title: Treatment of plague with gentamicin or doxycycline in a randomized clinical trial in Tanzania.
abstract: BACKGROUND
  Over the past 50 years, antibiotics of choice for treatment of plague, including streptomycin, chloramphenicol, and tetracycline, have mostly become outdated or unavailable. To test gentamicin in the treatment of naturally occurring plague and the implications of its use in the treatment of bioterrorist plague, a randomized, comparative, open-label, clinical trial comparing monotherapy with gentamicin or doxycycline was conducted in Tanzania.
  
  
  METHODS
  Sixty-five adults and children with symptoms of bubonic, septicemic, or pneumonic plague of < or =3 days duration were enrolled in the study. Bubo aspirates and blood were cultured for Yersinia pestis. Acute-phase and convalescent-phase serum samples were tested for antibody against fraction 1 antigen of Y. pestis. Thirty-five patients were randomized to receive gentamicin (2.5 mg/kg intramuscularly every 12 h for 7 days), and 30 patients were randomized to receive doxycycline (100 mg [adults] and 2.2 mg/kg [children] orally every 12 h for 7 days). Serum creatinine concentrations were measured before and after treatment, and peak and trough concentrations of antibiotics were measured.
  
  
  RESULTS
  Three patients, 2 of whom were treated with gentamicin and 1 of whom was treated with doxycycline, died on the first or second day of treatment, and these deaths were attributed to advanced disease and complications including pneumonia, septicemia, hemorrhage, and renal failure at the start of therapy. All other patients experienced cure or an improved condition after receiving therapy, resulting in favorable response rates of 94% for gentamicin (95% CI, 81.1%-99.0%) and 97% for doxycycline (95% CI, 83.4%-99.8%). Y. pestis isolates obtained from 30 patients belonged to biotype antigua and were susceptible to gentamicin and doxycycline, which had MICs of 0.13 mg/L and 0.25-0.5 mg/L, respectively. Serum concentrations of antibiotics were within therapeutic ranges, and adverse events were infrequent. Patients treated with gentamicin demonstrated a modest increase in the mean serum creatinine concentration after treatment (P<.05, by paired t test).
  
  
  CONCLUSIONS
  Both gentamicin and doxycycline were effective therapies for adult and pediatric plague, with high rates of favorable responses and low rates of adverse events.
authors.affiliation: Regional Medical Office, Tanga, Tanzania.
authors.forename: William
authors.initials: W
authors.lastname: Mwengee
authors.forename: Thomas
authors.initials: T
authors.lastname: Butler
authors.forename: Samuel
authors.initials: S
authors.lastname: Mgema
authors.forename: George
authors.initials: G
authors.lastname: Mhina
authors.forename: Yusuf
authors.initials: Y
authors.lastname: Almasi
authors.forename: Charles
authors.initials: C
authors.lastname: Bradley
authors.forename: James B
authors.initials: JB
authors.lastname: Formanik
authors.forename: C George
authors.initials: CG
authors.lastname: Rochester
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D004318:Doxycycline / Q000627:therapeutic use*; D005260:Female; D005839:Gentamicins / Q000627:therapeutic use*; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D010930:Plague / Q000188:drug therapy*; D013636:Tanzania
chemical_list: D000900:Anti-Bacterial Agents; D005839:Gentamicins; D004318:Doxycycline