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Agent-Specific Recommendations

Tularemia

1. Description of Agent / Syndrome
a. Etiology
Tularemia is an acute bacterial disease caused by a gram-negative bacillus Francisella tularensis which is transmitted by contact with infectious animal tissues and fluids, ingestion of contaminated water, food or soil, bites by infective anthropods and inhalation of infective aerosols. The six classic forms of tularemia are ucleroglandular, glandular, oculoglandular, pharyngeal, typhoidal and pneumonic. A bioterrorism-related outbreak may be expected to be airborne, causing pneumonic tularemia. (6, 7)

b. Clinical Features
Clinical features of pneumonic tularemia include:

• Fever, cough, plueritic chest pain.

• Minimal sputum production.

• Substernal tightness.

• Hemoptysis may occur but is uncommon.

• Radiographic findings include subsegmental or lobar infiltrates, hilar adenopathy and pleural effusion.

c. Modes of transmission

• Tularemia is usually transmitted by contact with infective animal tissues, by bites of infective anthropods or by inhalation of infective aerosols.

• Bioterrorism-related outbreaks are likely to be transmitted through dispersion of an aerosol.

• There is no evidence for person-to-person transmission of tularemia

d. Incubation period
The incubation period for pneumonic tularemia is usually 3 to 5 days with a range of 1 to 14 days.

2. Infection Control Practices for Patient Management
a. Isolation precautions
Universal Precautions are used for the care of patients with pneumonic tularemia.

b. Patient placement
Private room placement for patients with tularemia is not necessary. Airborne transmission of tularemia between patients does not occur.

c. Patient transport
Universal Precautions should be used for transport and movement of patients with tularemia.

d. Cleaning, disinfection, and sterilization of equipment and environment
Principles of Universal Precautions should be generally applied for the management of patient-care equipment and for environmental control.

e. Discharge management
No special discharge instructions are indicated. Home care providers should be taught to use Universal Precautions for all patient care.

f. Post-mortem care
Universal Precautions should be used for post-mortem care.

3. Treatment
Whenever possible, consultation with an Infectious Diseases Specialist is recommended. See Tables 5 and 6 for treatment and prophylaxis.

Table 5
Recommendations for Treatment of Patients with Tularemia in a Contained Casualty Setting* (7)

Contained Casualty Recommended Therapy

Adults Preferred choices      Streptomycin, 1 g IM twice daily      Gentamicin, 5 mg/kg IM or IV once daily† Alternative choices      Doxycycline, 100 mg IV twice daily      Chloramphenicol, 15 mg/kg IV 4 times daily†      Ciprofloxacin, 400 mg IV twice daily†

Children Preferred choices      Streptomycin, 15 mg/kg IM twice daily (should not exceed 2 g/d)      Gentamicin, 2.5 mg/kg IM or IV 3 times daily† Alternative choices      Doxycycline; if weight ≥45 kg, 100 mg IV twice daily;      if weight <45 kg, give 2.2 mg/kg IV twice daily      Chloramphenicol, 15 mg/kg IV 4 times daily†      Ciprofloxacin, 15 mg/kg IV twice daily†‡

Pregnant Women Preferred choices      Gentamicin, 5 mg/kg IM or IV once daily†      Streptomycin, 1 g IM twice daily Alternative choices      Doxycycline, 100 mg IV twice daily      Ciprofloxacin, 400 mg IV twice daily†

*Treatment with streptomycin, gentamicin, or ciprofloxacin should be continued for 10 days; treatment with doxycycline or chloramphenicol should be continued for 14-21 days. Persons beginning treatment with intramuscular (IM) or intravenous (IV) doxycycline, ciprofloxacin, or chloramphenicol can switch to oral antibiotic administration when clinically indicated. †Not a US Food and Drug Administration-approved use. ‡Ciprofloxacin dosage should not exceed 1 g/d in children.

Table 6
Recommendations for Treatment of Patients with Tularemia in a Mass Casualty Setting and for Postexposure Prophylaxis* (7)

Mass Casualty Recommended Therapy

Adults Preferred choices      Doxycycline, 100 mg orally twice daily      Ciprofloxacin, 500 mg orally twice daily†

Children Preferred choices      Doxycycline; if ≥45 kg, give 100 mg orally twice daily;      if <45 kg, give 2.2 mg/kg orally twice daily      Ciprofloxacin, 15 mg/kg orally twice daily†‡

Pregnant Women Preferred choices      Ciprofloxacin, 500 mg orally twice daily†      Doxycycline, 100 mg orally twice daily

*One antibiotic, appropriate for patient age, should be chosen from among alternatives. The duration of all recommended therapies in Table 6 is 14 days. †Not a US Food and Drug Administration-approved use. ‡Ciprofloxacin dosage should not exceed 1 g/d in children.

4. Laboratory Support and Confirmation
Diagnosis of tularemia is confirmed by aerobic culture performed in a BSL-2 laboratory.

a. Diagnostic samples
Diagnostic samples to obtain for culture include:

• Sputum

• Pharyngeal washings

• Fasting gastric aspirates

• Pleural fluid

• Blood

b. Laboratory selection
Handling of clinical specimens should be coordinated with local and state health departments, and undertaken in BSL-2 or 3 laboratories. The FBI will help coordinate collection of evidence and delivery of forensic specimens to FBI or Department of Defense laboratories.

c. Transport requirements
Specimen packaging and transport must be coordinated with local and state health departments, and the FBI. A chain of custody document should accompany the specimen from the moment of collection. For specific instructions, contact the Bioterrorism Emergency Number at the CDC Emergency Response Office, 770/488-7100. Advance planning may include identification of appropriate packaging materials and transport media in collaboration with the clinical laboratory at individual facilities.

5. Patient, Visitor, and Public Information
Fact sheets for distribution will be prepared, including a clear description of the symptoms of tularemia, and instructions to report for evaluation and care if such symptoms are recognized. The difference between prophylactic antimicrobial therapy and treatment of an actual infection will be clarified. Decontamination by showering thoroughly with soap and water will be recommended.