Key points
- Treatment regimens may need to be adjusted depending on a person’s age, medical history, underlying health conditions, pregnancy status, or allergies.
- Vaccination for tularemia is not generally available in the United States, nor is it useful to manage sick patients.
Treatment recommendations
| Population | Antimicrobial Class | Antimicrobial | Dosage | Duration (Days) |
|---|---|---|---|---|
| Adults aged ≥18 yrs | Fluoroquinolone | Ciprofloxacin* | 400 mg every 8 hrs IV or 750 mg every 12 hrs PO | 10 |
| Levofloxacin* | 750 mg every 24 hrs IV or PO | 10 | ||
| Aminoglycoside | Gentamicin* | 6 mg/kg every 24 hrs IV or IM † | 10 | |
| Tetracycline | Doxycycline | 200 mg loading dose, then 100 mg every 12 hrs IV or PO | 14–21 | |
| Children aged ≥1 mo. to ≤17 yrs | Fluoroquinolone | Ciprofloxacin* | 10 mg/kg every 8-12 hrs IV (maximum 400 mg/dose) or 15 mg/kg every 8-12 hrs PO (maximum 500 mg/dose every 8 hrs or 750 mg/dose every 12 hrs) | 10 |
| Levofloxacin* | Infants and children aged Children aged ≥5 yrs and adolescents: 10 mg/kg every 24 hours IV or PO (maximum 750 mg/dose) | 10 | ||
| Aminoglycoside | Gentamicin* | 5-7.5 mg/kg every 24 hrs IV or IM † (mg/kg dose determined by age;** upper range can be increased to 9.5 mg/kg based on age and AUC monitoring) | 10 | |
| Tetracycline | Doxycycline | 4.4 mg/kg loading dose (maximum 200 mg), then 2.2 mg/kg every 12 hrs IV or PO (maximum 100 mg/dose) | 14–21 |
*Not approved by the Food and Drug Administration (FDA) for treatment of tularemia. Ciprofloxacin, levofloxacin, and gentamicin have been used frequently off label for the treatment of naturally occurring tularemia in humans.
† Extended-interval dosing. Monitor drug levels and renal function; extend interval further (beyond 24 hours) if indicated.
** Adjust dose as needed based on drug levels and renal function. Consult local guidelines. Certain references suggest 7.5 mg/kg/day IV or IM every 24 hours for patients aged 1 month to ≤10 years and 6 mg/kg/day IV or IM every 24 hours for patients aged >10 years (Sources: Bialkowski S, Staatz CE, Clark J, Lawson R, Hennig S. Gentamicin pharmacokinetics and monitoring in pediatric patients with febrile neutropenia. Ther Drug Monit 2016;38:693–8 and Hartman SJF, Orriëns LB, Zwaag SM, Poel T, de Hoop M, de Wildt SN. External validation of model-based dosing guidelines for vancomycin, gentamicin, and tobramycin in critically ill neonates and children: a pragmatic two-center study. Paediatr Drugs 2020;22:433–44).
Health care providers should use clinical judgment and consider extending treatment for patients with persistent fevers, abscesses, or other concerning signs.
For patients with severe infection, health care providers should consider treating initially with an aminoglycoside, if possible. Combination therapy with two classes of effective antimicrobials can also be used for severe tularemia (e.g., gentamicin plus ciprofloxacin, or gentamicin plus doxycycline), although there is minimal evidence that initial treatment with two distinct classes of antimicrobials improves outcomes. Doxycycline monotherapy should not be used for patients with severe infection or substantial delays in treatment (>2 weeks).
Treatment recommendations for geriatric and immunocompromised patients do not differ from those for the general population. However, healthcare providers should recognize the potential for polypharmacy with resultant drug-drug interactions and adjust antimicrobials accordingly.
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