Table 1.

Population	Category	Antimicrobial^,† Class*	Dosage^§
Adults aged ≥18 yrs	First-line	Ciprofloxacin Fluoroquinolone	400 mg every 8 hrs IV or 750 mg every 12 hrs PO
		Levofloxacin Fluoroquinolone	750 mg every 24 hrs IV or PO
		Moxifloxacin Fluoroquinolone	400 mg every 24 hrs IV or PO
		Gentamicin^¶ Aminoglycoside	5 mg/kg every 24 hrs IV or IM
		Streptomycin** Aminoglycoside	1 g every 12 hrs IV^†† or IM
	Alternatives	Doxycycline Tetracycline	200 mg loading dose, then 100 mg every 12 hrs IV or PO
		Chloramphenicol^¶,** Amphenicol	12.5–25 mg/kg every 6 hrs IV^§§ (maximum 1 g/dose)
		Ofloxacin^¶,¶¶ Fluoroquinolone	400 mg every 12 hrs PO***
		Gemifloxacin^¶ Fluoroquinolone	320 mg every 24 hrs PO
		Amikacin^¶ Aminoglycoside	15–20 mg/kg every 24 hrs IV or IM
		Tobramycin^¶ Aminoglycoside	5–7 mg/kg every 24 hrs IV or IM
		Plazomicin^¶,** Aminoglycoside	15 mg/kg every 24 hrs IV
		Trimethoprim-sulfamethoxazole^¶ Sulfonamide	5 mg/kg (trimethoprim component) every 8 hrs IV or PO
Children aged ≥1 mos to ≤17 yrs (unless otherwise noted)	First-line	Ciprofloxacin Fluoroquinolone ^†††	10 mg/kg every 8 or 12 hrs IV or 15 mg/kg every 8 or 12 hrs PO (maximum 400 mg/dose IV, 500 mg/dose every 8 hrs PO, or 750 mg/dose every 12 hrs PO)
		Levofloxacin Fluoroquinolone ^†††	Body weight <50 kg: 8 mg/kg every 12 hrs IV or PO (maximum 250 mg/dose) Body weight ≥50 kg: 500–750 mg every 24 hrs IV or PO
		Gentamicin^¶ Aminoglycoside	4.5–7.5 mg/kg every 24 hrs IV or IM
		Streptomycin** Aminoglycoside	15 mg/kg every 12 hrs IV^†† or IM (maximum 1 g/dose)
	Alternatives	Doxycycline Tetracycline ^†††	Body weight <45 kg: 4.4 mg/kg loading dose, then 2.2 mg/kg every 12 hrs IV or PO Body weight ≥45 kg: 200 mg loading dose, then 100 mg every 12 hrs IV or PO
		Chloramphenicol^¶,** Amphenicol	12.5–25 mg/kg every 6 hrs IV^§§ (maximum 1 g/dose)
		Moxifloxacin^§§§ Fluoroquinolone ^†††	Infants and children aged ≥3 mos to ≤23 mos: 6 mg/kg every 12 hrs IV or PO^¶¶¶ Children aged 2–5 yrs: 5 mg/kg every 12 hrs IV or PO^¶¶¶ Children aged 6–11 yrs: 4 mg/kg every 12 hrs IV or PO^¶¶¶ Children and adolescents aged 12 to ≤17 yrs: Body weight <45 kg: 4 mg/kg every 12 hrs IV or PO^¶¶¶ Maximum dose for all children <45 kg: 200 mg/dose Body weight ≥45 kg: 400 mg every 24 hrs IV or PO^¶¶¶
		Ofloxacin^¶,¶¶ Fluoroquinolone ^†††	7.5 mg/kg every 12 hrs PO*** (maximum 400 mg/dose)
		Amikacin^¶ Aminoglycoside	15–20 mg/kg every 24 hrs IV or IM
		Tobramycin^¶ Aminoglycoside	4.5–7.5 mg/kg every 24 hrs IV or IM
		Trimethoprim-sulfamethoxazole^¶ Sulfonamide	Infants and children aged ≥2 mos to ≤17 yrs: 5 mg/kg (trimethoprim component) every 8 hrs IV or PO

Table 1. Treatment of adults and children with pneumonic or septicemic plague

Abbreviations: IM = intramuscular; IV = intravenous; PO = per os.

Note: All oral antimicrobials recommended in these guidelines can be administered via alternative enteral routes (e.g., nasogastric tube and gastric tube) except for ciprofloxacin.

* Dual therapy with two distinct classes of antimicrobials should be used for initial treatment of patients with severe pneumonic or septicemic plague and patients infected after intentional release of Yersinia pestis.

^† Antimicrobials are not listed in order of preference within each category.

^§ Recommended treatment duration is 10–14 days.

^¶ Not approved by the Food and Drug Administration (FDA) for treatment of plague. In some instances, these antimicrobials have been used off label for the treatment of naturally occurring plague^[17,19,88]. Large-scale distribution and use of these antimicrobials during a bioterrorism response might be under FDA-issued Emergency Use Authorization.

** At the time of publication, these antimicrobials might not be readily and consistently available in the United States because of limited production.

^†† The IV formulation of streptomycin is not approved by FDA; however, the IM formulation of streptomycin has been given intravenously as an off-label use (Sources: Morris JT, Cooper RH. Intravenous streptomycin: a useful route of administration. Clin Infect Dis 1994;19:1150–1. Pérez Tanoira R, Sánchez-Patán F, Jiménez Girón A. et al. Tolerance and safety of intravenous streptomycin therapy in patients with tuberculosis. Infection 2014;42:597–8).

^§§ The lower end of the chloramphenicol dosing range (12.5 mg/kg every 6 hours) is sufficient for treatment of plague in most cases. Severe infections might require increased dosing, but these doses should be decreased as soon as feasible (Sources: Chloramphenicol sodium succinate [Package insert]. Lake Zurich, IL: Fresenius Kabl, LLC; 2019. Chloromycetin sodium succinate [Package insert]. Bristol, TN: Monarch Pharmaceuticals, LLC; 2004). Serum concentration monitoring should be performed when available, especially in children.

^¶¶ Additional fluoroquinolone alternatives, such as delafloxacin, also can be considered depending on drug availability.

*** Ofloxacin suspension for oral liquid administration is not available in the United States.

^††† Data on use of fluoroquinolones and doxycycline in infants and young children are limited.

^§§§ Moxifloxacin is not FDA approved for use in children aged ≤17 years but has been used off label^[79]. Data on use in neonates and children aged ≤2 months are extremely limited; however, successful use in neonates has been reported (Source: Watt KM, Massaro MM, Smith B, Cohen-Wolkowiez M, Benjamin DK Jr, Laughon MM. Pharmacokinetics of moxifloxacin in an infant with Mycoplasma hominis meningitis. Pediatr Infect Dis J 2012;31:197–9). For children aged 12–17 years weighing ≥45 kg with risk factors for cardiac events, consider 200 mg twice daily to reduce risk for QT prolongation.

^¶¶¶ Although no commercial liquid formulation is available for moxifloxacin, hospitals and compounding retail pharmacies can use a published recipe to make liquid suspension.

Table 2.

Population	Category	Antimicrobial^,† Class*	Dosage^§
Adults aged ≥18 yrs	First-line	Ciprofloxacin Fluoroquinolone	400 mg every 8 hrs IV or 750 mg every 12 hrs PO
		Levofloxacin Fluoroquinolone	750 mg every 24 hrs IV or PO
		Moxifloxacin Fluoroquinolone	400 mg every 24 hrs IV or PO
		Doxycycline Tetracycline	200 mg loading dose, then 100 mg every 12 hrs IV or PO
		Gentamicin^¶ Aminoglycoside	5 mg/kg every 24 hrs IV or IM
		Streptomycin** Aminoglycoside	1 g every 12 hrs IV^†† or IM
	Alternatives	Chloramphenicol^¶,** Amphenicol	12.5–25 mg/kg every 6 hrs IV^§§ (maximum 1 g/dose)
		Ofloxacin^¶,¶¶ Fluoroquinolone	400 mg every 12 hrs PO***
		Gemifloxacin^¶ Fluoroquinolone	320 mg every 24 hrs PO
		Amikacin^¶ Aminoglycoside	15–20 mg/kg every 24 hrs IV or IM
		Tobramycin^¶ Aminoglycoside	5–7 mg/kg every 24 hrs IV or IM
		Plazomicin^¶,** Aminoglycoside	15 mg/kg every 24 hrs IV
		Tetracycline^¶ Tetracycline	500 mg every 6 hrs PO
		Omadacycline^¶ Tetracycline	200 mg loading dose on day 1, then 100 mg every 24 hrs IV or 450 mg loading dose every 24 hrs on days 1 and 2, then 300 mg every 24 hrs PO
		Minocycline^¶ Tetracycline	200 mg loading dose, then 100 mg every 12 hrs IV or PO
		Eravacycline^¶ Tetracycline	1 mg/kg every 12 hrs IV
		Trimethoprim-sulfamethoxazole^¶ Sulfonamide	5 mg/kg (trimethoprim component) every 8 hrs IV or PO
Children aged ≥1 mos to ≤17 yrs (unless otherwise noted)	First-line	Ciprofloxacin Fluoroquinolone ^†††	10 mg/kg every 8 or 12 hrs IV 15 mg/kg every 8 or 12 hrs PO (maximum 400 mg/dose IV, 500 mg/dose every 8 hrs PO or 750 mg/dose every 12 hrs PO)
		Levofloxacin Fluoroquinolone ^†††	Body weight <50 kg: 8 mg/kg every 12 hrs IV or PO (maximum 250 mg/dose) Body weight 50 kg: 500–750 mg every 24 hrs IV or PO
		Doxycycline Tetracycline ^†††	Body weight <45 kg: 4.4 mg/kg loading dose, then 2.2 mg/kg every 12 hrs IV or PO Body weight ≥45 kg: 200 mg loading dose, then 100 mg every 12 hrs IV or PO
		Gentamicin^¶ Aminoglycoside	4.5–7.5 mg/kg every 24 hrs IV or IM
		Streptomycin** Aminoglycoside	15 mg/kg every 12 hrs IV^†† or IM (maximum 1 g/dose)
	Alternatives	Chloramphenicol^¶,** Amphenicol	12.5–25 mg/kg every 6 hrs IV^§§ (maximum 1 g/dose)
		Moxifloxacin^§§§ Fluoroquinolone ^†††	Infants and children aged ≥3 mos to ≤23 mos: 6 mg/kg every 12 hrs IV or PO^¶¶¶ Children aged 2–5 yrs: 5 mg/kg every 12 hrs IV or PO^¶¶¶ Children aged 6–11 yrs: 4 mg/kg every 12 hrs IV or PO^¶¶¶ Children and adolescents aged 12 to ≤17 yrs: Body weight <45 kg: 4 mg/kg every 12 hrs IV or PO^¶¶¶ Maximum dose for all children <45 kg: 200 mg/dose Body weight ≥45 kg: 400 mg every 24 hrs IV or PO^¶¶¶
		Ofloxacin^¶,¶¶ Fluoroquinolone ^†††	7.5 mg/kg every 12 hrs PO*** (maximum 400 mg/dose)
		Amikacin^¶ Aminoglycoside	15–20 mg/kg every 24 hrs IV or IM
		Tobramycin^¶ Aminoglycoside	4.5–7.5 mg/kg every 24 hrs IV or IM
		Tetracycline^¶ Tetracycline ^†††	10 mg/kg every 6 hrs PO (maximum 500 mg/dose)
		Minocycline^¶ Tetracycline ^†††	4 mg/kg loading dose (maximum dose 200 mg), then 2 mg/kg every 12 hrs IV or PO (maximum 100 mg/dose)
		Trimethoprim-sulfamethoxazole^¶ Sulfonamide	Infants and children aged ≥2 mos to ≤17 yrs: 5 mg/kg (trimethoprim component) every 8 hrs IV or PO

Table 2. Treatment of adults and children with bubonic or pharyngeal plague

Abbreviations: IM = intramuscular; IV = intravenous; PO = per os.

Note: All oral antimicrobials recommended in these guidelines can be administered via alternative enteral routes (e.g., nasogastric tube and gastric tube) except for ciprofloxacin.

*Monotherapy is recommended for patients with naturally occurring plague, although dual therapy can be considered for patients with large buboes. Dual therapy with two distinct classes of antimicrobials should be used for initial treatment of patients infected after intentional release of Yersinia pestis.

^† Antimicrobials are not listed in order of preference within each category.

^§ Recommended treatment duration is 10–14 days.

^¶ Not approved by the Food and Drug Administration (FDA) for treatment of plague. In some instances, these antimicrobials have been used off label for the treatment of naturally occurring plague^[17,19,88]. Large-scale distribution and use of these antimicrobials during a bioterrorism response might be under FDA-issued Emergency Use Authorization.

** At the time of publication, these antimicrobials might not be readily and consistently available in the United States because of limited production.

^†† The IV formulation of streptomycin is not approved by FDA; however, the IM formulation of streptomycin has been given intravenously as an off-label use (Sources: Morris JT, Cooper RH. Intravenous streptomycin: a useful route of administration. Clin Infect Dis 1994;19:1150–1. Pérez Tanoira R, Sánchez-Patán F, Jiménez Girón A. et al. Tolerance and safety of intravenous streptomycin therapy in patients with tuberculosis. Infection 2014;42:597–8).

^§§ The lower end of the chloramphenicol dosing range (12.5 mg/kg every 6 hours) is sufficient for treatment of plague in most cases. Severe infections might require increased dosing, but these doses should be decreased as soon as feasible. (Sources: Chloramphenicol sodium succinate [Package insert]. Lake Zurich, IL: Fresenius Kabl, LLC; 2019. Chloromycetin sodium succinate [Package insert]. Bristol, TN: Monarch Pharmaceuticals, LLC; 2004). Serum concentration monitoring should be performed when available, especially in children.

^¶¶ Additional fluoroquinolone alternatives, such as delafloxacin, also can be considered depending on drug availability.

*** Ofloxacin suspension for oral liquid administration is not available in the United States.

^††† Data on use of fluoroquinolones and tetracyclines in infants and young children are limited. 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 treatment options have been exhausted.

^§§§ Moxifloxacin is not FDA approved for use in children aged ≤17years but has been used off label^[79]. Data on use in neonates and children aged ≤2 months are extremely limited; however, successful use in neonates has been reported (Source: Watt KM, Massaro MM, Smith B, Cohen-Wolkowiez M, Benjamin DK Jr, Laughon MM. Pharmacokinetics of moxifloxacin in an infant with Mycoplasma hominis meningitis. Pediatr Infect Dis J 2012;31:197–9). For children aged 12–17 years weighing ≥45 kg with risk factors for cardiac events, consider 200 mg twice daily to reduce risk for QT prolongation.

^¶¶¶ Although no commercial liquid formulation is available for moxifloxacin, hospitals and compounding retail pharmacies can use a published recipe to make liquid suspension.

Table 3.

Population	Category	Antimicrobial* Class	Dosage
Adults aged ≥18 yrs	First-line^†,§	Chloramphenicol^¶,** Amphenicol	25 mg/kg every 6 hrs IV^†† (maximum 1 g/dose)
		Levofloxacin Fluoroquinolone	750 mg every 24 hrs IV or PO
		Moxifloxacin Fluoroquinolone	400 mg every 24 hrs IV or PO
Neonates, infants, and children aged ≤17 yrs (unless otherwise noted)	First-line^†,§	Chloramphenicol^¶,** Amphenicol	Neonates aged ≤7 days: 25 mg/kg/dose every 24 hrs IV^†† Neonates aged 8–28 days: 25 mg/kg/dose every 12 hrs IV^†† Infants and children aged ≥29 days to ≤17 yrs: 25 mg/kg every 6 hrs IV^†† (maximum 1 g/dose)
		Levofloxacin Fluoroquinolone ^§§	Neonates aged ≤28 days: 10 mg/kg/dose every 12 hrs IV Infants and children aged ≥29 days to ≤17 yrs: Body weight <50 kg: 8 mg/kg every 12 hrs IV or PO (maximum 250 mg/dose) Body weight ≥50 kg: 500–750 mg every 24 hrs IV or PO
		Moxifloxacin^¶¶ Fluoroquinolone ^§§	Infants and children aged ≥3 mos to ≤23 mos: 6 mg/kg every 12 hrs IV or PO* Children aged 2–5 yrs: 5 mg/kg every 12 hrs IV or PO* Children aged 6–11 yrs: 4 mg/kg every 12 hrs IV or PO* Children and adolescents aged 12 to ≤17 yrs: Body weight <45 kg: 4 mg/kg every 12 hrs IV or PO* Maximum dose for all children <45 kg: 200 mg/dose Body weight ≥45 kg: 400 mg every 24 hrs IV or PO***

Table 3. Treatment of patients of all ages and pregnant women with plague meningitis

Abbreviations: IV = intravenous; PO = per os.

Note: All oral antimicrobials recommended in these guidelines can be administered via alternative enteral routes (e.g., nasogastric tube and gastric tube) except for ciprofloxacin.

*Antimicrobials are not listed in order of preference within each category.

^† Dual therapy with chloramphenicol plus moxifloxacin or levofloxacin should be used for initial treatment of patients with plague who present with symptoms of meningitis. If chloramphenicol is not available, a nonfluoroquinolone first-line or alternative antimicrobial for treatment of septicemic plague can be substituted Table 1. Recommended treatment duration is 10–14 days.

^§ For patients with secondary plague meningitis, chloramphenicol should be added to the patient’s existing antimicrobial treatment regimen for plague. If chloramphenicol is not available, or clinicians would prefer to avoid using this drug in young children because of potential adverse effects, moxifloxacin or levofloxacin can be added to the patient’s existing treatment regimen instead. After chloramphenicol, moxifloxacin, or levofloxacin have been added, the entire regimen of antimicrobials the patient is receiving for plague should be continued for an additional 10 days.

^¶ Not approved by the Food and Drug Administration (FDA) for treatment of plague. Chloramphenicol has been used off label for the treatment of naturally occurring plague^[17,19,88]. Large-scale distribution and use of these antimicrobials during a bioterrorism response might be under FDA-issued Emergency Use Authorization.

** At the time of publication, these antimicrobials might not be readily and consistently available in the United States because of limited production.

^†† After clinical improvement, chloramphenicol can be reduced to a lower dose of 12.5 mg/kg every 6 hours in adults and given orally. Serum concentration monitoring should be performed when available, especially in children (Source: Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for bacterial meningitis. Clin Infect Dis 2004;39:1267–84).

^§§ Data on use of fluoroquinolones in infants and young children are limited.

^¶¶ Moxifloxacin is not FDA approved for use in children aged ≤17 years but has been used off label^[79]. Data on use in neonates and children aged ≤2 months are extremely limited; however, successful use in neonates has been reported (Source: Watt KM, Massaro MM, Smith B, Cohen-Wolkowiez M, Benjamin DK Jr, Laughon MM. Pharmacokinetics of moxifloxacin in an infant with Mycoplasma hominis meningitis. Pediatr Infect Dis J 2012;31:197–9). For children aged 12–17 years weighing ≥45 kg with risk factors for cardiac events, consider 200 mg twice daily to reduce risk for QT prolongation.

*** Although no commercial liquid formulation is available for moxifloxacin, hospitals and compounding retail pharmacies can use a published recipe to make a liquid suspension.

Table 4.

Population	Category	Antimicrobial^,† Class*	Dosage^§
Adults aged ≥18 yrs	First-line	Ciprofloxacin Fluoroquinolone	500–750 mg every 12 hrs PO
		Levofloxacin Fluoroquinolone	500–750 mg every 24 hrs PO
		Moxifloxacin Fluoroquinolone	400 mg every 24 hrs PO
		Doxycycline Tetracycline	100 mg every 12 hrs PO
	Alternatives	Ofloxacin^¶,*^,†† Fluoroquinolone*	400 mg every 12 hrs PO
		Gemifloxacin^¶ Fluoroquinolone	320 mg every 24 hrs PO
		Tetracycline^¶ Tetracycline	500 mg every 6 hrs PO
		Omadacycline^¶ Tetracycline	300 mg every 24 hrs PO
		Minocycline^¶ Tetracycline	100 mg every 12 hrs PO
		Trimethoprim- sulfamethoxazole^¶ Sulfonamide	5 mg/kg (trimethoprim component) every 12 hrs PO
Children aged ≥1 mos to ≤17 yrs (unless otherwise noted)	First-line	Ciprofloxacin Fluoroquinolone ^§§	15 mg/kg every 12 hrs PO (maximum 750 mg/dose)
		Levofloxacin Fluoroquinolone ^§§	Body weight <50 kg: 8 mg/kg every 12 hrs PO (maximum 250 mg/dose) Body weight ≥50 kg: 500–750 mg every 24 hrs PO
		Doxycycline Tetracycline ^§§	Body weight <45 kg: 2.2 mg/kg every 12 hrs PO Body weight ≥45 kg: 100 mg every 12 hrs PO
	Alternatives	Moxifloxacin^¶¶ Fluoroquinolone ^§§	Infants and children aged ≥3 mos to ≤23 mos: 6 mg/kg every 12 hrs PO* Children aged 2–5 yrs: 5 mg/kg every 12 hrs PO* Children aged 6–11 yrs: 4 mg/kg every 12 hrs PO* Children and adolescents aged 12 to ≤17 yrs: Body weight <45 kg: 4 mg/kg every 12 hrs PO* Maximum dose for all children <45 kg: 200 mg/dose Body weight ≥45 kg: 400 mg every 24 hrs PO***
		Ofloxacin^¶,*^,†† Fluoroquinolone* ^§§	7.5 mg/kg every 12 hrs PO (maximum 400 mg/dose)
		Tetracycline^¶ Tetracycline ^§§	10 mg/kg every 6 hrs PO (maximum 500 mg/dose)
		Minocycline^¶ Tetracycline ^§§	2 mg/kg every 12 hrs PO (maximum 100 mg/dose)
		Trimethoprim-sulfamethoxazole^¶ Sulfonamide	Infants and children aged ≥2 mos to ≤17 yrs: 5 mg/kg (trimethoprim component) every 12 hrs PO

Table 4. Pre- and postexposure prophylaxis for adults and children potentially exposed to Yersinia pestis

Abbreviations: PO = per os.

Note: All oral antimicrobials recommended in these guidelines can be administered via alternative enteral routes (e.g., nasogastric tube and gastric tube) except for ciprofloxacin.

* Prophylaxis with a single antimicrobial class is recommended for potentially exposed persons following a case of naturally acquired infection or intentional release of Yersinia pestis, with targeting of drug choice if engineered resistance is detected in the aftermath of a bioterrorism attack.

^† Antimicrobials are not listed in order of preference within each category.

^§ Pre-exposure prophylaxis can be discontinued 48 hours after the last perceived exposure. Recommended duration for postexposure prophylaxis is 7 days.

^¶ Not approved by the Food and Drug Administration (FDA) for treatment of plague. In some instances, these antimicrobials have been used off label for the treatment of naturally occurring plague^[17,19,88]. Large-scale distribution and use of these antimicrobials during a bioterrorism response might be under FDA-issued Emergency Use Authorization.

** Additional fluoroquinolone alternatives, such as delafloxacin, also can be considered depending on drug availability.

^†† Ofloxacin suspension for oral liquid administration is not available in the United States.

^§§ Data on use of fluoroquinolones and tetracyclines in infants and young children are limited. 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 prophylaxis options have been exhausted.

^¶¶ Moxifloxacin is not FDA approved for use in children aged ≤17 years but has been used off label (79). Data on use in neonates and children aged ≤2 months are extremely limited; however, successful use in neonates has been reported (Source: Watt KM, Massaro MM, Smith B, Cohen-Wolkowiez M, Benjamin DK Jr, Laughon MM. Pharmacokinetics of moxifloxacin in an infant with Mycoplasma hominis meningitis. Pediatr Infect Dis J 2012;31:197–9). For children aged 12–17 years weighing ≥45 kg with risk factors for cardiac events, consider 200 mg twice daily to reduce risk for QT prolongation.

*** Although no commercial liquid formulation is available for moxifloxacin, hospitals and compounding retail pharmacies can use a published recipe to make liquid suspension.

Table 5.

Category	Antimicrobial^,† Class*	Dosage^§,¶
*First-line: Gentamicin plus* either ciprofloxacin or levofloxacin**	Ciprofloxacin Fluoroquinolone	400 mg every 8 hrs IV or 500 mg every 8 hrs PO
	Levofloxacin Fluoroquinolone	750 mg every 24 hrs IV or PO
	Gentamicin** Aminoglycoside	5 mg/kg every 24 hrs IV or IM
Alternatives	Moxifloxacin Fluoroquinolone	400 mg every 24 hrs IV or PO
	Ofloxacin*^,†† Fluoroquinolone*	400 mg every 12 hrs PO
	Streptomycin^§§ Aminoglycoside	1 g every 12 hrs IV or IM
	Amikacin** Aminoglycoside	15–20 mg/kg every 24 hrs IV or IM
	Tobramycin** Aminoglycoside	5–7 mg/kg every 24 hrs IV or IM
	Plazomicin*^,§§ Aminoglycoside*	15 mg/kg every 24 hrs IV
	Doxycycline Tetracycline	200 mg loading dose IV, then 100 mg every 12 hrs IV or PO or 200 mg every 24 hrs IV
	Chloramphenicol*^,§§ Amphenicol*	12.5–25 mg/kg every 6 hrs IV^¶¶ (maximum 1 g/dose)
	Trimethoprim-sulfamethoxazole** Sulfonamide	5 mg/kg (trimethoprim component) every 8 hrs IV or PO

Table 5. Treatment of pregnant women with pneumonic, septicemic, bubonic, or pharyngeal plague

Abbreviations: IM = intramuscular; IV = intravenous; PO = per os.

Note: All oral antimicrobials recommended in these guidelines can be administered via alternative enteral routes (e.g., nasogastric tube and gastric tube) except for ciprofloxacin.

* Dual therapy with distinct classes of antimicrobials is recommended for treatment of plague in pregnant women caused by naturally acquired infection or intentional release of Yersinia pestis.

^† Antimicrobials are not listed in order of preference within each category.

^§ Recommended treatment duration is 10–14 days.

^¶ Parenteral administration is preferred route for all antimicrobials initially, when applicable.

** Not approved by the Food and Drug Administration (FDA) for treatment of plague. In some instances, these antimicrobials have been used off label for the treatment of naturally occurring plague^[17,19,88]. Large-scale distribution and use of these antimicrobials during a bioterrorism response might be under FDA-issued Emergency Use Authorization.

^†† Additional fluoroquinolone alternatives, such as gemifloxacin and delafloxacin, also can be considered depending on drug availability.

^§§ At the time of publication, these antimicrobials might not be readily and consistently available in the United States because of limited production.

^¶¶ The lower end of the chloramphenicol dosing range (12.5 mg/kg every 6 hours) is sufficient for treatment of plague in most cases. Severe infections might require increased dosing, but these doses should be decreased as soon as feasible (Sources: Chloramphenicol sodium succinate [Package insert]. Lake Zurich, IL: Fresenius Kabl, LLC; 2019. Chloromycetin sodium succinate [Package insert]. Bristol, TN: Monarch Pharmaceuticals, LLC; 2004). Serum concentration monitoring should be performed when available.

Table 6.

Category	Antimicrobial^,† Class*	Dosage^§
First-line	Ciprofloxacin Fluoroquinolone	500 mg every 8 hrs PO or 750 mg every 12 hrs PO
First-line	Levofloxacin Fluoroquinolone	750 mg every 24 hrs PO
Alternatives	Moxifloxacin Fluoroquinolone	400 mg every 24 hrs PO
	Ofloxacin^¶,** Fluoroquinolone	400 mg every 12 hrs PO
	Tetracycline^¶, ^†† Tetracycline	500 mg every 6 hrs PO
	Doxycycline Tetracycline	100 mg every 12 hrs PO
	Minocycline^¶, ^†† Tetracycline	200 mg loading dose, then 100 mg every 12 hrs PO
	Trimethoprim-sulfamethoxazole^¶ Sulfonamide	5 mg/kg (trimethoprim component) every 12 hrs PO

Table 6. Pre- and postexposure prophylaxis for pregnant women potentially exposed to Yersinia pestis

Abbreviations: PO = per os.

Note: All oral antimicrobials recommended in these guidelines can be administered via alternative enteral routes (e.g., nasogastric tube and gastric tube) except for ciprofloxacin.

* Prophylaxis with a single antimicrobial class is recommended for potentially exposed pregnant women following a case of naturally acquired infection or intentional release of Yersinia pestis, with targeting of drug choice if engineered resistance is detected in the aftermath of a bioterrorism attack.

^† Antimicrobials are not listed in order of preference within each category.

^§ Pre-exposure prophylaxis can be discontinued 48 hours after the last perceived exposure. Recommended duration for postexposure prophylaxis is 7 days.

^¶ Not approved by the Food and Drug Administration (FDA) for treatment of plague. In some instances, these antimicrobials have been used off label for the treatment of naturally occurring plague^[17,19,88]. Large-scale distribution and use of these antimicrobials during a bioterrorism response might be under FDA-issued Emergency Use Authorization.

** Additional fluoroquinolone alternatives, such as gemifloxacin and delafloxacin, also can be considered depending on drug availability.

^†† In utero exposure can lead to permanent discoloration of developing teeth in the fetus. This is more likely to occur following repeated or long-term exposure.

Table 7.

Category	Antimicrobial^,† Class*	Dosage^§
First-line	Gentamicin^¶ Aminoglycoside	Neonates aged ≤7 days: 4 mg/kg every 24 hrs IM or IV Neonates aged 8–28 days: 5 mg/kg every 24 hrs IM or IV
	Ciprofloxacin Fluoroquinolone**	10 mg/kg every 8 or 12 hrs IV
	Levofloxacin Fluoroquinolone**	10 mg/kg every 12 hrs IV
	Streptomycin^†† Aminoglycoside	15 mg/kg every 12 hrs IV^§§ or IM
Alternatives	Tobramycin^¶ Aminoglycoside	Neonates aged ≤7 days: 4 mg/kg every 24 hrs IM or IV Neonates aged 8–28 days: 5 mg/kg every 24 hrs IM or IV
	Amikacin^¶ Aminoglycoside	Neonates aged ≤7 days: 15 mg/kg every 24 hrs IM or IV Neonates aged 8–28 days: 17.5 mg/kg every 24 hrs IM or IV
	Chloramphenicol^¶,†† Amphenicol	Neonates aged ≤14 days: 6.25 mg/kg every 6 hrs IM or IV Neonates aged 15–28 days: 12.5 mg/kg every 6 hrs IM or IV^¶¶
	Doxycycline Tetracycline**	4.4 mg/kg loading dose, then 2.2 mg/kg every 12 hrs IV

Table 7. Treatment of neonates aged ≤28 days with pneumonic or septicemic plague

Abbreviations: IM = intramuscular; IV = intravenous; PO = per os.

Note: All oral antimicrobials recommended in these guidelines can be administered via alternative enteral routes (e.g., nasogastric tube and gastric tube) except for ciprofloxacin. Additional considerations for treatment and postexposure prophylaxis of neonates, depending on the clinical status of both neonate and mother, are included in Supplementary Appendix 2 (https://stacks.cdc.gov/view/cdc/107427).

* Dual therapy with two distinct classes of antimicrobials should be used for initial treatment of neonates with severe pneumonic or septicemic plague and neonates infected after intentional release of Yersinia pestis.

^† Antimicrobials are not listed in order of preference within each category.

^§ Recommended treatment duration is 10–14 days.

^¶ Not approved by the Food and Drug Administration (FDA) for treatment of plague. In some instances, these antimicrobials have been used off label for the treatment of naturally occurring plague^[17,19,88]. Large-scale distribution and use of these antimicrobials during a bioterrorism response might be under FDA-issued Emergency Use Authorization.

** Data on use of fluoroquinolones and doxycycline in neonates are extremely limited; however, successful use of these antimicrobials in neonates has been reported (Sources: Kaguelidou F, Turner MA, Choonara I, Jacqz-Aigrain E. Ciprofloxacin Use in Neonates. Pediatr Infect Dis J 2011;30:e29–e37. Newby BD, Timberlake KE, Lepp LM, Mihic T, Dersch-Mills DA. Levofloxacin use in the neonate: A case series. J Pediatr Pharmacol Ther 2017;22:304–13. Forti G, Benincori C. Doxycycline and the teeth. Lancet 1969;1:782).

^†† At the time of publication, these antimicrobials might not be readily and consistently available in the United States because of limited production.

^§§ The IV formulation of streptomycin is not approved by the FDA; however, the IM formulation of streptomycin has been given intravenously as an off-label use (Sources: Morris JT, Cooper RH. Intravenous streptomycin: a useful route of administration. Clin Infect Dis 1994;19:1150–1. Pérez Tanoira R, Sánchez-Patán F, Jiménez Girón A. et al. Tolerance and safety of intravenous streptomycin therapy in patients with tuberculosis. Infection 2014;42:597–8).

^¶¶ Sources: Chloramphenicol sodium succinate [Package insert]. Lake Zurich, IL: Fresenius Kabl, LLC; 2019. Chloromycetin sodium succinate [Package insert]. Bristol, TN: Monarch Pharmaceuticals, LLC; 2004. Serum concentration monitoring should be performed when available.

Table 8.

Category	Antimicrobial^,† Class*	Dosage^§
First-line	Gentamicin^¶ Aminoglycoside	Neonates aged ≤7 days: 4 mg/kg every 24 hrs IM or IV Neonates aged 8–28 days: 5 mg/kg every 24 hrs IM or IV
	Ciprofloxacin Fluoroquinolone**	10 mg/kg every 8 or 12 hrs IV
	Levofloxacin Fluoroquinolone**	10 mg/kg every 12 hrs IV
	Streptomycin^†† Aminoglycoside	15 mg/kg every 12 hrs IV^§§ or IM
	Doxycycline Tetracycline**	4.4 mg/kg loading dose, then 2.2 mg/kg every 12 hrs IV
Alternatives	Tobramycin^¶ Aminoglycoside	Neonates aged ≤7 days: 4 mg/kg every 24 hrs IM or IV Neonates aged 8–28 days: 5 mg/kg every 24 hrs IM or IV
	Amikacin^¶ Aminoglycoside	Neonates aged ≤7 days: 15 mg/kg every 24 hrs IM or IV Neonates aged 8–28 days: 17.5 mg/kg every 24 hrs IM or IV
	Chloramphenicol^¶,†† Amphenicol	Neonates aged ≤14 days: 6.25 mg/kg every 6 hrs IM or IV Neonates aged 15–28 days: 12.5 mg/kg every 6 hrs IM or IV^¶¶

Table 8. Treatment of neonates aged ≤28 days with bubonic or pharyngeal plague

Abbreviations: IM = intramuscular; IV = intravenous.

Note: All oral antimicrobials recommended in these guidelines can be administered via alternative enteral routes (e.g., nasogastric tube and gastric tube) except for ciprofloxacin. Additional considerations for treatment and postexposure prophylaxis of neonates, depending on the clinical status of both neonate and mother, are included in Supplementary Appendix 2 (https://stacks.cdc.gov/view/cdc/107427).

* Dual therapy with two distinct classes of antimicrobials should be used for initial treatment of neonates infected after intentional release of Yersinia pestis.

^† Antimicrobials are not listed in order of preference within each category.

^§ Recommended treatment duration is 10–14 days.

^¶ Not approved by the Food and Drug Administration (FDA) for treatment of plague. In some instances, these antimicrobials have been used off label for the treatment of naturally occurring plague^[17,19,88]. Large-scale distribution and use of these antimicrobials during a bioterrorism response might be under FDA-issued Emergency Use Authorization.

** Data on use of fluoroquinolones and doxycycline in neonates are extremely limited; however, successful use of these antimicrobials in neonates has been reported (Sources: Kaguelidou F, Turner MA, Choonara I, Jacqz-Aigrain E. Ciprofloxacin use in neonates. Pediatr Infect Dis J 2011;30:e29–e37. Newby BD, Timberlake KE, Lepp LM, Mihic T, Dersch-Mills DA. Levofloxacin Use in the Neonate: A case series. J Pediatr Pharmacol Ther 2017;22:304–13. Forti G, Benincori C. Doxycycline and the teeth. Lancet 1969;1:782).

^†† At the time of publication, these antimicrobials might not be readily and consistently available in the United States because of limited production.

^§§ The IV formulation of streptomycin is not approved by FDA; however, the IM formulation of streptomycin has been given intravenously as an off-label use (Sources: Morris JT, Cooper RH. Intravenous streptomycin: a useful route of administration. Clin Infect Dis 1994;19:1150–1. Pérez Tanoira R, Sánchez-Patán F, Jiménez Girón A. et al. Tolerance and safety of intravenous streptomycin therapy in patients with tuberculosis. Infection 2014;42:597–8).

^¶¶ Sources: Chloramphenicol sodium succinate [Package insert]. Lake Zurich, IL: Fresenius Kabl, LLC; 2019. Chloromycetin sodium succinate [Package insert]. Bristol, TN: Monarch Pharmaceuticals, LLC; 2004. Serum concentration monitoring should be performed when available.

Table 9.

Category	Antimicrobial^,† Class*	Dosage^§
First-line	Ciprofloxacin Fluoroquinolone ^¶	15 mg/kg every 12 hrs PO
	Levofloxacin Fluoroquinolone ^¶	10 mg/kg every 12 hrs PO
	Doxycycline Tetracycline ^¶	2.2 mg/kg every 12 hrs PO
Alternatives	Gentamicin** Aminoglycoside	Neonates aged ≤7 days: 4 mg/kg every 24 hrs IM or IV Neonates aged 8–28 days: 5 mg/kg every 24 hrs IM or IV
Alternatives	Ofloxacin*^,†† Fluoroquinolone* ^¶	7.5 mg/kg every 12 hrs PO

Table 9. Postexposure prophylaxis for neonates aged ≤28 days potentially exposed to Yersinia pestis

Abbreviations: IM = intramuscular; IV = intravenous; PO = per os.

Note: All oral antimicrobials recommended in these guidelines can be administered via alternative enteral routes (e.g., nasogastric tube and gastric tube) except for ciprofloxacin. Additional considerations for treatment and postexposure prophylaxis of neonates, depending on the clinical status of both neonate and mother, are included in Supplementary Appendix 2 (https://stacks.cdc.gov/view/cdc/107427).

* Antimicrobials are not listed in order of preference within each category.

^† Postexposure prophylaxis with a single antimicrobial agent is recommended for potentially exposed neonates following a case of naturally acquired infection or intentional release of Yersinia Pestis, with targeting of drug of choice if engineered resistance is detected in the aftermath of a bioterrorism attack. Postexposure prophylaxis should be given to neonates orally when possible, unless the neonate is hospitalized and has existing intravenous access. For neonates with highly concerning exposure to Y. pestis who cannot take medications orally, IV or IM formulations of the drugs listed in this table can be given.

^§ Recommended postexposure prophylaxis duration is 7 days.

^¶ Data on use of fluoroquinolones and doxycycline in neonates are extremely limited; however, successful use of these antimicrobials in neonates has been reported (Sources: Kaguelidou F, Turner MA, Choonara I, Jacqz-Aigrain E. Ciprofloxacin use in neonates. Pediatr Infect Dis J 2011;30:e29–e37. Newby BD, Timberlake KE, Lepp LM, Mihic T, Dersch-Mills DA. Levofloxacin Use in the Neonate: A case series. J Pediatr Pharmacol Ther 2017;22:304–13. Forti G, Benincori C. Doxycycline and the teeth. Lancet 1969;1:782).

** Not approved by the Food and Drug Administration (FDA) for prophylaxis of plague. In some instances, these antimicrobials have been used off label for the prophylaxis of naturally occurring plague^[17,19,88]. Large-scale distribution and use of these antimicrobials during a bioterrorism response might be under FDA-issued Emergency Use Authorization.

^†† Ofloxacin suspension for oral liquid administration is not available in the United States.

Mead PS. Plague (Yersinia pestis) In: Bennett JE, Dolin R, Blaser MJ. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. 9th ed. Philadelphia, PA: Elsevier Saunders; 2019.
Dennis DT, Gage KL, Gratz N, Poland JD, Tikhomirov E. Diagnosis and clinical manifestations. In: Plague manual: epidemiology, distribution, and surveillance and control. Geneva: World Health Organization;1999:43–54.
Kugeler KJ, Staples JE, Hinckley AF, Gage KL, Mead PS. Epidemiology of human plague in the United States, 1900–2012. Emerg Infect Dis 2015;21:16–22.
Yang R, Cui Y, Bi Y. Perspectives on Yersinia pestis: A model for studying zoonotic pathogens. In: Yang R., Anisimov A, eds. Yersinia pestis: retrospective and perspective. Advances in experimental medicine and biology. Springer, Dordecht; 2016:918;377–91.
Prentice MB, Rahalison L. Plague. Lancet 2007;369:1196–207.
Koirala J. Plague: disease, management, and recognition of act of terrorism. Infect Dis Clin North Am 2006;20:273–87, viii.
Lawrenz MB. Model systems to study plague pathogenesis and develop new therapeutics. Front Microbiol 2010;1:1–9.
Inglesby TV, Dennis DT, Henderson DA, et al. Plague as a biological weapon: medical and public health management. JAMA 2000;283:2281–90.
Kool JL, Weinstein RA. Risk of person-to-person transmission of pneumonic plague. Clin Infect Dis 2005;40:1166–72.
Richard V, Riehm JM, Herindrainy P, et al. Pneumonic plague outbreak, Northern Madagascar, 2011. Emerg Infect Dis 2015;21:8–15.
Anderson DM, Ciletti NA, Lee-Lewis H, et al. Pneumonic plague pathogenesis and immunity in Brown Norway rats. Am J Pathol 2009;174:910–21.
Becker TM, Poland JD, Quan TJ, White ME, Mann JM, Barnes AM. Plague meningitis—a retrospective analysis of cases reported in the United States, 1970–1979. West J Med 1987;147:554–7.
Anisimov AP, Amoako KK. Treatment of plague: promising alternatives to antibiotics. J Med Microbiol 2006;55:1461–75.
Roux AH, Mercier C. Five cases of primary pneumonic plague with three cured. Bull Soc Pathol Exot 1946;39:173–8.
Munter EJ. Pneumonic plague: Report of a case with recovery. JAMA 1945;128:281–3.
Kugeler KJ, Mead PS, Campbell SB, Nelson CA. Antimicrobial treatment patterns and illness outcome among United States patients with plague, 1942–2018. Clin Infect Dis 2020;70(Suppl 1):S20–6.
Mwengee W, Butler T, Mgema S, et al. Treatment of plague with gentamicin or doxycycline in a randomized clinical trial in Tanzania. Clin Infect Dis 2006;42:614–21.
Apangu T, Griffith K, Abaru J, et al. Successful treatment of human plague with oral ciprofloxacin. Emerg Infect Dis 2017;23:553–5.
Nelson CA, Fleck-Derderian S, Cooley KM, et al. Antibiotic treatment of human plague: a systematic review of the literature on individual cases, 1937–2019. Clin Infect Dis 2020;70(Suppl 1):S3–10.
Martin AR, Hurtado FP, Plessala RA, et al. Plague meningitis. A report of three cases in children and review of the problem. Pediatrics 1967;40:610–6.
Fleck-Derderian S, Nelson CA, Cooley KM, et al. Plague during pregnancy: A systematic review. Clin Infect Dis 2020;70(Suppl 1):S30–6.
Begier EM, Asiki G, Anywaine Z, et al. Pneumonic plague cluster, Uganda, 2004. Emerg Infect Dis 2006;12:460–7.
Hinckley AF, Biggerstaff BJ, Griffith KS, Mead PS. Transmission dynamics of primary pneumonic plague in the USA. Epidemiol Infect 2012;140:554–60.
Butler T. Plague and other Yersinia infections. In: William Greenough III & Thomas Merigan, ed. Current Topics In Infectious Disease. 1st edition. New York: Plenum Medical Book Company; 1983.
Runfola JK, House J, Miller L, et al. Outbreak of human pneumonic plague with dog-to-human and possible human-to-human transmission—Colorado, June–July 2014. MMWR Morb Mortal Wkly Rep 2015;64:429–34.
Randremanana R, Andrianaivoarimanana V, Nikolay B, et al. Epidemiological characteristics of an urban plague epidemic in Madagascar, August-November, 2017: an outbreak report. Lancet Infect Dis 2019;19:537–45.
Donaires LF, Céspedes M, Valencia P, et al. Primary pneumonic plague with nosocomial transmission in La Libertad, Peru 2010. Rev Peru Med Exp Salud Publica 2010;27:326–36.
Luo H, Dong X, Li F, et al. A cluster of primary pneumonic plague transmitted in a truck cab in a new enzootic focus in China. Am J Trop Med Hyg 2013;88:923–8.
Wang H, Cui Y, Wang Z, et al. A dog-associated primary pneumonic plague in Qinghai Province, China. Clin Infect Dis 2011;52:185–90.
Federal Select Agent Program. Biosafety/biocontainment plan guidance. Atlanta, GA: U.S. Department of Health and Human Services, CDC; 2020. https://www.selectagents.gov/compliance/guidance/biosafety/definitions.htm#:~:text=Tier%201%20Select%20agents%20and,economy%2C%20critical%20infrastructure%2C%20or%20public
Wagar E. Bioterrorism and the role of the clinical microbiology laboratory. Clin Microbiol Rev 2016;29:175–89.
Federal Select Agent Program. Select agents and toxins list. Atlanta, GA: U.S. Department of Health and Human Services, CDC; 2020. https://www.selectagents.gov/sat/list.htm
World Health Organization. Health aspects of chemical and biological weapons; Report of a WHO group of consultants. 1st ed. Geneva: World Health Organization; 1970.
Ansari I, Grier G, Byers M. Deliberate release: Plague - A review. J Biosaf Biosecur 2020;2:10–22.
Eitzen EM, Takafuji ET. Historical overview of biological warfare. In: Sidell FR, Takafuji ET, Franz DR. Military medicine: Medical aspects of chemical and biological warfare. Office of the Surgeon General, Department of the Army, Walter Reed Army Medical Center, 1997:415–23.
Cunha CB, Cunha BA. Impact of plague on human history. Infect Dis Clin North Am 2006;20:253–72, viii.
Alibek K, Handelman S. Biohazard: the chilling true story of the largest covert biological weapons program in the world, told from the inside by the man who ran it. New York, NY: Random House; 1999.
Low P-M. Paul. The role of Veterans Affairs in support of DOD in biodefense. https://apps.dtic.mil/docs/citations/AD1001643
Griffin A. Isis laptop reveals terror group ‘wants to turn bubonic plague into a weapon of war’. Independent. August 31, 2014. https://www.independent.co.uk/news/world/middle-east/seized-isis-laptop-reveals-wmd-plans-9702030.html
Bhavsar TR, Esbitt DL, Yu PA, Yu Y, Gorman SE. Planning considerations for state, local, tribal, and territorial partners to receive medical countermeasures from CDC’s Strategic National Stockpile during a public health emergency. Am J Public Health 2018;108(S3):S183–7.
Food and Drug Administration. FDA approves new antibacterial treatment for plague. Washington, DC: U.S. Food and Drug Administration; 2012. https://wayback.archive-it.org/7993/20170111193903/http:/www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm302220.htm
Food and Drug Administration. FDA approves additional antibacterial treatment for plague. Washington, DC: U.S. Food and Drug Administration; 2015. https://web.archive.org/web/20180126014628/https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm446283.htm
Laessig KA. Supplemental new drug application approval: Animal efficacy. Silver Spring, MD: U.S. Department of Health and Human Services, Food and Drug Administration; 2012. https://www.accessdata.fda.gov/drugsatfda_docs/appletter/2012/020634s061,020635s067,021721s028ltr.pdf
Tandan M, Cormican M, Vellinga A. Adverse events of fluoroquinolones vs. other antimicrobials prescribed in primary care: A systematic review and meta-analysis of randomized controlled trials. Int J Antimicrob Agents 2018;52:529–40.
Institute of Medicine. Crisis standards of care: A systems framework for catastrophic disaster response; 2012. Washington, DC: National Academies Press; 2012.
Godfred-Cato S, Cooley KM, Fleck-Derderian S, et al. Treatment of human plague: A systematic review of published aggregate data on antimicrobial efficacy, 1939–2019. Clin Infect Dis 2020;70(Suppl 1):S11–9.
National Notifiable Diseases Surveillance System. Plague (Yersinia pestis). Atlanta, GA: U.S. Department of Health and Human Services, CDC. https://ndc.services.cdc.gov/conditions/plague
Yu PA, Tran EL, Parker CM, et al. Safety of antimicrobials during pregnancy: A systematic review of antimicrobials considered for treatment and postexposure prophylaxis of plague. Clin Infect Dis 2020;70(Suppl 1):S37–50.
Hewitt JA, Lanning LL, Campbell JL. The African green monkey model of pneumonic plague and US Food and Drug Administration approval of antimicrobials under the animal rule. Clin Infect Dis 2020;70(Supplement_1):S51–9.
Food and Drug Administration. Animal rule information. Washington, DC: U.S. Department of Health and Human Services, Food and Drug Administration; 2018. https://www.fda.gov/emergency-preparedness-and-response/mcm-regulatory-science/animal-rule-information
Bergman KL. The animal rule: The role of clinical pharmacology in determining an effective dose in humans. Clin Pharmacol Ther 2015;98:365–8.
Boulanger LL, Ettestad P, Fogarty JD, Dennis DT, Romig D, Mertz G. Gentamicin and tetracyclines for the treatment of human plague: review of 75 cases in New Mexico, 1985–1999. Clin Infect Dis 2004;38:663–9.
Chanteau S, Ratsifasoamanana L, Rasoamanana B, et al. Plague, a reemerging disease in Madagascar. Emerg Infect Dis 1998;4:101–4.
Chung S, Baum CR, Nyquist A-C. Chemical-biological terrorism and its impact on children. Pediatrics 2020;145:1–7.
Wong JD, Barash JR, Sandfort RF, Janda JM. Susceptibilities of Yersinia pestis strains to 12 antimicrobial agents. Antimicrob Agents Chemother 2000;44:1995–6.
Welch TJ, Fricke WF, McDermott PF, et al. Multiple antimicrobial resistance in plague: an emerging public health risk. PLoS One 2007;2: 1–6.
Taitt CR, Malanoski AP, Lin B, et al. Discrimination between biothreat agents and ‘near neighbor’ species using a resequencing array. FEMS Immunol Med Microbiol 2008;54:356–64.
Kasatkina IV, Shcherbaniuk AI, Makarovskaia LN, Padeĭskaia EN. Chromosomal resistance of plague agent to quinolones. Antibiot Khimioter 1991;36:35–7.
Ryzhko IV, Trishina AV, Verkina LM. Lack of levofloxacin and moxyfloxacin efficacy in experimental plague of albino mice infected with nalidixic acid resistant pathogen (Nal[r]). Antibiot Khimioter 2010;55:22–4.
Dubey VD. Streptomycin in bubonic plague. J Indian Med Assoc 1953;22:250–2.
Arbaji A, Kharabsheh S, Al-Azab S, et al. A 12-case outbreak of pharyngeal plague following the consumption of camel meat, in north-eastern Jordan. Ann Trop Med Parasitol 2005;99:789–93.
Girard G. Streptomycin in experimental guinea pig pulmonary plague. Bull Soc Pathol Exot 1949;42:339–42.
Wargo KA, Edwards JD. Aminoglycoside-induced nephrotoxicity. J Pharm Pract 2014;27:573–7.
Jiang M, Karasawa T, Steyger PS. Aminoglycoside-induced cochleotoxicity: A review. Front Cell Neurosci 2017;11: 1–14.
Eyler RF, Shvets K. Clinical pharmacology of antibiotics. Clin J Am Soc Nephrol 2019;14:1080–90.
Layton RC, Mega W, McDonald JD, et al. Levofloxacin cures experimental pneumonic plague in African green monkeys. PLoS Negl Trop Dis 2011;5: 1–9.
Campbell JL, Fay MP, Lanning LL, Hewitt JA. Effect of delaying treatment on efficacy of ciprofloxacin and levofloxacin in the African green monkey model of pneumonic plague. Clin Infect Dis 2020;70(Suppl 1):S60–5.
Finegold MJ. Pathogenesis of plague. A review of plague deaths in the United States during the last decade. Am J Med 1968;45:549–54.
Saeed AAB, Al-Hamdan NA, Fontaine RE. Plague from eating raw camel liver. Emerg Infect Dis 2005;11:1456–7.
Mega WM, Doyle-Eisele M, Cass RT, et al. Plazomicin is effective in a non-human primate pneumonic plague model. Bioorg Med Chem 2016;24:6429–39.
Boselli E, Breilh D, Rimmelé T, et al. Pharmacokinetics and intrapulmonary diffusion of levofloxacin in critically ill patients with severe community-acquired pneumonia. Crit Care Med 2005;33:104–9.
Capitano B, Mattoes HM, Shore E, et al. Steady-state intrapulmonary concentrations of moxifloxacin, levofloxacin, and azithromycin in older adults. Chest 2004;125:965–73.
Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia: An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med 2019;200:e45–67.
Jackson MA, Schutze GE. The use of systemic and topical fluoroquinolones. Pediatrics 2016;138:e1–13.
Bradley JS, Arguedas A, Blumer JL, Sáez-Llorens X, Melkote R, Noel GJ. Comparative study of levofloxacin in the treatment of children with community-acquired pneumonia. Pediatr Infect Dis J 2007;26:868–78.
Urich SK, Chalcraft L, Schriefer ME, Yockey BM, Petersen JM. Lack of antimicrobial resistance in Yersinia pestis isolates from 17 countries in the Americas, Africa, and Asia. Antimicrob Agents Chemother 2012;56:555–8.
Galimand M, Carniel E, Courvalin P. Resistance of Yersinia pestis to antimicrobial agents. Antimicrob Agents Chemother 2006;50:3233–6.
Briasoulis A, Agarwal V, Pierce WJ. QT prolongation and torsade de pointes induced by fluoroquinolones: infrequent side effects from commonly used medications. Cardiology 2011;120:103–10.
Dixit A, Karandikar MV, Jones S, Nakamura MM. Safety and tolerability of moxifloxacin in children. J Pediatric Infect Dis Soc 2018;7:e92–101.
Abo-Salem E, Fowler JC, Attari M, et al. Antibiotic-induced cardiac arrhythmias. Cardiovasc Ther 2014;32:19–25.
Zientek J, Dahlgren FS, McQuiston JH, Regan J. Self-reported treatment practices by healthcare providers could lead to death from Rocky Mountain spotted fever. J Pediatr 2014;164:416–8.
Todd SR, Dahlgren FS, Traeger MS, et al. No visible dental staining in children treated with doxycycline for suspected Rocky Mountain Spotted Fever. J Pediatr 2015;166:1246–51.
Frean JA, Arntzen L, Capper T, Bryskier A, Klugman KP. In vitro activities of 14 antibiotics against 100 human isolates of Yersinia pestis from a southern African plague focus. Antimicrob Agents Chemother 1996;40:2646–7.
Wagner C, Sauermann R, Joukhadar C. Principles of antibiotic penetration into abscess fluid. Pharmacology 2006;78:1–10.
Schlessinger D. Failure of aminoglycoside antibiotics to kill anaerobic, low-pH, and resistant cultures. Clin Microbiol Rev 1988;1:54–9.
Baudoux P, Bles N, Lemaire S, Mingeot-Leclercq M-P, Tulkens PM, Van Bambeke F. Combined effect of pH and concentration on the activities of gentamicin and oxacillin against Staphylococcus aureus in pharmacodynamic models of extracellular and intracellular infections. J Antimicrob Chemother 2006;59:246–53.
Steenbergen J, Tanaka SK, Miller LL, Halasohoris SA, Hershfield JR. In vitro and in vivo activity of omadacycline against two biothreat pathogens, Bacillus anthracis and Yersinia pestis. Antimicrob Agents Chemother 2017;61:e02434–16.
Butler T, Levin J, Ngoc Linh N, Chau DM, Adickman M, Arnold K. Yersinia pestis infection in Vietnam. II. Quantitative blood cultures and detection of endotoxin in the cerebrospinal fluid of patients with meningitis. J Infect Dis 1976;133:493–9.
Gage KL, Dennis DT, Orloski KA, et al. Cases of cat-associated human plague in the Western US, 1977–1998. Clin Infect Dis 2000;30:893–900.
Nau R, Sörgel F, Eiffert H. Penetration of drugs through the blood-cerebrospinal fluid/blood-brain barrier for treatment of central nervous system infections. Clin Microbiol Rev 2010;23:858–83.
Siegel JD, Rhinehart E, Jackson M, Chiarello L. 2007 Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Atlanta, GA: U.S. Department of Health and Human Services, CDC, Healthcare Infection Control Practices Advisory Committee; 2019. https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf
Bonacorsi SP, Scavizzi MR, Guiyoule A, Amouroux JH, Carniel E. Assessment of a fluoroquinolone, three beta-lactams, two aminoglycosides, and a cycline in treatment of murine Yersinia pestis infection. Antimicrob Agents Chemother 1994;38:481–6.
Yefet E, Schwartz N, Chazan B, Salim R, Romano S, Nachum Z. The safety of quinolones and fluoroquinolones in pregnancy: a meta-analysis. BJOG 2018;125:1069–76.
Committee on Obstetric Practice. Committee opinion no. 713: Antenatal corticosteroid therapy for fetal maturation. Obstet Gynecol 2017;130:e102–9.
Plante LA, Pacheco LD, Louis JM. SMFM Consult Series #47: Sepsis during pregnancy and the puerperium. Am J Obstet Gynecol 2019;220:B2–10.
Committee on Gynecologic Practice. ACOG Committee opinion no. 762: Prepregnancy counseling. Obstet Gynecol 2019;133:e78–89.
White ME, Rosenbaum RJ, Canfield TM, Poland JD. Plague in a neonate. Am J Dis Child 1981;135:418–9.
Landsborough D, Tunnell N. Observations on plague meningitis. BMJ 1947;1:4–7.
Meyer FP, Specht H, Quednow B, Walther H. Influence of milk on the bioavailability of doxycycline—new aspects. Infection 1989;17:245–6.
Neuvonen PJ, Kivistö KT, Lehto P. Interference of dairy products with the absorption of ciprofloxacin. Clin Pharmacol Ther 1991;50:498–502.
Drugs and Lactation Database. Bethesda, MD: National Library of Medicine; 2006. https://www.ncbi.nlm.nih.gov/books/NBK501922
Association for Promotion of and Cultural and Scientific Research into Breastfeeding. 2002. E-lactancia; 2002 http://e-lactancia.org
Gregory KE, Walker WA. Immunologic factors in human milk and disease prevention in the preterm infant. Curr Pediatr Rep 2013;1:222–8.
Eidelman AI, Schanler RJ. Breastfeeding and the Use of Human Milk. Pediatrics 2012;129:e827–41.
National Library of Medicine. Ciprofloxacin: Drugs and lactation database (LactMed) Bethesda, MD: National Institutes of Health, National Library of Medicine; 2018.
National Library of Medicine. Ofloxacin: Drugs and lactation database (LactMed) Bethesda, MD: National Institutes of Health, National Library of Medicine; 2018.
National Library of Medicine. Gentamicin, tobramycin, and streptomycin: Drugs and lactation database (LactMed) Bethesda, MD: National Institutes of Health, National Library of Medicine; 2018.
National Library of Medicine. Tetracycline: Drugs and lactation database (LactMed). Bethesda, MD: National Institutes of Health, National Library of Medicine; 2018.
National Library of Medicine. Doxycycline: Drugs and lactation database (LactMed). Bethesda, MD: National Institutes of Health, National Library of Medicine; 2018.
Posner AC, Prigot A, Konicoff NG. Further observations on the use of tetracycline hydrochloride in prophylaxis and treatment of obstetric infections. Antibiot Annu 1954;5:594–8.
Basler RS, Lynch PJ. Black galactorrhea as a consequence of minocycline and phenothiazine therapy. Arch Dermatol 1985;121:417–8.
Hunt MJ, Salisbury ELC, Grace J, Armati R. Black breast milk due to minocycline therapy. Br J Dermatol 1996;134:943–4.
Miller RD, Salter AJ. The passage of trimethoprim/sulfamethoxazole into breast milk and its significance. Antibacterial Chemotherapy 1974;1:687–91.
Forna F, McConnell M, Kitabire FN, et al. Systematic review of the safety of trimethoprim-sulfamethoxazole for prophylaxis in HIV-infected pregnant women: implications for resource-limited settings. AIDS Rev 2006;8:24–36.
National Library of Medicine. Trimethoprim-sulfamethoxazole: Drugs and lactation database (LactMed). Bethesda, MD: National Institutes of Health, National Library of Medicine; 2018.
National Library of Medicine. Chloramphenicol: Drugs and lactation database (LactMed). Bethesda, MD: National Institutes of Health, National Library of Medicine; 2018.
Cummings ED, Kongs EL, Edens MA. Gray baby syndrome. Treasure Island, FL: StatPearls Publishing, StatPearls Publishing LLC; 2020.
Havelka J, Hejzlar M, Popov V, Viktorinová D, Procházka J. Excretion of chloramphenicol in human milk. Chemotherapia (Basel) 1968;13:204–11.
Hull HF, Montes JM, Mann JM. Septicemic plague in New Mexico. J Infect Dis 1987;155:113–8.
Botton A, Queinnec J, Nedelec G. 9 epidemic cases of bubonic plague in Tananarive (Madagascar). Med Trop (Mars) 1982;42:491–5.
Villafane Lastra T, Goobar JK, Rodeiro M, Videla LF. Tratamiento de la peste de Oriente. Boletin Mensual Cordoba 1942;2:3–22.
Townsend SL. Plague (bubonic and pneumonic) in Port Said. J R Nav Med Serv 1944;30:25–9.
Hirschfeld J, McKinsey T, Arbeter A, Storrs B, Warner W. Plague—San Juan County, New Mexico. MMWR Morb Mortal Wkly Rep 1970;19:347–8.
Tourdjman M, Ibraheem M, Brett M, et al. Misidentification of Yersinia pestis by automated systems, resulting in delayed diagnoses of human plague infections—Oregon and New Mexico, 2010–2011. Clin Infect Dis 2012;55:e58–60.
CDC. Imported plague—New York City, 2002. MMWR Morb Mortal Wkly Rep 2003;52:725–8.
CDC. Fatal laboratory-acquired infection with an attenuated Yersinia pestis Strain—Chicago, Illinois, 2009. MMWR Morb Mortal Wkly Rep 2011;60:201–5.
Crellin E, Mansfield KE, Leyrat C, et al. Trimethoprim use for urinary tract infection and risk of adverse outcomes in older patients: cohort study. BMJ 2018;360:k341.
Meng L, Mui E, Holubar MK, Deresinski SC. Comprehensive guidance for antibiotic dosing in obese adults. Pharmacotherapy 2017;37:1415–31.
Monarch Pharmaceuticals. Chloramphenicol sodium succinate [package insert]. Bristol, TN: Monarch Pharmaceuticals; 2004.
Kendrick JG, Carr RR, Ensom MHH. Pediatric obesity: Pharmacokinetics and implications for drug dosing. Clin Ther 2015;37:1897–923.
Autmizguine J, Melloni C, Hornik CP, et al. Population phamacokinetics of trimethoprim-sulfamethoxazole in infants and children. Antimicrob Agents Chemother 2017;62:301813–7.
Kang K, Absher R, Farrington E, Ackley R, So TY. Evaluation of different methods used to calculate ideal body weight in the pediatric population. J Pediatr Pharmacol Ther 2019;24:421–30.
Matson KL, Horton ER, Capino AC. Medication dosage in overweight and obese children. J Pediatr Pharmacol Ther 2017;22:81–3.
Feodorova VA, Motin VL. Plague vaccines: current developments and future perspectives. Emerg Microbes Infect 2012;1: e36.
Sun W, Singh AK. Plague vaccine: recent progress and prospects. NPJ Vaccines 2019;4: 1–11.
Gur D, Glinert I, Aftalion M, et al. Inhalational gentamicin treatment is effective against pneumonic plague in a mouse model. Front Microbiol 2018;9:1–10.

CME / ABIM MOC / CE

Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response

Authors: Christina A. Nelson, MD, MPH; Dana Meaney-Delman, MD, MPH; Shannon Fleck-Derderian, MPH; Katharine M. Cooley, MPH; Patricia A. Yu, MPH; Paul S. Mead, MD, MPH
CME / ABIM MOC / CE Released: 9/14/2021
THIS ACTIVITY HAS EXPIRED
Valid for credit through: 9/14/2022

Start Activity

Target Audience and Goal Statement

This activity is intended for infectious disease clinicians, bioterrorism experts, public health officials, internists, pediatricians, intensivists, and other clinicians caring for patients with or at risk for plague.

The goal of this activity is to describe Centers for Disease Control and Prevention recommendations to US healthcare providers regarding treatment, pre-exposure prophylaxis, and postexposure prophylaxis of plague, both for naturally acquired infections and for bioterrorism response.

Upon completion of this activity, participants will:

Describe notable changes and updates in the new Centers for Disease Control and Prevention (CDC) recommendations compared with the Working Group on Civilian Biodefense guidelines published in 2000, based on new data, expert forum discussions, and other developments
Determine additional considerations regarding response to Yersinia pestis release as a biological weapon, according to the new CDC recommendations
Identify additional recommendations regarding treatment, pre-exposure prophylaxis, and postexposure prophylaxis of adults and children, according to the new CDC guidelines

Disclosures

As an organization accredited by the ACCME, Medscape, LLC requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.

Medscape, LLC encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.

Faculty

Christina A. Nelson, MD, MPH

Bacterial Diseases Branch
Division of Vector-Borne Diseases
National Center for Emerging and Zoonotic Infectious Diseases
Centers for Disease Control and Prevention (CDC)
Fort Collins, Colorado

Disclosures

Disclosure: Christina A. Nelson, MD, MPH, has disclosed no relevant financial relationships.

Dana Meaney-Delman, MD, MPH

Infant Outcomes Monitoring, Research and Prevention Branch
Division of Birth Defects and Infant Disorders
National Center on Birth Defects and Developmental Disabilities
Centers for Disease Control and Prevention (CDC)
Atlanta, Georgia

Disclosures

Disclosure: Dana Meaney-Delman, MD, MPH, has disclosed no relevant financial relationships.

Shannon Fleck-Derderian, MPH

Bacterial Diseases Branch
Division of Vector-Borne Diseases
National Center for Emerging and Zoonotic Infectious Diseases
Centers for Disease Control and Prevention (CDC)
Fort Collins, Colorado

Disclosures

Disclosure: Shannon Fleck-Derderian, MPH, has disclosed no relevant financial relationships.

Katharine M. Cooley, MPH

Bacterial Diseases Branch
Division of Vector-Borne Diseases
National Center for Emerging and Zoonotic Infectious Diseases
Centers for Disease Control and Prevention (CDC)
Fort Collins, Colorado

Disclosures

Disclosure: Katharine M. Cooley, MPH, has disclosed no relevant financial relationships.

Patricia A. Yu, MPH

Emergency Preparedness and Response Branch
Division of Preparedness and Emerging Infections
National Center for Emerging and Zoonotic Infectious Diseases
Centers for Disease Control and Prevention (CDC)
Atlanta, Georgia

Disclosures

Disclosure: Patricia A. Yu, MPH, has disclosed no relevant financial relationships.

Paul S. Mead, MD, MPH

Bacterial Diseases Branch
Division of Vector-Borne Diseases
National Center for Emerging and Zoonotic Infectious Diseases
Centers for Disease Control and Prevention (CDC)
Fort Collins, Colorado

Disclosures

Disclosure: Paul S. Mead, MD, MPH, has disclosed no relevant financial relationships.

CME Author

Laurie Barclay, MD

Freelance writer and reviewer
Medscape, LLC

Disclosures

Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

CME Reviewer/Nurse Planner

Stephanie Corder, ND, RN, CHCP

Associate Director, Accreditation and Compliance
Medscape, LLC

Disclosures

Disclosure: Stephanie Corder, ND, RN, CHCP, has disclosed no relevant financial relationships.

Medscape, LLC staff have disclosed that they have no relevant financial relationships.

Accreditation Statements

In support of improving patient care, Medscape LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

For Physicians

Medscape, LLC designates this enduring material for a maximum of 2.0 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 2.0 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

Contact This Provider

For Nurses

Awarded 2.0 contact hour(s) of nursing continuing professional development for RNs and APNs; 0 contact hours are in the area of pharmacology.

Contact This Provider

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]

Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 70% on the post-test.

Follow these steps to earn CME/CE credit*:

Read about the target audience, learning objectives, and author disclosures.
Study the educational content online or print it out.
Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate, but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period, you can print out the tally as well as the certificates from the CME/CE Tracker.

*The credit that you receive is based on your user profile.

From Morbidity & Mortality Weekly Report

CME / ABIM MOC / CE

Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response

Authors: Christina A. Nelson, MD, MPH; Dana Meaney-Delman, MD, MPH; Shannon Fleck-Derderian, MPH; Katharine M. Cooley, MPH; Patricia A. Yu, MPH; Paul S. Mead, MD, MPHFaculty and Disclosures

THIS ACTIVITY HAS EXPIRED

CME / ABIM MOC / CE Released: 9/14/2021

Valid for credit through: 9/14/2022

processing....

Summary

This report provides CDC recommendations to U.S. health care providers regarding treatment, pre-exposure prophylaxis, and postexposure prophylaxis of plague. Yersinia pestis, the bacterium that causes plague, leads to naturally occurring disease in the United States and other regions worldwide and is recognized as a potential bioterrorism weapon. A bioweapon attack with Y. pestis could potentially infect thousands, requiring rapid and informed decision making by clinicians and public health agencies. The U.S. government stockpiles a variety of medical countermeasures to mitigate the effects of a bioterrorism attack (e.g., antimicrobials, antitoxins, and vaccines) for which the 21st Century Cures Act mandates the development of evidence-based guidelines on appropriate use. Guidelines for treatment and postexposure prophylaxis of plague were published in 2000 by a nongovernmental work group; since then, new human clinical data, animal study data, and U.S. Food and Drug Administration approvals of additional countermeasures have become available. To develop a comprehensive set of updated guidelines, CDC conducted a series of systematic literature reviews on human treatment of plague and other relevant topics to collect a broad evidence base for the recommendations in this report. Evidence from CDC reviews and additional sources were presented to subject matter experts during a series of forums. CDC considered individual expert input while developing these guidelines, which provide recommended best practices for treatment and prophylaxis of human plague for both naturally occurring disease and following a bioterrorism attack. The guidelines do not include information on diagnostic testing, triage decisions, or logistics involved in dispensing medical countermeasures. Clinicians and public health officials can use these guidelines to prepare their organizations, hospitals, and communities to respond to a plague mass-casualty event and as a guide for treating patients affected by plague.

Page 1 of 7

Introduction

CME / ABIM MOC / CE Information

Disclaimer

The educational activity presented above may involve simulated, case-based scenarios. The patients depicted in these scenarios are fictitious and no association with any actual patient, whether living or deceased, is intended or should be inferred. The material presented here does not necessarily reflect the views of Medscape, LLC, or any individuals or commercial entities that support companies that support educational programming on medscape.org. These materials may include discussion of therapeutic products that have not been approved by the US Food and Drug Administration, off-label uses of approved products, or data that were presented in abstract form. These data should be considered preliminary until published in a peer-reviewed journal. Readers should verify all information and data before treating patients or employing any therapies described in this or any educational activity. A qualified healthcare professional should be consulted before using any therapeutic product discussed herein.

Table 1.

Table 2.

Table 3.

Table 4.

Table 5.

Table 6.

Table 7.

Table 8.

Table 9.

References

Faculty and Disclosures

Faculty

Christina A. Nelson, MD, MPH

Dana Meaney-Delman, MD, MPH

Shannon Fleck-Derderian, MPH

Katharine M. Cooley, MPH

Patricia A. Yu, MPH

Paul S. Mead, MD, MPH

CME Author

Laurie Barclay, MD

CME Reviewer/Nurse Planner

Stephanie Corder, ND, RN, CHCP

CME / ABIM MOC / CE

Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response

Target Audience and Goal Statement

Disclosures

Faculty

Christina A. Nelson, MD, MPH

Dana Meaney-Delman, MD, MPH

Shannon Fleck-Derderian, MPH

Katharine M. Cooley, MPH

Patricia A. Yu, MPH

Paul S. Mead, MD, MPH

CME Author

Laurie Barclay, MD

CME Reviewer/Nurse Planner

Stephanie Corder, ND, RN, CHCP

Accreditation Statements

For Physicians

For Nurses

Instructions for Participation and Credit

Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response

Summary

Table of Contents