Pest

• Yersin, 1894
• Kitasato, 1894

Pestis, pestilentia, black death.

Notifiable infectious disease caused by the aerobic, gram-negative, "safety needle" bacterium.

• Millions of plague deaths occurred in the Middle Ages
• Endemically, it still occurs in Africa, Southeast Asia, India and on Indian reservations in the USA

• Yersinia pestis is ingested by fleas as part of the sucking act and is ultimately transmitted to rodents and humans. The plague manifests itself cutaneously (bubonic plague)
in 90%

• Pathogen: Yersinia pestis
• Transmission: flea bites
• Incubation period: 1-6 days

Bubonic plague (bubonic plague):

• 90% of all plague cases
• Reduced general condition, febrile temperatures, myalgias, arthralgias, tachycardia, delirium
• Small papules or papulovesicles appear in the area of the portal of entry, which are usually overlooked
• In the lymphatic drainage area, there is locoregional lymph node adenopathy
• In bacteraemia, there is petechiae, ecchymosis, disseminated intravascular coagulopathy, sepsis and pulmonary involvement (black death)

Pneumonic plague: dyspnoea, haemoptysis, cyanosis

• Anamnesis (travel anamnesis)
• Clinical
• Detection of pathogens: Bact. smear (sputum, bubones), blood culture
• Serological antibody detection

• Bubonic plague: untreated 50-90% lethality, treated 10-20%.
• Pneumonic plague: untreated 100% lethality, treated 50%.

• Bubones should not be incised!
• Isolation!
• Mandatory reporting (suspicion, pathogen detection, death)!

First-line therapy according to Lebwohl (no evidence level given):

• Aminoglycosides
• Intramuscular streptomycin
• Intramuscular or intravenous gentamicin

Second-line therapy according to Lebwohl:

• Doxycycline
• Ciprofloxacin

Third-line therapy according to Lebwohl:

• Chloramphenicol
• Sulfonamide

• Streptomycin i.m. 30 mg/kg bw daily in 2 single doses for 10 days. CAVE ototoxicity and nephrotoxicity
• Alternative: gentamicin i.v. 5 mg/kg bw
• Alternative: Doxycycline p.o. 100 mg 2x tgl.
• Alternative: Levofloxacin i.v. 500 mg 1x tgl.for 10 days
• Alternatively: Ciprofloxacinp.o 500 mg 2x tgl.
• For meningitis: chloramphenicol 25-30 mg/kg bw (max. 2g), in course 50-60 mg/kg bw (max. 4g daily) in 4 single doses

• Trimethoprim-sulfamethoxazole is not first-line therapy
• Penicillins, cephalosporins and macrolides should not be used

Post-exposure prophylaxis:

• If contact (distance less than 1 metre) has occurred with untreated patients with pneumonic plague, post-exposure prophylaxis should be given
• Doxycycline p.o. 100 mg 2x daily for 7 days
• Alternatively: levofloxacin p.o. 500 mg 1x daily for 10 days. In pregnant women or children: Trimethoprim-sulfamethoxazole 800/160 mg 2x tgl. for 5-7 days
• A vaccination is currently no longer available

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