Table 2.3.

Plague Treatment Guidelines Using National Pharmaceutical Stockpile Components

	Initial therapy	Duration
ADULTS	Gentamicin 5 mg/kg IM or IV once daily (or in 3 divided doses)a–e OR	7–10 days (switch to oral doxycycline when clinically appropriate to complete10-day therapy)
Parenteral	Doxycycline 100 mg IV twice daily OR	7–10 days
Oral	Doxycycline 100 mg PO twice daily	7–10 days
CHILDREN	Gentamicin 7.5 mg/kg IM or IV once daily (or, in 3 divided doses)a–e OR	(switch to oral doxycycline when clinically appropriate to complete 10-day therapy)
Parenteral	Doxycyclinef >45 kg: 100 mg IV twice daily ≤45 kg: 2.2 mg/kg IV twice daily OR Doxycyclinef
Oral	>45 kg: 100 mg PO twice daily ≤45 kg: 2.2 mg/kg PO twice daily	7–10 days
PREGNANCY	Same as for nonpregnant adultsg,h
IMMUNOCOMPROMISED	Same as for nonimmunocompromised adults and children

IM, intramuscularly; IV, intravenously; PO, orally.

^aHistoric treatment of choice for plague is streptomycin. Streptomycin can be difficult to obtain; therefore, gentamicin is recommended and is included in the National Pharmaceutical Stockpile. Oral therapy should be substituted when clinically indicated.

^b The frequency of administration is left up to the discretion of the clinician. The manufacturers recommend that the daily dose be given in equally divided doses at 8-hr intervals; however, current evidence suggests that once-daily dosing of aminoglycosides is at least as effective as, and may be less toxic than, conventional dosing regimens using multiple daily doses of the drugs.

^cAn initial loading dose of 2 mg/kg body weight is standard medical practice when gentamicin is given as three doses per day.

^d Not a US Food and Drug Administration-approved use.

^eRefer to package insert to adjust dose in the event of renal insufficiency.

^f In 1991, the American Academy of Pediatrics amended its recommendation to allow treatment of young children with tetracyclines for serious infections for which doxycycline may be indicated. Doxycycline is preferred for its twice daily dosing and low incidence of gastrointestinal side effects.

^g Aminoglycosides can cause fetal ototoxicity when administered to pregnant women; benefits may, however, outweigh risks when treating serious infections.

^hTetracyclines can cause damage to fetal teeth and bones when administered to pregnant women.