TABLE 2. Postexposure prophylaxis for adults and children potentially exposed to Francisella tularensis — CDC recommendations for occupational exposures and bioterrorism response, United States, 2025.

Population	Category	Antimicrobial class	Antimicrobial	Dosage	Duration (days)
Adults aged ≥18 yrs	First-line	Fluoroquinolone	Ciprofloxacin	500 mg every 12 hrs orally	7
			Levofloxacin	500 mg every 24 hrs orally	7
		Tetracycline	Doxycycline	100 mg every 12 hrs orally	10–14
	Alternative	Fluoroquinolone	Moxifloxacin*	400 mg every 24 hrs orally	7
			Ofloxacin†	400 mg every 12 hrs orally	7
		Tetracycline	Minocycline	100 mg every 12 hrs orally	10–14
			Tetracycline	500 mg every 6 hrs orally	10–14
		Macrolide	Azithromycin (for Type A and susceptible Type B biovars§)	500 mg every 24 hrs orally	10
Children and adolescents aged ≥1 mo to ≤17 yrs (unless otherwise noted)	First-line	Fluoroquinolone	Ciprofloxacin	15 mg/kg every 12 hrs orally (maximum 500 mg/dose)	7
			Levofloxacin	Infants and children aged <5 yrs: 8 mg/kg every 12 hours orally (maximum 250 mg/dose) Children aged ≥5 yrs and adolescents: 8 mg/kg every 24 hours orally (maximum 500 mg/dose)	7
		Tetracycline	Doxycycline	2.2 mg/kg every 12 hrs orally (maximum 100 mg/dose)	10–14
	Alternative	Fluoroquinolone	Moxifloxacin*	Infants and children aged ≥3 mos to ≤23 mos: 6 mg/kg every 12 hrs orally Children aged 2–5 yrs: 5 mg/kg every 12 hrs orally Children aged 6–11 yrs: 4 mg/kg every 12 hrs orally Children and adolescents aged 12 to ≤17 yrs: Body weight <45 kg: 4 mg/kg every 12 hrs orally (maximum dose for all children weighing <45 kg: 200 mg/dose) Body weight ≥45 kg: 400 mg every 24 hrs orally	7
			Ofloxacin†	7.5 mg/kg every 12 hrs orally (maximum 400 mg/dose)	7
		Tetracycline	Minocycline¶	2 mg/kg every 12 hrs orally (maximum 100 mg/dose)	10–14
			Tetracycline¶	10 mg/kg every 6 hrs orally (maximum 500 mg/dose)	10–14
		Macrolide	Azithromycin (for Type A and susceptible Type B biovars§)	Body weight <45 kg: 10 mg/kg every 24 hrs orally Body weight ≥45 kg: 500 mg every 24 hrs orally	10
• Antimicrobials are listed alphabetically within each class. • Prophylaxis recommendations for geriatric patients and those with immunocompromise do not differ from those for the general population. However, health care providers should recognize the potential for polypharmacy with resultant drug–drug interactions and adjust antimicrobials accordingly. • Note: The antibiotics listed in this table are not approved by the FDA for prophylaxis of tularemia. Ciprofloxacin has been used frequently off-label for prophylaxis of naturally occurring tularemia in humans. Large-scale distribution and use of these antimicrobials after a mass exposure event would be at the discretion of the FDA under an Emergency Use Authorization or other authority.

Abbreviations: FDA = Food and Drug Administration; PEP = postexposure prophylaxis.

* Moxifloxacin suspension for oral liquid administration is not available in the United States; however, hospitals and compounding retail pharmacies can use a published recipe to make a liquid suspension. Moxifloxacin is not FDA-approved for use in children and adolescents aged ≤17 years but has been used off-label (Source: Dixit A, Karandikar MV, Jones S, Nakamura MM. Safety and tolerability of moxifloxacin in children. J Pediatric Infect Dis Soc 2018;7:e92–101). For children and adolescents aged 12–17 years weighing ≥45 kg with risk factors for cardiac events, consider 200 mg twice daily to reduce risk for QT prolongation.

^† Ofloxacin suspension for oral liquid administration is not available in the United States; however, hospitals and compounding retail pharmacies can use a published recipe to make a liquid suspension. Ofloxacin is not FDA-approved for use in children and adolescents aged ≤17 years but has been used off-label (Source: Garcia-Prats AJ, Draper HR, Thee S, et al. Pharmacokinetics and safety of ofloxacin in children with drug-resistant tuberculosis. Antimicrob Agents Chemother 2015;59:6073–9).

^§ Francisella tularensis subspecies tularensis (Type A) is limited to North America and susceptible to macrolides. F. tularensis subspecies holarctica (Type B) biovar I strains (in North America and Western Europe) and biovar japonica strains (primarily found in Japan) are also susceptible to macrolides. F. tularensis subspecies holarctica biovar II strains found in Eastern Europe and Asia are inherently resistant to macrolides. Thus, azithromycin can be used if PEP is indicated after natural occupational exposures in the United States (e.g., contact with an infected animal). In the wake of an intentional release, azithromycin can be used for PEP initially if needed. If additional information identifies a resistant strain, patients should be switched to another antimicrobial.

^¶ Because of the risk for permanent tooth discoloration and tooth enamel hypoplasia, tetracycline and minocycline should only be used for children aged <8 years when other options are unavailable.