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.
Yersinia infection can cause plague or yersiniosis, both of which are notifiable conditions. Plague may be naturally occurring, or may potentially be the result of a bioterrorist attack.
Plague may be suggested by characteristic clinical findings together with a history of potential exposure in an endemic area. Microbiologic studies are used to confirm the diagnosis.
Plague has a high case fatality rate, but is treatable with antibiotic therapy and supportive care. Patients with pneumonic plague should be isolated immediately and placed on standard and droplet precautions. Pre-exposure or postexposure prophylaxis may be required in people exposed to plague.
Yersiniosis generally presents as a self-limiting gastroenteritis. The mainstay of management is supportive care; however, antibiotics may be required in invasive infection.
In humans, Yersinia pestis causes plague and Yersinia enterocolitica causes yersiniosis. Infection with Yersinia pseudotuberculosis is uncommon and causes similar symptoms to yersiniosis.
The plague bacillus Y pestis is transmitted to people mainly by the bites of infected fleas. Infection is characterized by the sudden onset of systemic symptoms such as fever and painful swelling of lymph nodes (buboes) in bubonic plague; systemic features, but without buboes, in septicemic plague; and chest pain, dyspnea, and hemoptysis in pneumonic plague. Pharyngeal and meningeal plague are less common. Y pestis is categorized as a tier 1 bioterrorism select agent due to its low infectious dose, high case fatality rate, and history of use as an agent of bioterrorism.
Y enterocolitica and Y pseudotuberculosis are mainly acquired by consuming contaminated food and water. Symptoms are mostly confined to the gastrointestinal tract (self-limiting gastroenteritis), but reactive arthritis is a common complication.
History and exam
- 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)
- 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)
John Williams, MRCP, DTM&H, Dip HIV Med
Consultant Infectious Diseases Physician
Department of Infection and Travel Medicine
The James Cook University Hospital
JW declares that he has no competing interests.
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
Medical Director of Infection Control
Department of Medicine
SUNY Upstate Medical University
WJ declares that he has no competing interests.
Alistair Leanord, BSc, MBChB, MD, DTM&H, FRCPath
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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