Etiotropic antibiotic therapy
The main condition for successful treatment of tularemia is the correct choice of an antibacterial drug. Specific serological diagnostics (indirect hemagglutination assay — IHA, agglutination assay — AA) become most informative only by the 2nd–3rd week of the disease. Therefore, therapy often has to be started empirically, relying on the patient's typical appearance (facial puffiness and hyperemia, scleral injection, pale nasolabial triangle) and epidemiological history.
Clinical cases clearly demonstrate that the administration of semisynthetic penicillins (e.g., ampicillin) or macrolides (azithromycin) is ineffective: against their background, fever persists, intoxication increases, and the inflammatory process progresses with the formation of new buboes.
Drugs of choice for tularemia are:
- Aminoglycosides;
- Long-acting tetracycline drugs;
- Chloramphenicol;
- Rifampicin (administered in average therapeutic doses).
The duration of a continuous course of antibiotic therapy must be at least 14 days, regardless of how quickly clinical improvement occurs.
Management tactics and surgical treatment
All patients are subject to immediate routing and hospitalization in a specialized infectious diseases hospital. If a patient was mistakenly referred to another department (e.g., with a misdiagnosis of diphtheria), urgent transfer to a boxed ward is required.
Particular attention is required for the management of patients with tularemia buboes. A typical bubo is characterized by the absence of lymphangitis, mobility, mild tenderness, and normal skin color over it (without signs of periadenitis). As long as the lymph node maintains a dense consistency, exclusively conservative therapy is used.
Surgical treatment is strictly indicated when local inflammation progresses — with the appearance of signs of fluctuation (suppuration and softening of the infiltrate). In this case, the bubo is opened and drained.
Criteria for discharge from the hospital
Discharge of convalescents is possible only after achieving strict clinical and laboratory parameters.
Main criterion for recovery: persistent disappearance of all pathological symptoms, which includes:
- Persistent normalization of body temperature;
- Normalization of hemogram parameters (disappearance of leukopenia and relative lymphomonocytosis);
- General satisfactory condition of the patient.
There are important nuances depending on the clinical form contracted:
- In localized forms (e.g., ulceroglandular): the patient is allowed to be discharged with residual symptoms of lymphadenitis. The presence of enlarged lymph nodes measuring no more than 2 cm is permitted, but they must be completely painless and maintain mobility.
- In the pulmonary form (pneumonic): a mandatory condition before discharge is performing a follow-up chest X-ray to confirm the regression of infiltrates and a decrease in the size of root, paratracheal, and mediastinal lymph nodes.
Basics of prevention (epidemiological control)
Tularemia prevention is based on interrupting the routes of infection transmission, which can be vector-borne, contact, alimentary, and airborne.
In endemic areas, it is necessary to carefully collect the epidemiological history and avoid the following risk factors:
- Bites of blood-sucking insects (especially horseflies in the summer period);
- Direct contact with rodents (e.g., rats) at home or in the workplace;
- Consumption of raw (unboiled) cow's or goat's milk;
- Working with last year's hay or agricultural feed without respiratory protection (inhalation of contaminated dust leads to a severe pulmonary form with the formation of peribronchial infiltrates).
Briefly: answers to topical questions
What specific vaccine is used for routine immunoprophylaxis of tularemia in endemic foci?
For specific prevention of tularemia, a dry live tularemia vaccine is used. The preparation was developed by B.Ya. Elbert and N.A. Haysky.
Key characteristics:
- The basis of the vaccine is strain No. 15 of F. tularensis subspecies holarctica.
- Route of administration: applied once percutaneously.
- Revaccination: performed after 5 years in seronegative individuals.
Immunization is indicated routinely and according to epidemic indications, while the target immune layer should be at least 90%.
What dosages of streptomycin and gentamicin are used to treat tularemia in adults?
In the treatment of tularemia, the following dosages of the specified antibacterial drugs are used:
- Streptomycin is prescribed at a dose of 7.5–10 mg/kg 2 times a day.
- Gentamicin is prescribed at a dose of 3–5 mg/kg/day (divided into 3 administrations).
Both drugs are administered intramuscularly or intravenously. The total duration of the course of antibiotic therapy should be at least two weeks.
To remember effective antibiotic groups, use the acronym "A-T-R-H": Aminoglycosides, Tetracyclines, Rifampicin, Chloramphenicol.
Class and exam questions
Why are penicillins not prescribed for tularemia?
The tularemia pathogen has a natural insensitivity to semisynthetic penicillins (e.g., ampicillin) and macrolides. Their use does not stop the fever and does not halt the growth of the bubo.
When is it necessary to operate on a tularemic bubo?
Surgical intervention (opening) is indicated exclusively when signs of fluctuation appear, indicating purulent melting of the lymph node.
Is it possible to discharge a patient if the lymph node has not yet returned to normal?
Yes, in localized forms, discharge is permitted if the residual size of the lymph node does not exceed 2 cm, it is painless upon palpation, and is mobile.
Which diagnostic method is most informative for confirming the diagnosis?
The serological method (IHA, AA) is a priority. Bacteriological culture of an oropharyngeal swab is impractical due to the need for expensive media and long cultivation.
What else to study on this topic
- Characteristics and differential diagnosis of the tularemia bubo
- Differences in oropharyngeal lesions in diphtheria and tularemia
- X-ray presentation of the pulmonary form of tularemia
- Changes in the hemogram: why leukopenia occurs
- Specific rash ("socks and gloves") in the generalized form
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