Key points
- Begin appropriate therapy as soon as plague is suspected.
- Patients can be treated with intravenous or oral antimicrobials, depending on severity of illness and other clinical factors.
- Local and state health departments should be notified immediately.
Treatment options
DO NOT WAIT FOR DIAGNOSTIC TEST RESULTS IF YOU SUSPECT PLAGUE
Begin appropriate therapy as soon as plague is suspected. Gentamicin and fluoroquinolones are first-line treatments in the United States. Duration of treatment is 10 to 14 days, but treatment can be extended for patients with ongoing fever or other concerning signs. Patients can be treated with intravenous or oral antimicrobials, depending on severity of illness and other clinical factors.
The regimens listed below may need to be adjusted depending on a patient's age, medical history, underlying health conditions, or allergies. Please use clinical judgment and, if needed, consult an infectious disease specialist regarding individual patient treatment decisions.
Additional information:
- Nelson CA, Meaney-Delman D, Fleck-Derderian S, et al. Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response. MMWR Morb Mortal Wkly Rep. 2021 Jul 16;70(3):1-27.
- Koirala J. Plague: disease, management, and recognition of act of terrorism. Infect Dis Clin North Am. 2006 Jun;20(2):273-87, viii.
Treatment recommendations
Pediatric regimens are for children aged ≥1 month to ≤17 years. Only first-line treatment options are listed here. For additional treatment options, see: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response.
Recommended antibiotic treatment for plague
| Antibiotic | Dose | Route of administration | Notes |
|---|---|---|---|
| Ciprofloxacin | Adults: 400 mg every 8 hrs | IV | FDA approved based on animal studies and clinical data. |
| Children: 10 mg/kg every 8 or 12 hrs (maximum 400 mg/dose) | |||
| Adults: 750 mg every 12 hrs | PO | ||
| Children: 15 mg/kg every 8 or 12 hrs (maximum 500 mg/dose every 8 hrs or 750 mg/dose every 12 hrs) | |||
| Levofloxacin | Adults: 750 mg every 24 hrs | IV or PO | FDA approved based on animal studies; clinical data for human plague is limited. |
| Children: Weight <50 kg: 8 mg/kg every 12 hrs Weight ≥50 kg: 500-750 mg every 24 hrs |
|||
| Moxifloxacin | Adults: 400 mg every 24 hrs | IV or PO | FDA approved based on animal studies; clinical data for human plague is limited. Moxifloxacin is a first-line treatment for adults but an alternative for children, since it is not FDA approved for use in children aged ≤17 years. |
| Children: see notes | |||
| Gentamicin | Adults: 5 mg/kg every 24 hrs | IV or IM | Not FDA approved but considered an effective alternative to streptomycin. |
| Children: 4.5-7.5 mg/kg every 24 hrs | |||
| Streptomycin | Adults: 1 g every 12 hrs | IV or IM | FDA approved based on clinical experience. Not widely available in the US. The IV formulation is not approved by FDA; however, the IM formulation has been given IV as an off-label use. |
| Children: 15 mg/kg every 12 hrs (maximum 1 g/dose) |
Pediatric regimens are for children aged ≥1 month to ≤17 years. Only first-line treatment options are listed here. For additional treatment options, see: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response
| Antimicrobial | Dose | Route of administration | Notes |
|---|---|---|---|
| Ciprofloxacin | Adults: 400 mg every 8 hrs | IV | FDA approved based on animal studies and clinical data. |
| Children: 10 mg/kg every 8 or 12 hrs (maximum 400 mg/dose) | |||
| Adults: 750 mg every 12 hrs | PO | ||
| Children: 15 mg/kg every 8 or 12 hrs (maximum 500 mg/dose every 8 hrs or 750 mg/dose every 12 hrs) | |||
| Levofloxacin | Adults: 750 mg every 24 hrs | IV or PO | FDA approved based on animal studies; clinical data for human plague is limited. |
| Children: Weight <50 kg: 8 mg/kg every 12 hrs (maximum 250 mg/dose) Weight ≥50 kg: 500-750 mg every 24 hrs |
|||
| Moxifloxacin | Adults: 400 mg every 24 hrs | IV or PO | FDA approved based on animal studies; clinical data for human plague is limited. Moxifloxacin is a first-line treatment for adults but an alternative for children, since it is not FDA approved for use in children aged ≤17 years. |
| Children: see notes | |||
| Doxycycline | Adults: 200 mg loading dose, then 100 mg every 12 hrs | IV or PO | Bacteriostatic, but FDA approved and effective in a randomized trial when compared to gentamicin. No evidence of tooth staining after multiple short courses. |
| Children: Weight <45 kg: 4.4 mg/kg loading dose, then 2.2 mg/kg every 12 hrs (maximum 100 mg/dose)
Weight ≥45 kg: same as adult dose |
|||
| Gentamicin | Adults: 5 mg/kg every 24 hrs | IM or IV | Not FDA approved but considered an effective alternative to streptomycin. |
| Children: 4.5-7.5 mg/kg every 24 hrs | |||
| Streptomycin | Adults: 1 g every 12 hrs | IM or IV | FDA approved based on clinical experience. Not widely available in the US. The IV formulation is not approved by FDA; however, the IM formulation has been given IV as an off-label use. |
| Children: 15 mg/kg every 12 hrs (maximum 1 g/dose) |
Only first-line treatment options are listed here. For additional treatment options, see: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response
| Antimicrobial | Dose | Route of administration | Notes |
|---|---|---|---|
| Gentamicin
AND ONE OF THE FOLLOWING |
Same as adult dose | IM or IV | Not FDA approved but considered an effective alternative to streptomycin. |
| Ciprofloxacin
OR |
400 mg every 8 hrs for IV or
500 mg every 8 hrs for PO |
IV or PO | FDA approved based on animal studies and clinical data. |
| Levofloxacin | Same as adult dose | IV or PO | FDA approved based on animal studies; clinical data for human plague is limited. |
Pre-exposure prophylaxis for first responders and health care providers who will care for patients with pneumonic plague is not considered necessary as long as standard and droplet precautions can be maintained. In cases of surgical mask shortages, patient overcrowding, poor ventilation in hospital wards, or other situations, pre-exposure prophylaxis might be warranted if sufficient supplies of antimicrobials are available. Prophylaxis can be discontinued 48 hours after the last perceived exposure. For more information, see Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response.
Post-exposure prophylaxis is indicated for persons with known exposure to plague, such as close (< 6 ft), sustained contact with a patient or animal with pneumonic plague or direct contact with infected body fluids or tissues. Post-exposure prophylaxis should be given for 7 days. Prophylaxis with a single antimicrobial agent is recommended for potentially exposed persons following a case of naturally acquired infection or intentional release of Y. pestis. If engineered resistance is detected in the aftermath of a bioterrorism attack, antimicrobial choice can be targeted based on available information. For more information, see Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response.
Pediatric regimens are for children aged ≥1 month to ≤17 years. Only first-line prophylaxis options are listed here. For additional prophylaxis options, see: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response
Recommended antimicrobial pre-and post-exposure prophylaxis for plague pdf icon[PDF – 1 page] – Print only
| Antimicrobial | Dose | Route of administration | |
|---|---|---|---|
| Adults | Ciprofloxacin | 500-750 mg every 12 hrs | PO |
| Levofloxacin | 500-750 mg every 24 hrs | PO | |
| Moxifloxacin | 400 mg every 24 hrs | PO | |
| Doxycycline | 100 mg every 12 hrs | PO | |
| Children | Ciprofloxacin | 15 mg/kg every 12 hrs (maximum 750 mg/dose) | PO |
| Levofloxacin | Weight <50 kg: 8 mg/kg every 12 hrs (maximum 250 mg/dose)
Weight ≥50 kg: 500-750 mg every 24 hrs |
PO | |
| Doxycycline | Weight <45 kg: 2.2 mg/kg every 12 hrs
Weight ≥45 kg: 100 mg every 12 hrs |
PO | |
| Pregnant women | Ciprofloxacin | 500 mg every 8 hrs or 750 mg every 12 hrs | PO |
| Levofloxacin | 750 mg every 24 hrs | PO |
- Apangu T, Griffith K, Abaru J, et al. Successful treatment of human plague with oral ciprofloxacin. Emerg Infect Dis. 2017;23:553-5.
- Boulanger LL, Ettestad P, Fogarty JD, Dennis DT, Romig D, Mertz G. Gentamicin and tetracyclines for the treatment of human plague: Review of 75 cases in New Mexico, 1985–1999. Clin Infect Dis. 2004 38(5):663-669.
- Morris JT, Cooper RH. Intravenous streptomycin: a useful route of administration. Clin Infect Dis. 1994;19:1150–1.
- Mwengee W, Butler T, Mgema S, Mhina G, Almasi Y, Bradley C, Formanik JB, Rochester CG. Treatment of plague with gentamicin or doxycycline in a randomized clinical trial in Tanzania. Clin Infect Dis. 2006 42(5):614-21.
- Todd SR, Dahlgren FS, Traeger MS, Beltrán-Aguilar ED, Marianos DW, Hamilton C, McQuiston JH, Regan JJ. No visible dental staining in children treated with doxycycline for suspected Rocky Mountain spotted fever. J Pediatr. 2015 May;166(5):1246-51.