Last reviewed: 29 Oct 2021
Last updated: 27 Oct 2021
27 Oct 2021

CDC updates plague guidance

The US Centers for Disease Control and Prevention (CDC) has issued the first recommendations for the treatment and prevention of plague since 2000. The guideline includes recommendations for both naturally occurring disease and following a bioterrorism attack. The CDC based its revised guidance on an extensive systematic review of the literature, alongside multiple sessions with experts.

The key change to the guideline is that it has been simplified into treatment and prophylaxis scenarios, and the treatment scenarios are now based on the clinical form of plague. Previously, the guidelines were divided into contained casualty versus mass casualty scenarios. The rationale behind this change is that it may not be clear initially how large an outbreak will be. The new approach provides greater flexibility for responding to uncertain situations.

Other key changes to the guideline include:

  • Recommendations for clinical forms of plague other than pneumonic plague

  • Specific recommendations for pregnant women, neonates, and breastfeeding infants

  • Ciprofloxacin is now recommended as a first-line option rather than an alternative option; levofloxacin and moxifloxacin have also been added as first-line options

  • Extended treatment options now include oral and parenteral options, as well as same-class alternative antibiotics

  • Pre-exposure prophylaxis recommendations have been added and postexposure prophylaxis recommendations have been revised.

Plague has a high case fatality rate but is treatable with antibiotic therapy and supportive care.

See Management: approach

See Management: treatment algorithm

See Management: prevention

Original source of update



History and exam

Key diagnostic factors

  • constitutional symptoms
  • lymphadenitis (bubonic plague)
  • hemoptysis (pneumonic plague)
  • diarrhea (yersiniosis)
  • abdominal pain (yersiniosis)

Other diagnostic factors

  • pleuritic chest pain (pneumonic plague)
  • dyspnea (pneumonic plague)

Risk factors

  • exposure to fleas (plague)
  • residence in, or travel to, an endemic area (plague)
  • contact with infected animals (plague)
  • bioterrorism (plague)
  • young children (yersiniosis)
  • consumption of raw or undercooked pork products (yersiniosis)
  • exposure to people with plague (plague)
  • iron-overload syndromes (yersiniosis)
  • chronic liver disease, diabetes, alcoholism (yersiniosis)

Diagnostic investigations

1st investigations to order

  • blood culture (plague)
  • bubo aspirate culture (bubonic plague)
  • sputum culture (pneumonic plague)
  • cerebrospinal fluid culture (septicemic plague)
  • antigen detection (plague)
  • WBC count (plague)
  • chest x-ray (pneumonic plague)
  • stool culture (yersiniosis)

Emerging tests

  • polymerase chain reaction (PCR)

Treatment algorithm



John Williams, MRCP, DTM&H, Dip HIV Med
John Williams

Consultant Infectious Diseases Physician

Department of Infection and Travel Medicine

The James Cook University Hospital




JW declares that he has no competing interests.

Peer reviewers

Vladimir L. Motin, PhD


Pathology/Microbiology and Immunology

University of Texas Medical Branch




VLM declares that he has no competing interests.

Waleed Javaid, MD, FACP, FIDSA

Associate Professor

Medical Director of Infection Control

Infectious Disease

Department of Medicine

SUNY Upstate Medical University




WJ declares that he has no competing interests.

Alistair Leanord, BSc, MBChB, MD, DTM&H, FRCPath

Consultant Microbiologist

Microbiology Department

Southern General Hospital




AL declares that he has no competing interests.

Janak Koirala, MD

Associate Professor of Medicine

Division of Infectious Diseases

Department of Internal Medicine

Southern Illinois University School of Medicine




JK declares that he has no competing interests.

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