Version August 2025
| Drug | Adult dosing | Pediatric dosing |
| Aminoglycosides | ||
| Gentamicin¶ | 5 mg/kg intramuscularly or intravenously per day, given once dailyΔ or divided every 8 hours for 7 to 10 days | 5 mg/kg intramuscularly or intravenously per day, given once dailyΔ or 2.5 mg/kg every 8 or 12 hours for 7 to 10 days◊ |
| Streptomycin§ | 10 mg/kg intramuscularly every 12 hours for 7 to 10 days (maximum daily dose 2 g) | 30 to 40 mg/kg per day intramuscularly, in divided doses every 12 hours for 7 to 10 days◊ (maximum daily dose 2 g) |
| Fluoroquinolones | ||
| Ciprofloxacin | Oral: 500 to 750 mg orally twice daily for 7 to 10 days Intravenous: 400 mg intravenously twice daily for 7 to 10 days | 15 mg/kg per day orally or intravenously every 12 hours for 10 days (maximum daily dose 800 mg)¥ |
| Levofloxacin | 750 mg orally or intravenously once daily for 7 to 10 days | Children 6 months to <5 years: 8 mg/kg orally or intravenously twice daily for 10 days (maximum 250 mg/dose) Children ≥5 years: 10 mg/kg/dose orally or intravenously once daily for 10 days (maximum daily dose 500 mg) |
| Tetracyclines | ||
| Doxycycline | 100 mg orally twice daily for 14 to 21 days‡ | 2.2 mg/kg/day orally every 12 hours for 21 days‡ (maximum 200 mg/day) |
* For patients with severe infection, we suggest an aminoglycoside (typically gentamicin). A fluoroquinolone is an alternative. For patients who can be managed reliably as outpatients and for hospitalized patients without severe disease, initial oral treatment is reasonable. In such cases, we suggest a fluoroquinolone or doxycycline.
Meningitis and endocarditis are rare complications of tularemia that should be managed in consultations with experts. Refer to other content for management of those conditions.
¶ Dosing for gentamicin must be adjusted according to serum concentrations for individuals with renal insufficiency, individuals over age 50 years, and for pediatric patients. For pediatric patients, adjust the dose of gentamicin to maintain a peak serum concentration of at least 5 mcg/mL. For individuals with normal renal function, once-daily dosing of gentamicin is also acceptable. For obese patients, dosing should be determined based on adjusted weight. (Refer to Calculator on ideal body weight (method of Devine) and dosing weight.)
Δ When gentamicin is given as once-daily, or extended-interval, dosing levels should be monitored to determine the appropriate dose and interval for administration. Refer to other UpToDate content on extended-interval aminoglycoside dosing.
◊ Some experts suggest that aminoglycosides be given for 10 to 14 days for children with the exception that 7 days is likely sufficient for children with mild disease.
§ Streptomycin is not widely available; gentamicin is the preferred aminoglycoside. Dosing for streptomycin must be adjusted according to serum concentrations for individuals with renal insufficiency, individuals over age 50 years, and for pediatric patients. Target serum streptomycin concentrations for intramuscular administration are trough <10 mcg/mL and peak up to 20 to 25 mcg/mL. For adults patients who are very ill, streptomycin 15 mg/kg every 12 hours may be administered. Streptomycin is more ototoxic than other aminoglycosides and audiometric testing is warranted for situations in which serum concentration monitoring is warranted. For obese patients, dosing should be determined based on adjusted weight. (Refer to Calculator on ideal body weight (method of Devine) and dosing weight.)
¥ Initial oral treatment is reasonable for patients who can be managed reliably as outpatients and for hospitalized patients without severe disease.
‡ Doxycycline is administered for a longer duration than other agents because of a higher risk of relapse with shorter courses.
