Yersinia pestis infection medical therapy
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When a diagnosis of plague is suspected, appropriate specimens for diagnosis should be obtained immediately and antimicrobial therapy should be started.  The drug of choice is either Streptomycin or Gentamicin, but Tetracyclines, Fluoroquinolones, and Chloramphenicol may also be effective. The treatment regimen should be adjusted depending on the patient's age, medical history, underlying health conditions, and allergies. Upon evidence of pneumonia, patients with suspected plague should be placed in isolation and managed under respiratory droplet precautions.. Supportive therapy includes aggressive monitoring and management for the possibility of complications such as septic shock, multiple organ failure, acute respiratory distress syndrome, and disseminated intravascular coagulopathy.
- 1. Plague treatment
- Preferred regimen (1): Streptomycin 2 g/day IM q12h for at least 10 days
- Note: Pediatric dose: Streptomycin 30 mg/kg/day (up to 2 g/day) IM q6-12h for at least 10 days
- Preferred regimen (2): Gentamicin 3 mg/kg/day IM or IV q8h for at least 10 days
- Note: Pediatric dose: Gentamicin 6-7.5 mg/kg/day IM or IV q8h for at least 10 days - if neonates/infants use 7.5 mg/kg/day.
- Alternative regimen (1): Chloramphenicol 50 mg/kg/day IV or PO q6h for 10 days
- Alternative regimen (2): Tetracycline 2 g/day PO qid for 10 days
- Note: Pediatric dose: Tetracycline 15 mg/kg of loading dose THEN 25-50 mg/kg/day (up to 2 g/day) PO qid for 10 days
- Alternative regimen (3): Sulfadiazine 2-4 g loading dose THEN 1 g PO q4-6h
- Alternative regimen (4): Doxycycline 200 mg/day PO q12-24h
- Note (1): Fluoroquinolones have good effect against Y. pestis in both in vitro and animal studies, but no studies have been published on its use in treating human plague.
- Note (2): Other antibiotics have been shown ineffective against plague.
- 2. Plague prophylaxis
- Preferred regimen: Tetracycline 1-2 g/day PO bid-qid
- Note: Pediatric dose: Tetracycline 25-50 mg/kg/day (up to 2 g/day) PO qid for 10 days
- Alternative regimen (1): Doxycycline 100-200 mg/day PO q12-24h
- Alternative regimen (2): Sulfamethoxazole-Trimethoprim 1.6 g/day PO bid
- Note: Pediatric dose: Sulfamethoxazole-Trimethoprim 40 mg/kg/day PO bid
Other Classes of Antibiotics
Other cases of antibiotics, such as penicillins, cephalosporins, and macrolides have demonstrated to be ineffective or of variable effect in the treatment of plague and should not be used for this purpose.
Clinicians must prepare for intense supportive management of plague complications, utilizing the latest developments for dealing with Gram-negative sepsis. Aggressive monitoring and management should be instituted for the possibility of:
- Septic shock
- Multiple organ failure
- Adult respiratory distress syndrome (ARDS)
- Disseminated intravascular coagulopathy
Treatment of Plague During Pregnancy and in Children
- Streptomycin may be ototoxic and nephrotoxic to the fetus.
- Tetracycline has an adverse effect on the developing teeth and bones of a fetus.
- Chloramphenicol carries a low risk of "gray baby" syndrome or bone marrow suppression.
- A judiciously administered aminoglycoside is effective and safe for both the mother and fetus, and in children. Because of its intravenous and intramuscular administration and its low risk of adverse effects, gentamicin is the preferred antibiotic for treating plague during pregnancy.
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