Most tularemia cases are managed with recommended first-line or alternative antimicrobial regimens. When those options are no longer appropriate or available, a defined third-tier approach is required. This protocol addresses that escalation scenario.
The patient has tularemia and has reached a point where standard recommended antimicrobial options and their established alternatives have been exhausted. The protocol provides structured guidance on which agents to consider next and under what conditions.
Third-tier antimicrobial agents are specified for this situation — agents that differ in class from earlier treatment lines and are reserved for cases where no recommended option remains viable.
Streptomycin should be considered for treatment of tularemia only when first-line and alternative antimicrobial drugs have been exhausted.
Chloramphenicol should be considered for treatment of tularemia in nonpregnant adults and children only when other recommended antimicrobial options have been exhausted.
Azithromycin has been added as an alternative option for PEP and as a third-tier option for treatment.
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