Yersinia pestis infection medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Assistant Editors-In-Chief: Esther Lee, M.A.; João André Alves Silva, M.D. [2]; Alison Leibowitz [3]


When a diagnosis of plague is suspected, appropriate specimens for diagnosis should be obtained immediately and antimicrobial therapy should be started. [1][2] The drug of choice is either Streptomycin or Gentamicin, but Tetracyclines, Fluoroquinolones, and Chloramphenicol may also be effective. The treatment regimen should be adjusted depending on the patient's age, medical history, underlying health conditions, and allergies.[3] Upon evidence of pneumonia, patients with suspected plague should be placed in isolation and managed under respiratory droplet precautions.[4]. Supportive therapy includes aggressive monitoring and management for the possibility of complications such as septic shock, multiple organ failure, acute respiratory distress syndrome, and disseminated intravascular coagulopathy.

Medical Therapy

Antibiotic regimens

  • 1. Plague treatment[5]
  • Preferred regimen (1): Streptomycin 2 g/day IM q12h for at least 10 days
  • Note: Pediatric dose: Streptomycin 30 mg/kg/day (up to 2 g/day) IM q6-12h for at least 10 days
  • Preferred regimen (2): Gentamicin 3 mg/kg/day IM or IV q8h for at least 10 days
  • Note: Pediatric dose: Gentamicin 6-7.5 mg/kg/day IM or IV q8h for at least 10 days - if neonates/infants use 7.5 mg/kg/day.
  • Alternative regimen (1): Chloramphenicol 50 mg/kg/day IV or PO q6h for 10 days
  • Alternative regimen (2): Tetracycline 2 g/day PO qid for 10 days
  • Note: Pediatric dose: Tetracycline 15 mg/kg of loading dose THEN 25-50 mg/kg/day (up to 2 g/day) PO qid for 10 days
  • Alternative regimen (3): Sulfadiazine 2-4 g loading dose THEN 1 g PO q4-6h
  • Alternative regimen (4): Doxycycline 200 mg/day PO q12-24h
  • Note (1): Fluoroquinolones have good effect against Y. pestis in both in vitro and animal studies, but no studies have been published on its use in treating human plague.
  • Note (2): Other antibiotics have been shown ineffective against plague.
  • 2. Plague prophylaxis[6]
  • Note: Pediatric dose: Tetracycline 25-50 mg/kg/day (up to 2 g/day) PO qid for 10 days

Other Classes of Antibiotics

Other cases of antibiotics, such as penicillins, cephalosporins, and macrolides have demonstrated to be ineffective or of variable effect in the treatment of plague and should not be used for this purpose.[1]

Supportive Therapy

Clinicians must prepare for intense supportive management of plague complications, utilizing the latest developments for dealing with Gram-negative sepsis.[7] Aggressive monitoring and management should be instituted for the possibility of:[1]

Treatment of Plague During Pregnancy and in Children

With prompt and proper therapy, complications of plague in pregnancy can be prevented.

The selection of antibiotics during pregnancy is confounded by the potential adverse effects of three of the most effective drugs:


  1. 1.0 1.1 1.2 "Plague manual--epidemiology, distribution, surveillance and control". Wkly Epidemiol Rec. 74 (51–52): 447. 1999. PMID 10635759.
  2. Longo, Dan L. (Dan Louis) (2012). Harrison's principles of internal medici. New York: McGraw-Hill. ISBN 978-0-07-174889-6.
  3. "Plague".
  4. Garner JS (1996). "Guideline for isolation precautions in hospitals. The Hospital Infection Control Practices Advisory Committee". Infect Control Hosp Epidemiol. 17 (1): 53–80. PMID 8789689.
  7. Wheeler, Arthur P.; Bernard, Gordon R. (1999). "Treating Patients with Severe Sepsis". New England Journal of Medicine. 340 (3): 207–214. doi:10.1056/NEJM199901213400307. ISSN 0028-4793.
  8. Inglesby TV, Dennis DT, Henderson DA, Bartlett JG, Ascher MS, Eitzen E; et al. (2000). "Plague as a biological weapon: medical and public health management. Working Group on Civilian Biodefense". JAMA. 283 (17): 2281–90. PMID 10807389.

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