Rapid administration of appropriate antimicrobial therapy is the only treatment for tularemia. No controlled clinical trials have evaluated the duration of therapy required for cure or the efficacy of different antimicrobial regimens. A literature review of case series and reports has suggested that bactericidal aminoglycosides appear to have the highest cure rate and the lowest incidence of relapse, compared with the bacteriostatic agents tetracyclines and chloramphenicol. Ciprofloxacin has also been used in the treatment of tularemia in both adults and children, but experience with this antimicrobial is limited. For years, the drug of choice for tularemia was streptomycin, an aminoglycoside that must be given intramuscularly. However, as of this writing, streptomycin is no longer produced in the United States, and availability of this drug is extremely limited. In the absence of streptomycin, gentamicin is the recommended therapy for tularemia in all adults, including pregnant women (3.0 to 5.0 mg/kg/day, administered intravenously or intramuscularly in a single dose or two or three divided doses for 7 to 14 days), and children (3.0 to 7.5 mg/day administered intravenously or intramuscularly in three divided doses for 7 to 14 days). The dose of aminoglycoside should be adjusted for renal insufficiency. As alternatives to an aminoglycoside, adults and children may be treated with oral doxycycline (doxycycline should not be used in children younger than 8 years of age unless no alternative therapy is available) for 14 days, and adults may be treated with 10 days of doxycycline or ciprofloxacin.
Ciprofloxacin has not been approved by the Food and Drug Administration (FDA) for treatment of tularemia in children younger than 18 years of age. More severe tularemia may require a longer course of treatment.
In the event of an intentional release of tularemia, the initial empirical therapy for adults and children would be streptomycin or gentamicin (depending on availability) for 10 days; alternatively, ciprofloxacin (for 10 days), doxycycline, or chloramphenicol (for 14 to 21 days) can be given, with the caveat that chloramphenicol should not be administered to pregnant women.