Treating Tularemia: CDC’s Antibiotic Doses for Adults and Children

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Tularemia is treated with antibiotics, and there is no vaccine to fall back on: vaccination is not generally available in the United States, and it would not help a patient who is already sick. CDC's recommendations for health care providers are below. Regimens may need adjusting for a patient's age, medical history, underlying conditions, pregnancy or allergies.

Recommended regimens

Patient	Drug (class)	Dose	Days
Adults, 18+	Ciprofloxacin* (fluoroquinolone)	400 mg every 8 hrs IV, or 750 mg every 12 hrs PO	10
	Levofloxacin* (fluoroquinolone)	750 mg every 24 hrs IV or PO	10
	Gentamicin* (aminoglycoside)	6 mg/kg every 24 hrs IV or IM†	10
	Doxycycline (tetracycline)	200 mg loading dose, then 100 mg every 12 hrs IV or PO	14–21
Children, 1 month–17 years	Ciprofloxacin*	10 mg/kg every 8–12 hrs IV (max 400 mg/dose), or 15 mg/kg every 8–12 hrs PO (max 500 mg/dose every 8 hrs or 750 mg/dose every 12 hrs)	10
	Levofloxacin*	Under 5: 10 mg/kg every 12 hrs IV or PO (max 375 mg/dose). 5 and older, and adolescents: 10 mg/kg every 24 hrs IV or PO (max 750 mg/dose)	10
	Gentamicin*	5–7.5 mg/kg every 24 hrs IV or IM† — the mg/kg dose set by age;** the upper range can go to 9.5 mg/kg with age and AUC monitoring	10
	Doxycycline	4.4 mg/kg loading dose (max 200 mg), then 2.2 mg/kg every 12 hrs IV or PO (max 100 mg/dose)	14–21

IV = intravenous; IM = intramuscular; PO = by mouth; AUC = area under the curve, the drug exposure over 24 hours.

* Not FDA-approved for tularemia. Ciprofloxacin, levofloxacin and gentamicin have been used often, off label, for naturally occurring tularemia.
† Extended-interval dosing. Monitor drug levels and kidney function, and stretch the interval beyond 24 hours if needed.
** Adjust to drug levels and kidney function, and consult local guidelines. Some references suggest 7.5 mg/kg/day IV or IM every 24 hours for ages 1 month to 10 years, and 6 mg/kg/day for patients over 10 (Bialkowski et al., Ther Drug Monit 2016; Hartman et al., Paediatr Drugs 2020).

Severe and complicated cases

Start with an aminoglycoside if possible for a severe infection.
Two drug classes together — gentamicin plus ciprofloxacin, or gentamicin plus doxycycline — can be used for severe tularemia, though there is minimal evidence that starting with two classes improves outcomes.
Never doxycycline alone for a severe infection, or when treatment has been delayed more than 2 weeks.
Consider a longer course for persistent fever, abscesses or other worrying signs, using clinical judgment.

Older and immunocompromised patients

The recommendations are the same as for everyone else. But providers should watch for polypharmacy — interactions between an antibiotic and a patient's other medicines — and adjust accordingly.