Prophylactic Treatment

In the event of a known exposure to F. tularensis antibiotic prophylaxis should be initiated as soon as possible. Prophylaxis should continue until exposure has been excluded. Ciprofloxacin is the prophylactic agent of choice when there is a credible threat of exposure to a biological agent. Ciprofloxacin has the added advantage that it is also effective prophylactic treatment for other potential bioterrorist agents such as anthrax and plague. The risk of adverse effects from antibiotic prophylaxis must be weighed against the risk of developing serious disease.

After an initial five day treatment with ciprofloxacin, doxycycline may be substituted to complete the 14 days prophylaxis. Only the initial course of antibiotics for prophylaxis is held in pods as part of the antibiotic stockpile. Arrangements for the supply of the remainder of the prophylactic course are being developed and individuals should be advised to report to their own GP. See DH Patient Group Directions  for the initial and further supply of ciprofloxacin and the further supply of doxycycline in the event of exposure to a suspect biological agent.

In a major incident information on how to access stocks of antibiotics for initial treatment or prophylaxis can be found on the DH website.

The regimen may be modified when information regarding the identity and/or antibiotic susceptibility of an organism becomes available. One small study, in which volunteers were exposed to an aerosol of a virulent strain of F. tularensis, showed that oral tetracycline 1g/day for 24 days or 2g/day for 14 days were effective in preventing clinical infection if given within 24 hours of exposure. A shorter course was associated with symptomatic tularemia in two of ten exposed individuals.

In the case of significant exposure of a laboratory worker, via aerosol or autoinoculation of infected material from a patient with tularemia, ciprofloxacin or doxycycline should be started immediately and given for 14-21 days.

Although ciprofloxacin is not licensed for use in children or pregnant women and there have been no formal studies of the use of ciprofloxacin during pregnancy, it is unlikely to be associated with a high risk of abnormalities of foetal development.

Paediatric use of fluoroquinolones and tetracyclines may be associated with adverse effects and their use must be weighed against the risk of developing an infectious disease with significant morbidity and mortality. In general doxycycline is not recommended for use in children under 12 years unless no alternative anti-bacterial can be given.

Recommended prophylaxis after exposure to F. tularensis

Immunisation for exposed persons

A live attenuated vaccine was developed and has been used to immunise laboratory staff who work with F. tularensis. The vaccine is unlicensed and provides incomplete protection, particularly against inhalational tularemia. It is not currently recommended for use as post-exposure prophylaxis.

Prophylactic treatment for contacts of cases

There is no need to provide antimicrobial prophylaxis to contacts of patients unless there is concern that they were also exposed to the initial release.

Prophylactic treatment for frontline and healthcare workers

Frontline workers includes all emergency staff involved in the management at the scene of a release and staff involved in the care of patients. Frontline workers entering the exposed zone should be offered post-exposure antibiotic prophylaxis (as outlined above). Prophylactic antibiotics may also be considered for frontline workers involved in other activities including:

Decisions about who should receive prophylaxis should be taken on an individual basis according to duration and degree of exposure and taking into account the availability and side effects of prophylactic treatments available. The live attenuated vaccine currently used for the protection of laboratory staff who work with live F. tularensis provides incomplete protection against inhalational tularemia and is not currently recommended for use as post-exposure prophylaxis.

Case finding

If cases of tularemia arise and a covert release is suspected, health services should be contacted to determine whether other possible cases have presented.

Preventing secondary spread

Person-to-person spread of F.tularensis does not occur therefore there is no specific treatment or advice required for secondary contacts. There is no requirement for quarantine of infected patients. There is no need to provide antibiotic prophylaxis to contacts of patients unless there is concern that they were also exposed to the initial release.

Last reviewed: 28 December 2011