Tularemia Antimicrobial Treatment and Prophylaxis: CDC Recommendations for Naturally Acquired Infections and Bioterrorism Response - United States, 2025.

Abstract

This report provides CDC recommendations to U.S. health care providers and preparedness personnel regarding treatment and postexposure prophylaxis (PEP) of tularemia, an uncommon but potentially serious disease caused by the gram-negative coccobacillus, Francisella tularensis. Tularemia occurs naturally in the United States and other Northern Hemisphere regions. Because F. tularensis has a low infectious inoculum, it is classified as a potential bioterrorism agent that could infect thousands of persons if intentionally released, requiring rapid, informed decision-making by public health agencies, first responders, and clinicians. To mitigate the effects of a bioterrorism attack, the U.S. government stockpiles medical countermeasures, and the 21st Century Cures Act mandates development of evidence-based guidelines for their use. Since 2001 when guidelines for tularemia treatment and PEP were last published, new animal study data and human clinical data have become available. CDC compiled a broad evidence base by conducting a series of systematic reviews of the literature on human tularemia through 2023, analyzing U.S. surveillance data, gathering outbreak reports and case series, and collecting animal data. During a series of scientific forums, evidence was presented from these investigations and additional data sources to subject matter experts, and individual expert input on proposed recommendations was solicited. The guidelines team then assessed the available evidence, considered different perspectives and feedback shared in the expert forums, and used the Grading of Recommendations, Assessment, Development and Evaluation summary of findings and the Evidence to Decision framework to formulate recommendations based on the balance of benefits and harms. Notable changes include use of a treatment and prophylaxis framework; designation of fluoroquinolones (ciprofloxacin or levofloxacin) and doxycycline as first-line treatment options for outbreaks of any size; identification of third-tier treatment options when first-line and alternative antimicrobials are unavailable or contraindicated for certain patients; and recommendations for neonates, breastfeeding infants, lactating mothers, patients with immunocompromise, and geriatric patients. These guidelines provide a summary of best practices for treatment and prophylaxis of human tularemia for both naturally occurring disease and after a bioterrorism attack. They do not include information on dispensing medical countermeasures, diagnostic testing, triage decisions, or adjunct treatments for patients with tularemia. Health care providers can use these guidelines to manage patients with naturally occurring infection and, with public health officials, prepare their organizations, clinics, hospitals, and communities to respond to a tularemia mass exposure event.