Clinical Care of Plague

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.
Doctors examining a bubo caused by plague.

Treatment options

DO NOT WAIT FOR DIAGNOSTIC TEST RESULTS IF YOU SUSPECT PLAGUE‎

A confirmatory diagnosis can be established later using specialized laboratory tests. Never delay or withhold treatment pending the receipt of laboratory test results. The decision to initiate antibiotic therapy for plague should be made based on clinical signs and symptoms and a careful patient history. A recent flea bite, exposure to areas with rodents, or contact with a sick or dead animal are risk factors for plague in endemic areas.

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:

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

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