active against F tularensis in vitro94 and in animals95 and has been used to successfully treat tularemia in both adults and chil-

dren.90,94,96,97 Treatment with cipro- floxacin should be continued for 10 days. In persons beginning treatment with parenteral doxycycline, cipro- floxacin, or chloramphenicol, therapy can be switched to oral antibiotic ad- ministration when clinically indi- cated. Very limited experiences in treat- ing tularemia patients with β-lactam and macrolide antibiotics have been re- ported, and treatment failures have oc- curred.98 Use of β-lactam and macro- lide antibiotics in treating tularemia is neither FDA-approved nor recom- mended by the working group.

Children. In children, streptomycin

or gentamicin is recommended by the working group as first-line treatment in a contained casualty situation (Table 2). Doxycycline, ciprofloxacin (≤1 g/d), and chloramphenicol can be used as alter- natives to aminoglycosides. Fluoroqui- nolones have been reported to cause car- tilage damage in immature animals and are not FDA-approved for use in chil- dren. However, short courses of these agents have not been associated with ar- thropathy in pediatric patients, and the potential risks of their use must be weighed against their benefits in treat- ing serious infections.96,99,100