Treatment of Tularemia with Ciprofloxacin

Sir—We read with interest the article by Limaye and Hooper [1] about tularemia therapy with fluoroquinolones. The authors reported 2 cases and reviewed 8 additional cases from the literature and found an excellent response. However, our experience with 14 cases of tularemia treated with ciprofloxacin was not so favorable as that described by Limaye and Hooper [1]. In Spain, tularemia was unknown in the clinical practice until 1998, when an outbreak of this disease was detected (biovar palearctica) [2]. In our hospital, in 1998, 57 cases were diagnosed according to the current criteria (culture of Francisella tularensis and/or serology >1:160 in the face of compatible disease) [3, 4]. Fourteen patients received ciprofloxacin, but the relapse was observed in 7 patients (table 1). This outcome is poorer than that reported by Limaye and Hooper. However, there are some clinical differences between our patients and those previously reported, for instance in the form of disease. In addition, we used ciprofloxacin as primary therapy in fewer cases (42% vs. 80%). Finally, other factors, such as distinct biovars, use of different fluoroquinolones, the criteria to diagnose relapse, or length of disease prior to therapy, could explain the distinct results observed [4]. In conclusion, in accordance with Limaye and Hooper, we believe that fluoroquinolones should be considered as alternative agents for tularemia therapy, but this treatment may be unsuccessful. Clinical characteristics of patients.