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Tularemia					minus icon
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			HomeTick IDOverview of Tickborne DiseasesLyme DiseaseTickborne Relapsing Fever (TBRF)Hard Tick Relapsing FeverAnaplasmosisEhrlichiosisRocky Mountain Spotted FeverRickettsia parkeri RickettsiosisTularemiaBabesiosisHeartland and Bourbon Virus DiseasesColorado Tick FeverPowassan Virus DiseaseTickborne Diseases AbroadTick Bites/PreventionLyme Disease Prophylaxis After Tick Bite					Related Pages
										Agent*Francisella tularensis*Tularemia is caused by the highly infectious *F. tularensis* bacteria. It is spread through exposure to infected arthropods (including deer flies and several species of ticks), contact with infected carcasses or animals (such as rabbits, hares, and rodents), contaminated food or water, or inhalation of aerosols (such as by mowing over an infected rabbit carcass).Where FoundTularemia has been reported in all states except Hawaii, but it is most common in the south-central United States, the Great Plains region, and parts of Massachusetts.Tularemia ulcer on persons thumbIncubation Period3–5 days (range 1–21 days)Signs and SymptomsThe clinical presentation of tularemia depends on many factors, including the route of inoculation and subtype of *F. tularensis.* Tularemia can be serious or fatal without adequate treatment. Unusual and severe clinical manifestations have been described in patients with immunocompromising conditions.Fever, chills
Headache
Malaise, fatigue
Anorexia
Myalgia
Chest discomfort, cough
Sore throat
Vomiting, diarrhea
Abdominal pain*(Ulcero) Glandular*Localized lymphadenopathy
Cutaneous ulcer at infection site (not always present)*Oculoglandular*Photophobia
Vision impairment/loss
Conjunctivitis
Regional lymphadenopathy*Oropharyngeal*Severe throat pain
Exudative pharyngitis or tonsillitis
Regional lymphadenopathy*Pneumonic*Non-productive cough
Substernal tightness
Pleuritic chest pain
Hilar adenopathy, infiltrate, or pleural effusion may be present on chest X-ray*Typhoidal*Characterized by any combination of the general symptoms without the localizing symptoms of other syndromes
May have infiltrates in chest radiograph in the absence of respiratory symptomsGeneral Laboratory FindingsHyponatremia
Leukocytosis
Thrombocytopenia
Elevated hepatic transaminases
Elevated creatine kinase
Elevated erythrocyte sedimentation rate
Myoglobinuria
Sterile pyuriaLaboratory DiagnosisIsolation of *F. tularensis* in culture is optimal for diagnosis but can be challenging due to the slow-growing, fastidious nature of the organism. Appropriate specimens for culture include swabs or scrapings of ulcers, lymph node aspirates or biopsies, pharyngeal swabs, or respiratory specimens (e.g., pleural fluid), depending on the form of illness. Blood cultures are often negative.
Seroconversion from negative to positive IgM and/or IgG can also confirm the diagnosis when tularemia is suspected. Ideally, these are performed as paired acute and convalescent specimens, the latter collected 2-3 weeks after initial illness.
When available, other tests can be useful, including:
Direct immunofluorescence assay (DFA)
Immunohistochemical staining
PCR assayClinicians who suspect tularemia should alert the laboratory to the possible need for special safety procedures to minimize risk of laboratory transmission.TreatmentThese regimens may need to be adjusted depending on a person’s age, medical history, underlying health conditions, pregnancy status, or allergies. Consult an infectious disease specialist regarding individual patient treatment decisions.
Tularemia treatment regimen
Age Category
Drug
Dosage
Maximum
Duration (Days)Adults
Gentamicin*
5 mg/kg IM or IV daily (with desired peak serum levels of at least 5 mcg/mL)
Monitor serum drug levels
Minimum 10Ciprofloxacin*
400 mg IV or 500 mg PO twice daily
N/A
10–14Doxycycline
100 mg IV or PO twice daily
N/A
14–21Children
Gentamicin*
2.5 mg/kg IM or IV 3 times daily**
Monitor serum drug levels and consult a pediatric infectious disease specialist
Minimum 10Ciprofloxacin*
15 mg/kg IV or PO twice daily
800 mg per day
10Doxycycline
2.2mg/kg IV or PO twice daily
100mg IV or PO twice daily
14
-21
* Not a U.S. FDA-approved use but has been used successfully to treat patients with tularemia.
** Once-daily dosing could be considered in consultation with a pediatric infectious disease specialist and a pharmacist**NOTE:** Gentamicin is preferred for treatment of severe tularemia. Dose should be adjusted for renal insufficiency.
**NOTE:** For tularemic meningitis, combination therapy should be considered in consultation with an infectious disease specialist.See Tularemia For Clinicians for detailed treatment information.
**Tularemia prophylaxis**is recommended in cases of laboratory exposure to infectious materials.
Doxycycline (100 mg orally twice daily for 14 days) is generally recommended for prophylaxis in adults.
Ciprofloxacin (500 mg orally twice daily) is not FDA-approved for prophylaxis of tularemia but has demonstrated efficacy in various studies and may be an alternative for patients unable to take doxycycline.ReferencesAuwaerter PG, Penn RL. *Francisella tularensis* (Tularemia). In: Bennett J, Dolin R, Blaser M., editors. Mandell, Douglas, and Bennett’s *Principles and Practice of Infectious Diseases*. 9th ed. Elsevier Health Sciences; 2020.
Centers for Disease Control and Prevention. Tularemia—United States, 2001-2010. *MMWR* *Morb Mortal Wkly Rep.*2013;62(47):963–966.
Dennis D, Inglesby TV, Henderson DA, et al. Tularemia as a biological weapon: medical and public health management. *JAMA.* 2001;285(21):2763–2773.
Feldman KA, Enscore RE, Lathrop SL, et al. An outbreak of primary pneumonic tularemia on Martha’s Vineyard. *NEJM.* 2001;345:1601–1606.
Johansson A, Berglund L, Sjöstedt A, et al. Ciprofloxacin for treatment of tularemia. *Clin Infect Dis.* 2001;33:267–8.
Tarnvik A. WHO Guidelines on tularaemia. Vol. WHO/CDS/EPR/2007.7. Geneva: World Health Organization, 2007.Top of Page
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						Page last reviewed:  August 5, 2022					Content source: 	Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of Vector-Borne Diseases (DVBD) homeTickborne Diseases of the United StatesTick IDOverview of Tickborne DiseasesLyme DiseaseTickborne Relapsing Fever (TBRF)Hard Tick Relapsing FeverAnaplasmosisEhrlichiosisRocky Mountain Spotted Fever*Rickettsia parkeri*RickettsiosisTularemiaBabesiosisHeartland and Bourbon Virus DiseasesColorado Tick FeverPowassan Virus DiseaseTickborne Diseases AbroadTick Bites/PreventionLyme Disease Prophylaxis After Tick Bite


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