Yersinia pestis infection medical therapy: Difference between revisions

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Latest revision as of 00:46, 30 July 2020

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]

Overview

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]

Preferred regimen: Tetracycline 1-2 g/day PO bid-qid

Note: Pediatric dose: Tetracycline 25-50 mg/kg/day (up to 2 g/day) PO qid for 10 days

Alternative regimen (1): Doxycycline 100-200 mg/day PO q12-24h
Alternative regimen (2): Sulfamethoxazole-Trimethoprim 1.6 g/day PO bid

Note: Pediatric dose: Sulfamethoxazole-Trimethoprim 40 mg/kg/day PO bid

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:

Streptomycin may be ototoxic and nephrotoxic to the fetus.
Tetracycline has an adverse effect on the developing teeth and bones of a fetus.
Chloramphenicol carries a low risk of "gray baby" syndrome or bone marrow suppression.
A judiciously administered aminoglycoside is effective and safe for both the mother and fetus, and in children. Because of its intravenous and intramuscular administration and its low risk of adverse effects, gentamicin is the preferred antibiotic for treating plague during pregnancy.^[8]

References

↑ ^1.0 ^1.1 ^1.2 "Plague manual--epidemiology, distribution, surveillance and control". Wkly Epidemiol Rec. 74 (51–52): 447. 1999. PMID 10635759.
↑ Longo, Dan L. (Dan Louis) (2012). Harrison's principles of internal medici. New York: McGraw-Hill. ISBN 978-0-07-174889-6.
↑ "Plague".
↑ 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.
↑ http://www.who.int/csr/resources/publications/plague/whocdscsredc992b.pdf
↑ http://www.who.int/csr/resources/publications/plague/whocdscsredc992b.pdf
↑ 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.
↑ 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.

Template:WikiDoc Sources

[pmid10635759-1] 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.

[CDC-3] "Plague".

[pmid8789689-4] 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.

[5] ttp://www.who.int/csr/resources/publications/plague/whocdscsredc992b.pdf

[6] ttp://www.who.int/csr/resources/publications/plague/whocdscsredc992b.pdf

[WheelerBernard1999-7] 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.

[pmid10807389-8] 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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[3]

[4]

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@@ Line 1: / Line 1: @@
+__NOTOC__
 {{Yersinia pestis infection}}
-{{CMG}}; '''Assistant Editors-In-Chief:''' [[Esther Lee, M.A.]]
+{{CMG}}; '''Assistant Editors-In-Chief:''' [[Esther Lee, M.A.]]; {{JS}}; {{AJL}}
 ==Overview==
-A plague vaccine is not currently available for use in the United States.
+When a diagnosis of plague is suspected, appropriate specimens for diagnosis should be obtained immediately and antimicrobial therapy should be started. <ref name="pmid10635759">{{cite journal| author=| title=Plague manual--epidemiology, distribution, surveillance and control. | journal=Wkly Epidemiol Rec | year= 1999 | volume= 74 | issue= 51-52 | pages= 447 | pmid=10635759 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10635759  }} </ref><ref>{{Cite book  | last1 = Longo | first1 = Dan L. (Dan Louis) | title = Harrison's principles of internal medici | date = 2012 | publisher = McGraw-Hill | location = New York | isbn = 978-0-07-174889-6 | pages =  }}</ref> 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.<ref name=CDC>{{cite web | title = Plague | url = http://www.cdc.gov/plague/healthcare/clinicians.html }}</ref>  Upon evidence of [[pneumonia]], patients with suspected plague should be placed in isolation and managed under respiratory droplet precautions.<ref name="pmid8789689">{{cite journal| author=Garner JS| title=Guideline for isolation precautions in hospitals. The Hospital Infection Control Practices Advisory Committee. | journal=Infect Control Hosp Epidemiol | year= 1996 | volume= 17 | issue= 1 | pages= 53-80 | pmid=8789689 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8789689  }} </ref>.  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]].
-According to treatment experts, a patient diagnosed with suspected plague should be hospitalized and medically isolated. Laboratory tests should be done, including blood cultures for plague bacteria and microscopic examination of [[lymph gland]], [[blood]], and [[sputum]] samples. [[Antibiotic treatment]] should begin as soon as possible after laboratory specimens are taken. Effective antibiotics are:
-*[[Streptomycin]] (First line)
-*[[Gentamicin]] (Used when streptomycin is not available)
-*[[Tetracyclines]]
-*[[Chloramphenicol]] (Used for critically ill patients, or rarely for suspected neuro-involvement)
-Persons who have been in close contact with a plague patient, particularly a patient with plague pneumonia, should be identified and evaluated. The [[U.S. Public Health Service]] requires that all cases of suspected plague be reported immediately to local and state health departments and that the diagnosis be confirmed by [[CDC]]. As required by the International Health Regulations, [[CDC]] reports all U.S. plague cases to the [[World Health Organization]].
 ==Medical Therapy==
-Early treatment of [[pneumonic plague]] is essential. To prevent a high risk of death, antibiotics should be given within 24 hours of the first symptoms. Several types of [[antibiotics]] are effective for curing the disease and for preventing it.
-===Oral ===
+====Antibiotic regimens====
-*[[tetracycline]] (such as [[doxycycline]])
+:*1. ''' Plague treatment'''<ref>http://www.who.int/csr/resources/publications/plague/whocdscsredc992b.pdf</ref>
-*[[fluoroquinolone]] (such as [[ciprofloxacin]]).
+::* 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'''<ref>http://www.who.int/csr/resources/publications/plague/whocdscsredc992b.pdf</ref>
+::* Preferred regimen: [[Tetracycline]]  1-2 g/day PO bid-qid
+:::* Note: Pediatric dose: [[Tetracycline]] 25-50 mg/kg/day (up to 2 g/day) PO qid for 10 days
+::* Alternative regimen (1): [[Doxycycline]] 100-200 mg/day PO q12-24h
+::* Alternative regimen (2): [[Sulfamethoxazole-Trimethoprim]] 1.6 g/day PO bid
+:::* Note: Pediatric dose: [[Sulfamethoxazole-Trimethoprim]] 40 mg/kg/day PO bid
-===Injection or intravenous medications (Preferred in pulmonary or advanced cases)===
+====Other Classes of Antibiotics====
-*[[streptomycin]]
+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.<ref name="pmid10635759">{{cite journal| author=| title=Plague manual--epidemiology, distribution, surveillance and control. | journal=Wkly Epidemiol Rec | year= 1999 | volume= 74 | issue= 51-52 | pages= 447 | pmid=10635759 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10635759  }} </ref>
-*[[Gentamicin]]
-Early in the response to a bioterrorism attack, the above drugs would be tested to determine which is most effective against the particular weapon that was used.
+==Supportive Therapy==
+Clinicians must prepare for intense supportive management of plague [[complications]], utilizing the latest developments for dealing with [[Gram-negative]] [[sepsis]].<ref name="WheelerBernard1999">{{cite journal|last1=Wheeler|first1=Arthur P.|last2=Bernard|first2=Gordon R.|title=Treating Patients with Severe Sepsis|journal=New England Journal of Medicine|volume=340|issue=3|year=1999|pages=207–214|issn=0028-4793|doi=10.1056/NEJM199901213400307}}</ref>  Aggressive monitoring and management should be instituted for the possibility of:<ref name="pmid10635759">{{cite journal| author=| title=Plague manual--epidemiology, distribution, surveillance and control. | journal=Wkly Epidemiol Rec | year= 1999 | volume= 74 | issue= 51-52 | pages= 447 | pmid=10635759 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10635759  }} </ref>
+* [[Septic shock]]
+* [[Multiple organ failure]]
+* [[Adult respiratory distress syndrome]] ([[ARDS]])
+* [[Disseminated intravascular coagulopathy]]
-Antibiotic treatment for 7 days will protect people who have had direct, close contact with infected patients. Wearing a close-fitting surgical mask also protects against infection. However, antibiotic treatment alone is insufficient for some patients, who may also require circulatory, ventilator, or [[kidney|renal]] support.
+==Treatment of Plague During Pregnancy and in Children==
+With prompt and proper therapy, [[complications]] of plague in [[pregnancy]] can be prevented.
-In an emergency department setting, [[Harrison's Principles of Internal Medicine|Harrison's ''Principles of Internal Medicine'']]  outlines the following treatment course.<ref name="isbn0-07-140235-7">{{cite book |author=Jameson, J. N. St C.; Dennis L. Kasper; Harrison, Tinsley Randolph; Braunwald, Eugene; Fauci, Anthony S.; Hauser, Stephen L; Longo, Dan L. |title=Harrison's principles of internal medicine |publisher=McGraw-Hill Medical Publishing Division |location=New York |year=2005 |pages= |isbn=0-07-140235-7 |oclc= |doi=}}</ref>
+The selection of [[antibiotics]] during [[pregnancy]] is confounded by the potential [[adverse effects]] of three of the most effective drugs:
+* [[Streptomycin]] may be [[ototoxic]] and [[nephrotoxic]] to the [[fetus]].
+* [[Tetracycline]] has an [[adverse effect]] on the developing [[teeth]] and [[bones]] of a [[fetus]].
+* [[Chloramphenicol]] carries a low risk of "[[Gray baby syndrome|gray baby]]" syndrome or [[bone marrow]] suppression.
+* A judiciously administered [[aminoglycoside]] is effective and safe for both the mother and [[fetus]], and in children. Because of its [[intravenous]] and [[intramuscular]] administration and its low risk of [[adverse effects]], [[gentamicin]] is the preferred [[antibiotic]] for treating plague during pregnancy.<ref name="pmid10807389">{{cite journal| author=Inglesby TV, Dennis DT, Henderson DA, Bartlett JG, Ascher MS, Eitzen E et al.| title=Plague as a biological weapon: medical and public health management. Working Group on Civilian Biodefense. | journal=JAMA | year= 2000 | volume= 283 | issue= 17 | pages= 2281-90 | pmid=10807389 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10807389  }} </ref>
 ==References==
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