Tularemia for clinicians: An up-to-date review on epidemiology, diagnosis, prevention and treatment

Tularemia, also known as rabbit fever, caused by Francisella tularensis, is re-emerging in the Northern Hemisphere and in particular in Europe in recent years. It is a bacterial zoonotic, arthropod-borne, air-borne, food- and water-borne disease and the multiple routes of infection result in six typical clinical pictures (ulceroglandular, glandular, oculoglandular, oropharyngeal, typhoidal, and pneumonic) along with several other uncommon presentations, potentially affecting any body site. In addition, due to the ease of airborne transmission, F. tularensis is a category A agent for bioterrorism. If not promptly diagnosed and treated, the fatality rate can be as high as 60 %, with the poorest outcomes reported in the pneumonic and typhoidal forms. Gentamicin is the first-line treatment for severe tularemia, while fluoroquinolones and tetracyclines are commonly the drugs of choice in less severe forms. Prevention is based on environmental and animal control strategies, proper signaling of the clinical suspicion to the laboratory staff and postexposure prophylaxis. In consideration of the re-emergence of the disease and the diagnostic and therapeutic challenges it poses, we performed a comprehensive up-to-date review of tularemia epidemiology, clinical presentation, diagnostic tools, treatment and prevention strategies.