Pneumonic Plague Tracker
View Live Data (opens in a new tab)
EN
  • English EN
  • 中文 Soon ZH (Translations are coming)
  • हिन्दी Soon HI (Translations are coming)
  • Español Soon ES (Translations are coming)
  • Français Soon FR (Translations are coming)
  • العربية Soon AR (Translations are coming)
  • বাংলা Soon BN (Translations are coming)
  • Русский Soon RU (Translations are coming)
  • Português Soon PT (Translations are coming)
  • اردو Soon UR (Translations are coming)

Record updated Sources on file 27 262 views

Pneumonic Plague Treatment

Not medical advice. This page reports what WHO, CDC, PHAC and the peer-reviewed literature state, and it carries no doses. Treatment decisions belong to a clinician.

What the official guidance says to give, when to give it, and to whom.

Updated · 9 sources, 1 with a DOI

No doses appear on this page on purpose. CDC's 2021 MMWR recommendations carry the full adult and paediatric tables.3

The 24 hour rule

1234
The 24 hour rule24 hoursTreat insidethis window,from symptomonsetCenters for Disease Control and Prevention: Guidance for Responding to a Plague Bioterrorism Event[1]24 hoursFrom symptom onset, the target for startingantimicrobialsCenters for Disease Control and Prevention: Guidance for Responding to a Plague Bioterrorism Event[1]18 to 24 hoursHow fast untreated pneumonic plague can kill, fromdisease onsetWorld Health Organization: Plague (fact sheet)[2]10 to 14 daysFull antimicrobial course, extendable for ongoing feveror other concerning signsNelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response[3]The 24 hour rule24 hoursTreat inside thiswindow, fromsymptom onsetCenters for Disease Control and Prevention: Guidance for Responding to a Plague Bioterrorism Event[1]24 hoursFrom symptom onset, the target for starting antimicrobialsCenters for Disease Control and Prevention: Guidance for Responding to a Plague Bioterrorism Event[1]18 to 24 hoursHow fast untreated pneumonic plague can kill, from disease onsetWorld Health Organization: Plague (fact sheet)[2]10 to 14 daysFull antimicrobial course, extendable for ongoing fever or otherconcerning signsNelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response[3]

24 hours from symptom onset is the target for starting antimicrobials, not a point past which treatment fails.

  • Later treatment is not futile. Survivors who started antimicrobials after 24 hours are documented, and the evidence is too sparse to stratify outcomes by timing.4
  • WHO and CDC both anchor on 24 hours from symptom onset. PHAC states a narrower window, 8 to 20 hours after onset of pneumonic plague.215

Treated against untreated, pneumonic plague

4
Treated against untreated, pneumonic plague0%25%50%75%100%Untreated98%% died, 95% confidence interval 73 to 100Salam AP, Rojek AM, Cai E, Raberahona M, Horby P: Deaths Associated with Pneumonic Plague, 1946-2017[4]Treated17%% died, 95% confidence interval 8 to 31Salam AP, Rojek AM, Cai E, Raberahona M, Horby P: Deaths Associated with Pneumonic Plague, 1946-2017[4]50%. Often quoted for treated pneumonic plagueand not supported by the reviewSalam AP, Rojek AM, Cai E, Raberahona M, Horby P: Deaths Associated with Pneumonic Plague, 1946-2017[4]The often quoted 50% figure for treated pneumonicplague is not supported by the systematic review,which found 17% and says so explicitly.Salam AP, Rojek AM, Cai E, Raberahona M, Horby P: Deaths Associated with Pneumonic Plague, 1946-2017[4]Treated against untreated, pneumonic plague0%25%50%75%100%Untreated98%% died, 95% confidence interval 73 to 100Salam AP, Rojek AM, Cai E, Raberahona M, Horby P: Deaths Associated with Pneumonic Plague, 1946-2017[4]Treated17%% died, 95% confidence interval 8 to 31Salam AP, Rojek AM, Cai E, Raberahona M, Horby P: Deaths Associated with Pneumonic Plague, 1946-2017[4]50%. Often quoted for treated pneumonic plague and not supported by the reviewSalam AP, Rojek AM, Cai E, Raberahona M, Horby P: Deaths Associated with Pneumonic Plague, 1946-2017[4]The often quoted 50% figure for treated pneumonic plague is not supported by the systematic review,which found 17% and says so explicitly.Salam AP, Rojek AM, Cai E, Raberahona M, Horby P: Deaths Associated with Pneumonic Plague, 1946-2017[4]

Both figures are pooled rates from one systematic review of 1946 to 2017, drawn with their confidence intervals.

First line antimicrobials

365
First line antimicrobialsPneumonic and septicaemicAminoglycosidesStreptomycin, gentamicinParenteralNelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response[3]FluoroquinolonesCiprofloxacin, levofloxacinOral or parenteralNelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response[3]BubonicTetracyclinesDoxycyclineOralNelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response[3]AminoglycosidesStreptomycin, gentamicinParenteralNelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response[3]10 to 14 daysTotal course, extendable for patients with ongoing feveror other concerning signs or symptomsNelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response[3]Plague meningitisDual therapy with chloramphenicol and moxifloxacin orlevofloxacin for initial treatment.Nelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response[3]PregnancyCDC recommends treatment and prophylaxis when indicatedeven though antimicrobial use in pregnancy carries somerisks, preferring dual therapy with gentamicin plusciprofloxacin or levofloxacin.Nelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response[3]ChildrenMoxifloxacin is listed as an alternative rather thanfirst line, for lack of approval in that group.Nelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response[3]Supportive careIntravenous fluids, oxygen and respiratory support.Public Health Agency of Canada: Pathogen Safety Data Sheet: Yersinia pestis[5]First line antimicrobialsPneumonic and septicaemicAminoglycosidesStreptomycin, gentamicinParenteralNelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response[3]FluoroquinolonesCiprofloxacin, levofloxacinOral or parenteralNelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response[3]BubonicTetracyclinesDoxycyclineOralNelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response[3]AminoglycosidesStreptomycin, gentamicinParenteralNelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response[3]10 to 14 daysTotal course, extendable for patients with ongoing fever or other concerning signs or symptomsNelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response[3]Plague meningitisDual therapy with chloramphenicol andmoxifloxacin or levofloxacin for initialtreatment.Nelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response[3]PregnancyCDC recommends treatment and prophylaxis whenindicated even though antimicrobial use inpregnancy carries some risks, preferring dualtherapy with gentamicin plus ciprofloxacin orlevofloxacin.Nelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response[3]ChildrenMoxifloxacin is listed as an alternative ratherthan first line, for lack of approval in thatgroup.Nelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response[3]Supportive careIntravenous fluids, oxygen and respiratorysupport.Public Health Agency of Canada: Pathogen Safety Data Sheet: Yersinia pestis[5]

Drug, class and route. No doses, by design.

  • WHO's 2021 guideline exists to settle whether fluoroquinolones belong in first line treatment, and lists fluoroquinolone case management as one of its three revised recommendation areas. Its recommendation tables could not be retrieved, so every drug level claim here is cited to CDC or PHAC rather than to that guideline.6
  • Canada's official sheet names the same set: streptomycin, gentamicin, doxycycline, ciprofloxacin, levofloxacin or moxifloxacin.5
  • Alternatives include doxycycline for pneumonic and septicaemic plague, chloramphenicol, trimethoprim-sulfamethoxazole, and other agents within each class.3

Who gets post-exposure prophylaxis

3712
Who gets post-exposure prophylaxisClose contact, under 6 feet, sustained, with a pneumonicplague patient while not wearing adequate personalprotective equipmentNelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response[3]Direct contact with infected body fluids or tissuesCenters for Disease Control and Prevention: Clinical Care of Plague[7]Close sustained contact with an animal with pneumonicplagueCenters for Disease Control and Prevention: Clinical Care of Plague[7]Veterinary staff accidentally exposed to infectiousmaterial, or in close contact with infected animalsCenters for Disease Control and Prevention: Guidance for Responding to a Plague Bioterrorism Event[1]7 days of oral antibioticsOne of ciprofloxacin, levofloxacin, moxifloxacin ordoxycyclineNelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response[3]Centers for Disease Control and Prevention: Clinical Care of Plague[7]WHO and CDC differ on how longCDCA flat 7 days.Nelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response[3]WHOSeven days, or at least as long as the person is exposedto infected patients. On a continuing exposure, such asa health worker nursing cases, that runs longer thanCDC's rule.World Health Organization: Plague (fact sheet)[2]Who gets post-exposure prophylaxisClose contact, under 6 feet, sustained, with apneumonic plague patient while not wearing adequatepersonal protective equipmentNelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response[3]Direct contact with infected body fluids or tissuesCenters for Disease Control and Prevention: Clinical Care of Plague[7]Close sustained contact with an animal with pneumonicplagueCenters for Disease Control and Prevention: Clinical Care of Plague[7]Veterinary staff accidentally exposed to infectiousmaterial, or in close contact with infected animalsCenters for Disease Control and Prevention: Guidance for Responding to a Plague Bioterrorism Event[1]7 days of oralantibioticsOne of ciprofloxacin, levofloxacin,moxifloxacin or doxycyclineNelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response[3]Centers for Disease Control and Prevention: Clinical Care of Plague[7]WHO and CDC differ on how longCDCA flat 7 days.Nelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response[3]WHOSeven days, or at least as long as the person isexposed to infected patients. On a continuingexposure, such as a health worker nursing cases,that runs longer than CDC's rule.World Health Organization: Plague (fact sheet)[2]

Any one of these four is enough to qualify.

  • Emergency and response workers at high risk may take prophylaxis before exposure, discontinued 48 hours after the last perceived exposure.1

Isolation and droplet precautions

31896
Isolation and droplet precautionsOn suspicionConfirmed, probable and suspected pneumonic plaguepatients need standard and respiratory dropletprecautions.Centers for Disease Control and Prevention: Guidance for Responding to a Plague Bioterrorism Event[1]Nelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response[3]First 48 hoursPrecautions run through the first 48 hours ofantimicrobial therapy and until clinical improvementoccurs.Centers for Disease Control and Prevention: Guidance for Responding to a Plague Bioterrorism Event[1]After 48 hoursPrecautions can be discontinued once the patient hasreceived antimicrobials for at least 48 hours and hasshown clinical improvement.Nelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response[3]WHOPneumonic cases require isolation, and medical staffneed protective equipment.World Health Organization: Plague (questions and answers)[8]ECDCHealth care workers should wear gloves and masks whennursing plague patients.European Centre for Disease Prevention and Control: Facts about plague[9]WHO 2021 guidelineCovers personal protective equipment specifically forpreventing post-mortem transmission from the body of aperson who died of plague.World Health Organization: WHO guidelines for plague management: revised recommendations for the use of rapid diagnostic tests, fluoroquinolones for case management and personal protective equipment for prevention of post-mortem transmission[6]Isolation and droplet precautionsOn suspicionConfirmed, probable andsuspected pneumonic plaguepatients need standard andrespiratory dropletprecautions.Centers for Disease Control and Prevention: Guidance for Responding to a Plague Bioterrorism Event[1]Nelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response[3]First 48 hoursPrecautions run through thefirst 48 hours of antimicrobialtherapy and until clinicalimprovement occurs.Centers for Disease Control and Prevention: Guidance for Responding to a Plague Bioterrorism Event[1]After 48 hoursPrecautions can be discontinuedonce the patient has receivedantimicrobials for at least 48hours and has shown clinicalimprovement.Nelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS: Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response[3]WHOPneumonic cases requireisolation, and medical staffneed protective equipment.World Health Organization: Plague (questions and answers)[8]ECDCHealth care workers should weargloves and masks when nursingplague patients.European Centre for Disease Prevention and Control: Facts about plague[9]WHO 2021 guidelineCovers personal protectiveequipment specifically forpreventing post-mortemtransmission from the body of aperson who died of plague.World Health Organization: WHO guidelines for plague management: revised recommendations for the use of rapid diagnostic tests, fluoroquinolones for case management and personal protective equipment for prevention of post-mortem transmission[6]

Standard plus droplet precautions, and a clear end condition.

Sources

Every figure above links to its row here. WHO and CDC pages are the current published versions; each peer-reviewed paper carries its DOI.

  1. [1]

    CDC Centers for Disease Control and Prevention

    Guidance for Responding to a Plague Bioterrorism Event

    Accessed 2026-10-07

    cdc.gov ↗ (opens in a new tab)
  2. [2]

    WHO World Health Organization

    Plague (fact sheet)

    Last updated 29 September 2026 · Accessed 2026-10-07

    who.int ↗ (opens in a new tab)
  3. [3]

    CDC Nelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS

    Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response

    MMWR Recommendations and Reports 2021;70(RR-3):1-27. Published 16 July 2021. The authoritative source for doses, which this site does not reproduce. · Accessed 2026-10-07

    cdc.gov ↗ (opens in a new tab)
  4. [4]

    Peer reviewed Salam AP, Rojek AM, Cai E, Raberahona M, Horby P

    Deaths Associated with Pneumonic Plague, 1946-2017

    Emerging Infectious Diseases 2020;26(10):2432-2434. Systematic review of 1,107 patients across 44 articles, with antimicrobial data for 108 confirmed or probable cases. · Accessed 2026-10-07

    doi.org/10.3201/eid2610.191270 ↗ (opens in a new tab)
  5. [5]

    PHAC Public Health Agency of Canada

    Pathogen Safety Data Sheet: Yersinia pestis

    Accessed 2026-10-07

    canada.ca ↗ (opens in a new tab)
  6. [6]

    WHO World Health Organization

    WHO guidelines for plague management: revised recommendations for the use of rapid diagnostic tests, fluoroquinolones for case management and personal protective equipment for prevention of post-mortem transmission

    Geneva: WHO, 27 May 2021. ISBN 978-92-4-001557-9. The recommendation tables inside the PDF could not be retrieved, so no drug-level claim on this site is cited to this guideline. · Accessed 2026-10-07

    who.int ↗ (opens in a new tab)
  7. [7]

    CDC Centers for Disease Control and Prevention

    Clinical Care of Plague

    Accessed 2026-10-07

    cdc.gov ↗ (opens in a new tab)
  8. [8]

    WHO World Health Organization

    Plague (questions and answers)

    Accessed 2026-10-07

    who.int ↗ (opens in a new tab)
  9. [9]

    ECDC European Centre for Disease Prevention and Control

    Facts about plague

    Accessed 2026-10-07

    ecdc.europa.eu ↗ (opens in a new tab)

The symptoms, the incubation ranges and the timeline from exposure are on the symptoms page.