para>Use aminoglycosides and quinolones with caution. ‚
Pregnancy Considerations
Use aminoglycosides and quinolones with caution.
‚
GENERAL MEASURES
- Contact and respiratory droplet isolation; negative air pressure room not necessary
- Handle secretions carefully.
- Hydration, fever control, antibiotics, wet saline dressings for skin lesions
- Recovery requires intact cell-mediated immunity.
- Bacterium is readily killed by heat (56 ‚ °C for 10 minutes)
MEDICATION
First Line
- Aminoglycosides (gentamicin or streptomycin) are the antimicrobials of choice:
- Gentamicin: 5 mg/kg/day divided BID " “TID
- Routine serum level monitoring for aminoglycosides
- Streptomycin (classic drug of choice but may not be available): 15 to 20 mg/kg/day IM divided BID for 7 to 14 days, not to exceed 2 g/day
- Rarely used
- Potential vestibular or nephrotoxicity
- Concern over drug-resistant strains in biologic warfare
- Tularemic meningitis: CSF aminoglycoside levels vary so treat with an aminoglycoside plus chloramphenicol or doxycycline for 14 to 21 days, following clinical findings, fever as guide (4)[C],(8)[A].
- For mild/moderate disease
- Doxycycline 100 mg BID for 14 days
- Ciprofloxacin 500 to 750 mg BID for 14 days
- Doxycycline and ciprofloxacin are considered drugs of choice in mass-casualty situations (biowarfare). Prophylaxis after an aerosol exposure is effective if administered within 24 hours:
- Ciprofloxacin: 500 mg PO BID for 10 days; not approved, usually not recommended in pediatrics
- Doxycycline (Doryx, Vibra-Tabs, Vibramycin): 100 mg PO BID for 14 to 21 days; if ≥8 years
- Ž ²-Lactams (e.g., penicillin derivatives), most cephalosporins, clotrimazole, and many macrolides are ineffective or have resistance.
Second Line
- Chloramphenicol: may be difficult to obtain
- Tetracycline: higher relapse rate
- Fluoroquinolones (ciprofloxacin) are gaining wider acceptance, show high cure rates/low side effects, and may be used as alternative therapy against F. tularensis type B only.
ISSUES FOR REFERRAL
- Infectious disease consult
- Notify public health authorities.
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
- Depends on severity
- Hospitalize if fever with shortness of breath, concern for septicemia, or need for surgery
Discharge Criteria
Based on clinical improvement and the ability to tolerate oral antibiotics and adhere to treatment/follow-up recommendations ‚
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
- Monitor hearing during long-term therapy with aminoglycosides.
- Monitor renal function during long-term therapy with aminoglycosides or quinolones.
DIET
As tolerated, high-calorie, easily digestible ‚
PATIENT EDUCATION
For patient information, see the CDC Web site/FAQ and Key Facts on Tularemia: ‚
- http://www.bt.cdc.gov/agent/tularemia
- http://emergency.cdc.gov/agent/tularemia/facts.asp
PROGNOSIS
- Complete cure if treated early; immunity is lifelong.
- Mortality: <2% if treated; higher in typhoidal disease
COMPLICATIONS
- Lung abscess, adult respiratory distress syndrome (ARDS)
- Hepatic dysfunction, rhabdomyolysis, renal failure
- Osteomyelitis, meningitis, endocarditis, mediastinitis, pericarditis, peritonitis, conjunctivitis
- Drug-induced side effects (e.g., diarrhea, renal failure)
REFERENCES
11 Centers for Disease Control and Prevention. Reported tularemia cases " ”United States, 2004-2013. http://www.cdc.gov/tularemia/statistics/state.html. Accessed 2015.22 Adams ‚ DA, Gallagher ‚ KM, Jajosky ‚ RA, et al. Summary of notifiable diseases " ”United States, 2011. MMWR Morb Mortal Wkly Rep. 2013;60(53):1 " “117.33 Snowden ‚ J, Stovall ‚ S. Tularemia: retrospective review of 10 years ' experience in Arkansas. Clin Pediatr (Phila). 2011;50(1):64 " “68.44 Hofinger ‚ DM, Cardona ‚ L, Mertz ‚ GJ, et al. Tularemic meningitis in the United States. Arch Neurol. 2009;66(4):523 " “527.55 T ƒ ¤rnvik ‚ A, Chu ‚ MC. New approaches to diagnosis and therapy of tularemia. Ann N Y Acad Sci. 2007;1105:378 " “404.66 Maurin ‚ M, Castan ‚ B, Roch ‚ N, et al. Real-time PCR for diagnosis of oculoglandular tularemia. Emerg Infect Dis. 2010;16(1):152 " “153.77 Splettstoesser ‚ W, Guglielmo-Viret ‚ V, Seibold ‚ E, et al. Evaluation of an immunochromatographic test for rapid and reliable serodiagnosis of human tularemia and detection of Francisella tularensis-specific antibodies in sera from different mammalian species. J Clin Microbiol. 2010;48(5):1629 " “1634.88 Weber ‚ IB, Turabelidze ‚ G, Patrick ‚ S, et al. Clinical recognition and management of tularemia in Missouri: a retrospective records review of 121 cases. Clin Infect Dis. 2012;55(10):1283 " “1290.
ADDITIONAL READING
- Ata ‚ N, K „ ±l „ ± ƒ § ‚ S, ƒ –vet ‚ G, et al. Tularemia during pregnancy. Infection. 2013;41(4):753 " “756.
- Centers for Disease Control and Prevention. Tularemia " ”United States, 2001 " “2010. MMWR Morb Mortal Wkly Rep. 2013;62(47):963 " “966.
- Dennis ‚ DT, Inglesby ‚ TV, Henderson ‚ DA, et al. Tularemia as a biological weapon: medical and public health management. JAMA. 2001;285(21):2763 " “2773.
- Kosker ‚ M, Celik ‚ T, Yuksel ‚ D. Treatment of tularemia during pregnancy. J Infect Dev Ctries. 2015;9(1):118 " “119.
- L ƒ µhmus ‚ M, Janse ‚ I, van de Goot ‚ F, et al. Rodents as potential couriers for bioterrorism agents. Biosecur Bioterror. 2013;11(Suppl 1):S247 " “S257.
- Steinr ƒ ¼cken ‚ J, Graber ‚ P. Oropharyngeal tularemia. CMAJ. 2014;186(1):E62.
CODES
ICD10
- A21.9 Tularemia, unspecified
- A21.0 Ulceroglandular tularemia
- A21.1 Oculoglandular tularemia
- A21.8 Other forms of tularemia
- A21.3 Gastrointestinal tularemia
- A21.2 Pulmonary tularemia
- A21.7 Generalized tularemia
ICD9
- 021.9 Unspecified tularemia
- 021.0 Ulceroglandular tularemia
- 021.3 Oculoglandular tularemia
- 021.8 Other specified tularemia
- 021.1 Enteric tularemia
- 021.2 Pulmonary tularemia
SNOMED
- Tularemia (disorder)
- Ulceroglandular tularemia (disorder)
- Oculoglandular tularemia (disorder)
- Oropharyngeal tularemia
- Glandular tularemia (disorder)
- Pulmonary tularemia
- Enteric tularemia
CLINICAL PEARLS
- A high index of suspicion is required to make the diagnosis of tularemia. Consider biologic terrorism based on epidemiologic presentation. If bioterrorism is suspected, contact appropriate authorities and coordinate rapid diagnostic testing through the Laboratory Response Network 1-866-576-5227.
- Treat suspected or confirmed cases.
- Aminoglycosides are treatment of choice.
- Serologic and special ELISA studies (and PCR/real-time PCR studies where available) are recommended for diagnosis. A CDC 24-hour/7-day-a-week toll-free hotline is available at 800-232-4636 to answer clinical questions.