TABLE 12.

Antibiotic treatment suggestions for treating tularemia (doses are for adults) according to clinical form based on current literature.

Clinical form	Antibiotics	Dose and duration*	Additional treatment	Comments
Acute and severe infection, F. tularensis bacteremia, especially if type A (PN, TY, others)	1st line: gentamicin ($)	3 to 8 mg/kg once daily, i.v., 7–10 days	Symptomatic treatment. Intensive care admission if needed	Ciprofloxacin can be used in combination with gentamicin or as a relay of gentamicin
	2nd line: ciprofloxacin (or levofloxacin or moxifloxacin)	400 mg bid i.v. or 500 mg bid p.o. if possible
UG, GL, OP	1st line: ciprofloxacin (or levofloxacin or moxifloxacin)	500 mg bid p.o., for 2–3 weeks or 3–4 weeks if treatment delay > 3 weeks after disease onset	Surgical resection or drainage, or fine-needle aspiration of suppurated lymph nodes Surgical treatment of associated skin and soft tissue infections, especially subcutaneous abscess, cellulitis, hand phlegmon, etc.	Surgery to be considered early after antibiotic treatment failure or relapse Higher treatment failure and relapse rates with doxycycline
	2nd line: doxycycline	200 mg once daily p.o., 3–4 weeks
	3rd line: gentamicin ($)	4 to 7 mg/kg once daily, 7–10 days
OG	1st line: ciprofloxacin (or levofloxacin or moxifloxacin)	500 mg bid p.o., for 2–3 weeks or 3–4 weeks if treatment delay > 3 weeks after disease onset	Local antibiotic therapy: ciprofloxacin or tobramycin drops for 7–10 days (1–2 drops per eye every 2 h for 2 days then every 4 h during daytime) Surgical treatment of suppurated lymphadenopathy or ocular complication (dacryocystitis, periorbital abscess, etc.)	Gentamicin combined with ciprofloxacin or doxycycline in case of complications (e.g., keratitis, dacryocystitis, and orbital cellulitis)
	2nd line: doxycycline	200 mg once daily p.o., 3–4 weeks
	3rd line: gentamicin ($)	3 to 8 mg/kg once daily, i.v., 7–10 days
PN (subacute or chronic)	1st line: ciprofloxacin (or levofloxacin or moxifloxacin)	400 mg bid i.v. or 500 mg bid p.o. if possible	Surgical treatment of suppurated mediastinal or hilar lymphadenopathy, lung abscess, pleural empyema, etc.)	Gentamicin combined with ciprofloxacin or doxycycline in case of complications (suppurated deep lymphadenopathy, lung abscess, pleurisy)
	2nd line: doxycycline	200 mg once daily p.o., 3–4 weeks
	3rd line: gentamicin ($)	3 to 8 mg/kg once daily, i.v., 7–10 days
Endocarditis	1st line: gentamicin plus ciprofloxacin	Usual dosages, i.v., 15 days for gentamicin and 4–6 weeks for ciprofloxacin (or more for prosthetic valve endocarditis or according to disease evolution)	Cardiac valve or prosthetic valve replacement if needed. Some patients did not relapse although the infected native or prosthetic cardiac valve was not removed.	Ciprofloxacin can be used in combination with gentamicin or as a relay of this antibiotic. Some patients were cured after only receiving ciprofloxacin
	2nd line: ciprofloxacin	500 mg bid, i.v. then p.o., 4–6 weeks
Osteoarticular infection without prosthesis	1st line : ciprofloxacin	500 mg bid, p.o., 4–6 weeks	Surgical treatment if needed	Very few data available
	2nd line : doxycycline	200 mg p.o. once daily, 4–6 weeks
Osteoarticular infection on prosthesis	1st line: gentamicin plus ciprofloxacin	Usual dosages, 7–10 days for gentamicin i.v. and 4–6 weeks for ciprofloxacin p.o., then prosthetic replacement and ciprofloxacin at least 6 weeks	Prosthesis replacement. The time of prosthesis replacement greatly varied between patients.	Few data available. Patients who denied prosthesis removal long-term doxycycline treatment was proposed
	2nd line: gentamicin plus doxycycline	Usual dosages, 7–10 days for gentamicin i.v. and 4–6 weeks for doxycycline p.o., then prosthetic replacement and doxycycline at least 12 weeks
Meningitis, encephalitis	1st line: gentamicin plus ciprofloxacin	Usual dosages, i.v., 7–10 days for gentamicin and 2–4 weeks for ciprofloxacin		Very few data available. Phenicols should no longer be used, but can be discussed in case of brain involvement
	2nd line: gentamicin plus doxycycline	Usual dosages, i.v., 7–10 days for gentamicin and 2–4 weeks for doxycycline

Clinical forms: ulceroglandular (UG), glandular (GL), oculoglandular (OG), oropharyngeal (OP), pneumonic (PN), typhoidal (TY). ($) Streptomycin can be used instead of gentamicin in countries where this antibiotic is still available although it’s usually considered more toxic.

*Antibiotic dosages are for adults. Treatment duration should be adapted to the patient status (e.g., longer in immunocompromised patients) and disease evolution. Treatment of tularemia in children should likely be similar to those for adults with appropriate dosage.