CDC

CDC updates tularemia treatment and prophylaxis guidance

October 2, 2025

CDC released updated recommendations for the antimicrobial treatment and postexposure prophylaxis (PEP) of tularemia, a rare but serious zoonotic disease caused by Francisella tularensis. The guidance addresses both naturally acquired infections and potential bioterrorism scenarios, reflecting new evidence from human and animal studies since the last update in 2001. Tularemia’s low infectious dose and environmental stability make it a Tier 1 Select Agent, prompting the need for rapid clinical and public health response in the event of intentional release. The updated guidance includes considerations for vulnerable populations such as neonates, pregnant individuals, immunocompromised patients, and older adults.

Key recommendations

• First-line treatment includes ciprofloxacin, levofloxacin, gentamicin, or doxycycline for adults and children; ciprofloxacin or gentamicin for neonates.
• Dual therapy is recommended when bioterrorism is suspected, using two distinct antimicrobial classes.
• PEP should begin promptly with ciprofloxacin, levofloxacin, or doxycycline; duration varies by drug (7–14 days).
• Special populations (pregnant, lactating, geriatric, immunocompromised) should receive tailored regimens prioritizing safety and efficacy.
• Early treatment is critical—delays over 2 weeks increase risk of complications and treatment failure.
• Standard precautions are sufficient for tularemia patient care (e.g., PPE); person-to-person transmission is exceedingly rare.

These guidelines are intended to support clinicians and public health officials in managing tularemia cases and preparing for mass exposure events. They don't address diagnostic testing, triage, or dispensing protocols but focus on antimicrobial selection and duration based on disease severity and patient-specific factors.

Source:

Nelson CA, et al. (2025, October 2). CDC. Tularemia Antimicrobial Treatment and Prophylaxis: CDC Recommendations for Naturally Acquired Infections and Bioterrorism Response — United States, 2025. https://www.cdc.gov/mmwr/volumes/74/rr/rr7402a1.htm