What is the treatment for the plague?

Treatment of Plague: A Comprehensive Guide

The most effective treatment for plague is dual antimicrobial therapy with a fluoroquinolone (ciprofloxacin, levofloxacin, or moxifloxacin) plus an aminoglycoside (gentamicin or streptomycin) for 10-14 days, which significantly reduces mortality across all clinical forms of plague. 1, 2

Clinical Forms of Plague

Bubonic Plague

• Characterized by painful, swollen lymph nodes (buboes)
• 50% mortality if untreated, reduced to 5-10% with appropriate treatment
• Most common form of naturally occurring plague

Pneumonic Plague

• Highly contagious through respiratory droplets
• Almost always fatal if untreated
• Requires respiratory isolation for at least 48 hours after starting effective therapy

Septicemic Plague

• Occurs with or without buboes
• Higher fatality rate than bubonic plague
• Requires aggressive treatment

Other Forms

• Meningeal plague
• Pharyngeal plague

First-Line Treatment Regimens

Adults with Pneumonic or Septicemic Plague

Antimicrobial	Dosage
Ciprofloxacin	400 mg every 8 hrs IV or 750 mg every 12 hrs PO
Levofloxacin	750 mg every 24 hrs IV or PO
Moxifloxacin	400 mg every 24 hrs IV or PO
Gentamicin	5 mg/kg every 24 hrs IV or IM
Streptomycin	15 mg/kg every 12 hrs IM (maximum 1 g/dose)

Adults with Bubonic Plague

• Same medications as above, but monotherapy may be sufficient for uncomplicated cases
• Dual therapy recommended if signs of progression to septicemic or pneumonic plague

Children

Antimicrobial	Dosage
Ciprofloxacin	10 mg/kg every 8-12 hrs IV or 15 mg/kg every 8-12 hrs PO
Gentamicin	4.5-7.5 mg/kg every 24 hrs IV or IM
Streptomycin	20-40 mg/kg/day in divided doses (maximum 2 g/day) [3]
Doxycycline (>8 years)	Age-appropriate dosing [4]

Treatment Algorithm

1. Initial Assessment:

   • Identify clinical form (bubonic, pneumonic, septicemic)
   • Assess severity (presence of sepsis, respiratory distress)
   • Consider potential bioterrorism exposure

2. Treatment Selection:

   • For severe pneumonic or septicemic plague or suspected bioterrorism: Start dual therapy with two distinct classes of antimicrobials
   • For uncomplicated bubonic plague: Monotherapy with a fluoroquinolone or aminoglycoside may be sufficient

3. Duration:

   • 10-14 days of treatment for all forms
   • Continue until patient is afebrile for at least 48 hours

4. Monitoring:

   • Monitor for clinical improvement within 24-48 hours
   • Check aminoglycoside levels as indicated
   • Adjust therapy based on culture and sensitivity results when available

Special Populations

Pregnant Women

• Fluoroquinolones remain first-line despite pregnancy
• Gentamicin is an acceptable alternative requiring monitoring
• Avoid doxycycline if possible

Children

• Same first-line agents as adults with adjusted dosing
• Doxycycline should only be used in children <8 years when other options are exhausted due to dental staining risk

Immunocompromised

• Dual therapy recommended
• Longer duration may be necessary

Treatment Outcomes

Survival rates with appropriate treatment:

• Aminoglycosides: 83-91% survival
• Tetracyclines: 95-98% survival
• Fluoroquinolones: 100% survival (limited data) 2

Critical Considerations

• Early treatment is essential - mortality increases significantly with delays beyond 24 hours 1, 5
• Dual therapy is crucial for suspected bioterrorism cases due to potential engineered resistance 1
• Respiratory isolation is necessary for pneumonic plague to prevent transmission 2
• Avoid beta-lactam antibiotics due to potential poor efficacy 2

Common Pitfalls to Avoid

1. Delayed diagnosis and treatment - plague should be considered in endemic areas when patients present with compatible symptoms
2. Inadequate isolation - pneumonic plague requires respiratory droplet precautions
3. Monotherapy in severe cases - dual therapy is recommended for severe disease
4. Insufficient treatment duration - complete the full 10-14 day course
5. Failure to monitor for toxicity - aminoglycosides require monitoring for nephrotoxicity and ototoxicity

Early recognition and prompt initiation of appropriate antimicrobial therapy are the most critical factors in reducing mortality from plague 6, 7.