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The U.S. recommendation for quinolones as first-line treatment of bubonic plague is based on animal data and weak clinical evidence, given the rarity of the disease. In Madagascar — where it remains endemic — Randremanana et al. randomized 450 patients with suspected bubonic plague to receive 10 days of oral ciprofloxacin or 3 days of injectable aminoglycoside followed by 7 days of ciprofloxacin. The investigators assessed treatment failure (the primary endpoint; death, fever, pneumonic plague, or need for alternative or prolonged therapy) on day 11 in 222 patients with probable or confirmed infections (53% male, median age, 14 years; range, 2–72).
Treatment failure occurred in 9.0% of the ciprofloxacin group and 8.1% of the aminoglycoside–c…