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Module 17710 lessonsRxPrep 2023 Chapter 23, reconciled with CDC 2025 tularemia treatment and prophylaxis recommendations, current CDC clinical, diagnostic, laboratory safety, occupational exposure, prevention, and surveillance resources

Tularemia

Recognize Francisella exposure across portals, protect the laboratory, match current antimicrobial exposure to severity and anatomy, and coordinate follow-up from one patient to a possible public health event.

01

Connect vector, animal, water, aerosol, ingestion, eye, and laboratory exposures to disease probability.

02

Differentiate ulceroglandular, glandular, oculoglandular, oropharyngeal, pneumonic, and typhoidal disease.

03

Triage severe physiology, deep infection, suppurative nodes, and dangerous mimics without delaying care.

04

Select the specimen and alert the laboratory before culture or aerosol generating work.

05

Apply the 2025 first line framework instead of repeating the older aminoglycoside only model.

06

Preserve exact adult, pediatric, treatment, prophylaxis, and monitoring exposures.

07

Treat neuroinvasive disease with active combination therapy and a complete 21 day course.

08

Individualize care for pregnancy, lactation, neonates, children, older adults, and immune compromise.

09

Separate routine prevention, natural exposure decisions, occupational PEP, and intentional release response.

10

Assign result ownership, response checkpoints, laboratory safety actions, and public health communication.

177.01

Lesson

Build the Exposure Route Before Naming the Syndrome

Tularemia begins at a portal. Tick, fly, animal, water, eye, ingestion, inhalation, and laboratory exposures lead to different anatomic clues even though the organism is the same.

What to learn
  • Francisella biology
  • Vectors
  • Animal reservoirs
  • Aerosol
  • Incubation
Clinical systemTrace exposure into anatomy
01SourceDefine the starting state

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

02PortalLocate the decision boundary

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

03IncubationMatch the intervention

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

04FormSecure the next checkpoint

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

Begin with an unusual organism

Francisella tularensis is a fastidious, highly infectious, intracellular gram negative coccobacillus. A low inoculum can cause disease, which matters for aerosol exposure, laboratory safety, and intentional release planning.

Use the correct vector map

Dermacentor variabilis, Dermacentor andersoni, and Amblyomma americanum can transmit tularemia in the United States. Deer flies matter in some regions. This is not the Ixodes only pathway used for Lyme risk.

Ask beyond the tick

Rabbits, hares, rodents, cats, hunting, skinning, bites, scratches, contaminated water, farming, mowing, aerosol, and laboratory material can all create exposure. The denied tick bite should not close the history.

Place symptoms on the clock

Symptoms usually begin after several days, although the range is broader. Person to person transmission has not been demonstrated, so routine household contact is not the exposure that drives prophylaxis decisions.

Quick check

0 of 1 answered
01Which exposure can cause pneumonic tularemia without a recognized tick bite?
Answer every question to submit.
177.02

Lesson

Read the Portal in the Clinical Form

Clinical forms are not separate diseases. They are the anatomy left behind by inoculation, ingestion, inhalation, ocular exposure, or systemic spread.

What to learn
  • Ulceroglandular
  • Glandular
  • Oculoglandular
  • Oropharyngeal
  • Pneumonic
  • Typhoidal
Clinical systemRead the disease from its portal
01SkinDefine the starting state

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

02Eye or throatLocate the decision boundary

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

03LungMatch the intervention

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

04SystemicSecure the next checkpoint

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

Find the inoculation pattern

Ulceroglandular disease combines a skin ulcer or eschar with regional lymphadenopathy. Glandular disease produces the node pattern without an obvious skin lesion.

Follow eye and ingestion portals

Oculoglandular disease can cause painful conjunctivitis and preauricular nodes. Oropharyngeal disease can cause pharyngitis, oral lesions, cervical nodes, abdominal pain, vomiting, or diarrhea after ingestion.

Recognize inhalational disease

Pneumonic tularemia can produce fever, cough, dyspnea, pleuritic pain, infiltrates, pleural fluid, and hilar adenopathy. It can follow primary inhalation or dissemination from another form.

Do not require a localizing sign

Typhoidal tularemia is a systemic febrile illness that can lack a portal lesion. Older adults and people with chronic illness can have gastrointestinal symptoms, hepatosplenomegaly, altered mental status, or sepsis.

Quick check

0 of 1 answered
01Fever, a hand ulcer, and painful axillary nodes after skinning a rabbit most strongly suggest what?
Answer every question to submit.
177.03

Lesson

Let Physiology Set the Care Environment

A small ulcer can coexist with dangerous systemic infection. Hemodynamics, oxygenation, neurologic function, organ injury, source control, and reliability decide whether care can remain outpatient.

What to learn
  • Sepsis
  • Respiratory failure
  • Neuroinvasion
  • Suppuration
  • Mimics
Clinical systemLet physiology define urgency
01PerfusionDefine the starting state

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

02OxygenLocate the decision boundary

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

03NeurologicMatch the intervention

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

04SourceSecure the next checkpoint

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

Define severe infection

Hemodynamic instability, end organ dysfunction, respiratory support, sepsis, neuroinvasion, or other critical physiology marks severe disease. These patients need hospital care and prompt effective treatment.

Consider combination therapy

For severe disease, initial aminoglycoside therapy has the deepest clinical experience. Two active classes, such as gentamicin plus ciprofloxacin or gentamicin plus doxycycline, can be considered while the case is clarified.

Examine persistent nodes

Lymph nodes can suppurate and may require aspiration or drainage. A fluctuant enlarging node after systemic improvement is an anatomy problem to reassess, not automatic proof that every active drug failed.

Keep dangerous alternatives visible

Plague, anthrax, rickettsial disease, brucellosis, tuberculosis, lymphoma, bacterial pneumonia, and routine skin infection can overlap. Isolation, laboratory, public health, and empiric treatment needs may differ.

Quick check

0 of 1 answered
01Which finding most clearly makes tularemia severe?
Answer every question to submit.
177.04

Lesson

Protect the Laboratory While You Build the Diagnosis

Francisella can be slow to reveal itself and dangerous to handle. The safest diagnostic plan pairs direct laboratory communication with a specimen selected from the involved compartment.

What to learn
  • Laboratory alert
  • Culture
  • PCR
  • Paired serology
  • Specimen selection
Clinical systemProtect people while finding proof
01AlertDefine the starting state

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

02SpecimenLocate the decision boundary

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

03Direct testMatch the intervention

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

04Paired serumSecure the next checkpoint

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

Alert before the specimen arrives

Tell the microbiology laboratory that tularemia is suspected before culture or aerosol generating work. The warning changes biosafety handling and protects staff from a recognized laboratory acquired infection hazard.

Match specimen to form

Ulcer material, conjunctival swab, node aspirate or biopsy, blood, respiratory material, and pleural fluid can be considered according to anatomy and laboratory guidance. Prior therapy and lesion age affect yield.

Use direct methods within their limits

Culture can confirm infection but is slow and hazardous. Validated PCR, immunohistochemistry, or sequencing can support or confirm the diagnosis depending on specimen and public health criteria.

Respect the antibody window

Antibodies often are not detectable until two to three weeks after symptom onset. A negative early result does not exclude disease. Paired acute and convalescent specimens can demonstrate seroconversion, while persistent antibody is not a test of cure.

Quick check

0 of 1 answered
01What is the most important safety step before culturing a specimen from suspected tularemia?
Answer every question to submit.
177.05

Lesson

Use the Current First Line Framework

The older aminoglycoside centered summary has changed. CDC now recognizes ciprofloxacin, levofloxacin, gentamicin, and doxycycline as first line treatment options, with selection driven by severity and delivery.

What to learn
  • Ciprofloxacin
  • Levofloxacin
  • Gentamicin
  • Doxycycline
  • Treatment delay
Clinical systemMatch active exposure to threat
01CiprofloxacinDefine the starting state

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

02LevofloxacinLocate the decision boundary

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

03GentamicinMatch the intervention

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

04DoxycyclineSecure the next checkpoint

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

Use the adult fluoroquinolone regimens

Ciprofloxacin is 400 mg IV every 8 hours or 750 mg orally every 12 hours for 10 days. Levofloxacin is 750 mg IV or orally every 24 hours for 10 days. These are active treatment doses, not PEP doses.

Use extended interval gentamicin

Adults receive gentamicin 6 mg/kg IV or IM every 24 hours for 10 days. Drug levels and renal function should be monitored during at least the initial treatment days.

Load and continue doxycycline

Adults receive doxycycline 200 mg once, then 100 mg IV or orally every 12 hours for 14 to 21 days. The longer duration and loading dose should remain visible in the order.

Account for delay and severity

When treatment is delayed, ciprofloxacin, levofloxacin, or gentamicin is preferred over doxycycline because relapse concern is greater. Severe illness favors initial aminoglycoside exposure and can justify two active classes.

Quick check

0 of 1 answered
01Which adult oral regimen matches current treatment guidance?
Answer every question to submit.
177.06

Lesson

Protect Drug Exposure From Order to Follow-Up

The right antimicrobial can still fail when dose, interval, absorption, concentration monitoring, renal adjustment, or source control is wrong.

What to learn
  • Chelation
  • QT
  • Tendon
  • Renal function
  • Drug levels
  • Response
Clinical systemPreserve exposure from order to response
01DeliverDefine the starting state

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

02AbsorbLocate the decision boundary

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

03MonitorMatch the intervention

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

04ReassessSecure the next checkpoint

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

Deliver fluoroquinolones safely

Separate iron, calcium, magnesium, aluminum, and interacting feeds. Review QT, tendon, neuropathy, glycemic, central nervous system, and aortic risks without losing sight of the need for effective treatment.

Deliver doxycycline safely

Use adequate water and upright posture to reduce esophageal injury. Separate polyvalent cations and interacting feeds, plan for photosensitivity, and address nausea without pairing the dose with an interfering mineral product.

Interpret gentamicin levels correctly

Use a local extended interval protocol. Document dose and sample times, follow creatinine and urine output, review nephrotoxins, and ask about hearing, tinnitus, balance, and neuromuscular symptoms.

Audit delayed response

Persistent fever, organ injury, abscess, or slow recovery triggers review of diagnosis, source control, exact exposure, absorption, adherence, complication, and coinfection before automatic extension.

Quick check

0 of 1 answered
01What information is essential for interpreting a gentamicin concentration?
Answer every question to submit.
177.07

Lesson

Treat Neuroinvasion as Its Own Compartment

Tularemia meningitis is rare, potentially fatal, and the major exception to using the same core regimen for every clinical form.

What to learn
  • Gentamicin
  • Fluoroquinolone
  • CSF penetration
  • Twenty one days
  • Deep foci
Clinical systemTreat the nervous system as a distinct compartment
01Two classesDefine the starting state

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

02CSFLocate the decision boundary

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

03Ten daysMatch the intervention

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

04Twenty one daysSecure the next checkpoint

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

Use active combination therapy

Neuroinvasive tularemia should receive gentamicin plus ciprofloxacin or levofloxacin. Gentamicin plus doxycycline is an alternative when fluoroquinolones are unavailable or contraindicated.

Complete the duration

Successful regimens generally include at least 10 days of aminoglycoside therapy. When gentamicin stops, continue an active oral agent so the total effective course reaches 21 days.

Do not rely on routine beta lactams

Penicillins, cephalosporins, carbapenems, glycopeptides, polymyxins, and sulfonamides are ineffective for tularemia. A familiar bacterial meningitis regimen is not automatically active against Francisella.

Search for focal complications

Endocarditis, osteomyelitis, septic arthritis, pericarditis, mastoiditis, and other focal infections require site specific imaging, specimens, source management, and expert duration decisions.

Quick check

0 of 1 answered
01Which regimen is preferred for neuroinvasive tularemia?
Answer every question to submit.
177.08

Lesson

Individualize Without Sacrificing Effective Therapy

Age, pregnancy, lactation, immune status, organ function, and formulation change how therapy is delivered, not whether serious infection deserves active treatment.

What to learn
  • Pregnancy
  • Lactation
  • Children
  • Neonates
  • Immune compromise
Clinical systemIndividualize without undertreating
01AgeDefine the starting state

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

02WeightLocate the decision boundary

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

03Organ functionMatch the intervention

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

04DeliverySecure the next checkpoint

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

Prioritize cure during pregnancy

Ciprofloxacin, levofloxacin, or gentamicin can be used as first line treatment during pregnancy. Choice uses severity, route, organ function, interactions, and available alternatives rather than obsolete pregnancy letters.

Support lactation safely

Lactation can usually continue. A breast ulcer should be covered, and direct feeding from the affected side may need to pause when a lesion is close to the nipple until it heals.

Calculate pediatric regimens

Children at least one month old can use weight based ciprofloxacin, gentamicin, doxycycline, or age specific levofloxacin. Use current kilogram weight, maximums, exact concentration, and caregiver teach back.

Protect neonates and higher risk adults

Neonates use ciprofloxacin or gentamicin as first line options. Older adults and immunocompromised patients use active therapy with closer attention to typhoidal disease, organ function, interactions, setting, and response.

Quick check

0 of 1 answered
01What is the best pregnancy principle for active tularemia?
Answer every question to submit.
177.09

Lesson

Separate Prevention From Treatment

Natural contact, recognized occupational exposure, intentional release, and active illness are different states. Each has a different antimicrobial objective.

What to learn
  • Occupational PEP
  • Natural exposure
  • Intentional release
  • No routine PrEP
  • Engineered resistance
Clinical systemName the state before selecting exposure
01NaturalDefine the starting state

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

02OccupationalLocate the decision boundary

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

03IntentionalMatch the intervention

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

04IllnessSecure the next checkpoint

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

Use occupational PEP precisely

Adults can receive ciprofloxacin 500 mg orally every 12 hours for 7 days, levofloxacin 500 mg orally every 24 hours for 7 days, or doxycycline 100 mg orally every 12 hours for 10 to 14 days after a recognized high risk exposure.

Do not medicate every natural contact

PEP is not routine after every outdoor or animal encounter. It can be considered after direct contact with a known infected animal, needlestick, bite, scratch, or infectious tissue exposure, with public health input or a reliable fever watch.

Respond differently to intentional release

Exposed asymptomatic persons should receive PEP as soon as possible, ideally within 48 hours. Symptomatic patients receive treatment, and initial dual active classes are recommended while engineered resistance is assessed.

Avoid routine pre-exposure antibiotics

First responders, health care workers using standard precautions, and the general public do not need routine antimicrobial PrEP because person to person transmission risk is low.

Quick check

0 of 1 answered
01Which adult regimen is a current occupational PEP option?
Answer every question to submit.
177.10

Lesson

Close the Clinical and Public Health Loop

Tularemia care continues after the first prescription. Culture, serology, occupational exposure, animal events, cluster detection, toxicity, source control, and response all require named ownership.

What to learn
  • Result ownership
  • Reporting
  • Source control
  • Response audit
  • Counseling
Clinical systemClose every clinical loop
01PatientDefine the starting state

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

02LaboratoryLocate the decision boundary

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

03Public healthMatch the intervention

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

04CheckpointSecure the next checkpoint

Connect exposure, anatomy, evidence, active therapy, and ownership without losing the patient context.

Assign every pending result

Name who reviews culture, PCR, paired serology, susceptibility information, and exposure investigation. Give the patient a direct route for reporting worsening symptoms or medication toxicity.

Coordinate early with public health

Tularemia is nationally notifiable and jurisdictional reporting applies. Early consultation supports confirmation, laboratory safety, occupational management, animal investigation, and recognition of a shared source or intentional event.

Reopen failures systematically

Audit diagnosis, treatment delay, dose, route, absorption, cations, adherence, renal adjustment, abscess, deep focus, alternate pathogen, and resistance context before adding or extending therapy.

Make counseling executable

Use teach back for the dosing schedule, cation separation, hydration, sun protection, tendon or neurologic symptoms, hearing or balance changes, fever recurrence, respiratory red flags, and follow-up timing.

Quick check

0 of 1 answered
01Which plan best closes a tularemia visit?
Answer every question to submit.

Module test

Check the connections.

Each attempt draws 10 questions from the complete 178 question bank.

178 questions in this module bank10 questions per attempt

Each attempt draws a fresh set and rearranges the answer choices.

References

Current clinical foundation.

Lecture material was synthesized with the following contemporary guidance. Verify local policy and current guidance before applying clinical information.

  1. CDC Tularemia Antimicrobial Treatment and Prophylaxis Recommendations, 2025
  2. CDC Clinical Care of Tularemia
  3. CDC Clinical Signs and Symptoms of Tularemia
  4. CDC Testing and Diagnosis for Tularemia
  5. CDC Managing Occupational Exposures to Francisella tularensis
  6. CDC Infection Control and Environmental Decontamination
  7. CDC 2026 Tularemia Case Definition
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