Inhibit bacterial 30S ribosomal subunit protein synthesis
Penetrate intracellular compartments
Gold standard for severe disease
Fluoroquinolones (bactericidal)
Inhibit DNA gyrase and topoisomerase IV
Excellent intracellular penetration
Preferred for oral step-down and mild disease
Tetracyclines (bacteriostatic)
Inhibit 30S ribosomal subunit
Higher relapse rate due to bacteriostatic mechanism
Adequate for mild disease with full 21-day course
Beta-lactam resistance mechanism
Francisella tularensis produces class A beta-lactamase (BlaB)
Hydrolyzes penicillins and early cephalosporins
Class C beta-lactamase also present
Treatment failure with beta-lactams is a diagnostic clue
Evidence base
Gentamicin vs. streptomycin: equivalent efficacy
Gentamicin preferred due to wider availability and IM/IV flexibility
Fluoroquinolones vs. doxycycline: fluoroquinolones superior
Lower relapse rate 5-10% vs. 10-15%
2024 CID surveillance data supports fluoroquinolone preference
2025 CDC MMWR recommendations: most current guidance
Fluoroquinolone first-line for mild-moderate naturally acquired disease
Aminoglycoside first-line for severe disease and bioterrorism response
Patient Discharge Instructions
copy discharge instructions
Discharge instructions for tularemia
Your diagnosis
You have been diagnosed with tularemia, a bacterial infection caused by Francisella tularensis
It is typically acquired from tick bites, handling wild animals, or outdoor exposures
It is NOT contagious from person to person
Your medications
Take your prescribed antibiotic exactly as directed
Complete the full course: 14-21 days as prescribed
Do not stop early even if you feel better
Take ciprofloxacin with a full glass of water
Avoid antacids, calcium, iron within 2 hours of ciprofloxacin
Take doxycycline with food and a full glass of water to reduce stomach upset
Expected recovery
Symptoms typically improve within 48-72 hours of starting antibiotics
Complete recovery may take several weeks
Fatigue and weakness may persist during recovery
Lymph nodes may remain swollen or drain for weeks to months
Follow-up appointments
Return to your doctor within 1 week to assess response
Repeat blood tests may be needed at 2-4 weeks (serology)
Report any new or worsening symptoms to your doctor immediately
Preventing future infections
Wear long sleeves and pants in tick-endemic areas
Use DEET-based insect repellent
Check for ticks after outdoor activity and remove promptly
Wear gloves when handling wild animals or carcasses
Avoid untreated water from natural sources
Cook wild game thoroughly before eating
Return to emergency department immediately for
Red flag symptoms requiring immediate care
Worsening or recurrent fever after initial improvement
New or worsening shortness of breath or chest pain
Coughing up blood
Increasing size, redness, or drainage from lymph nodes
Confusion, severe headache, or stiff neck
Inability to take oral medications due to nausea or vomiting
Signs of allergic reaction to antibiotics: rash, hives, swelling, difficulty breathing
References
Guidelines and key sources
Primary guidelines
Nelson CA, Meaney-Delman D, Fleck-Derderian S, et al. Tularemia Antimicrobial Treatment and Prophylaxis: CDC Recommendations for Naturally Acquired Infections and Bioterrorism Response - United States, 2025. MMWR Recomm Rep. 2025. PMID 41026652
Dennis DT, Inglesby TV, Henderson DA, et al. Tularemia as a Biological Weapon: Medical and Public Health Management. JAMA. 2001;285(21):2763-2773
Maurin M, Gyuranecz M. Tularaemia: Clinical Aspects in Europe. Lancet Infect Dis. 2016;16(1):113-124. PMID 26738841
Wu HJ, Bostic TD, Horiuchi K, et al. Tularemia Clinical Manifestations, Antimicrobial Treatment, and Outcomes: An Analysis of US Surveillance Data, 2006-2021. Clin Infect Dis. 2024. PMID 38294115
Clinical management references
Antonello RM, Giacomelli A, Riccardi N. Tularemia for Clinicians: An Up-to-Date Review on Epidemiology, Diagnosis, Prevention and Treatment. Eur J Intern Med. 2025. PMID 40107886
Weber IB, Turabelidze G, Patrick S, et al. Clinical Recognition and Management of Tularemia in Missouri: A Retrospective Records Review of 121 Cases. Clin Infect Dis. 2012. PMID 22911645
Maurin M, Pondérand L, Hennebique A, et al. Tularemia Treatment: Experimental and Clinical Data. Front Microbiol. 2023. PMID 38298538
Special topics
Widerström M, Mörtberg S, et al. Treatment Outcome of Severe Respiratory Type B Tularemia Using Fluoroquinolones. Clin Infect Dis. 2024. PMID 38294118
Adalja AA, Toner E, Inglesby TV. Clinical Management of Potential Bioterrorism-Related Conditions. N Engl J Med. 2015. PMID 26200985
Ho BM, Davis HE, Forrester JD, et al. Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Management of Tick-Borne Illness in the United States. Wilderness Environ Med. 2021
Zaghdoudi A, Robin F, Moulinie J, et al. Pulmonary Tularemia: A Diagnosis Not to Overlook. Int J Infect Dis. 2026. PMID 41482246
Evans ME, Gregory DW, Schaffner W, McGee ZA. Tularemia: A 30-Year Experience With 88 Cases. Medicine. 1985. PMID 3892222
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.