Oral Ciprofloxacin Shows Promise as Bubonic Plague Treatment, Study Finds
Antananarivo, Madagascar – In a potential turning point for global health, researchers in Madagascar have announced groundbreaking results from a randomized controlled study demonstrating that a 10-day course of oral ciprofloxacin is just as effective as the current standard treatment for bubonic plague – a combination of injectable aminoglycoside antibiotics and ciprofloxacin. This New England Journal of Medicine-published research offers a simpler, more accessible, and potentially life-saving alternative, particularly for regions with limited healthcare infrastructure.
A Simpler Path to Fighting a Historic Disease
For centuries, the bubonic plague, infamously known as the “Black Death,” has cast a long shadow over human history. Caused by the bacterium Yersinia pestis, primarily spread through rodents and their fleas, the disease remains a threat in several parts of the world, including Madagascar, the Democratic Republic of Congo, and Peru. While relatively rare today, outbreaks still occur, with Madagascar experiencing a significant epidemic in 2017, with over 2,400 suspected cases.
Current treatment guidelines in Madagascar previously recommended a sequential approach: three days of injectable aminoglycosides (streptomycin or gentamicin) followed by seven days of oral ciprofloxacin. For children under 15, oral ciprofloxacin alone was already the first-line option. However, the logistical challenges of administering injections – requiring trained personnel, reliable supply chains, and suitable facilities – have long been a hurdle, especially during outbreaks. The study, dubbed IMASOY, involved 450 patients between 2020 and 2024, with a median age of 14, and directly addressed this challenge.
Study Details: Ciprofloxacin Stands its Ground
The IMASOY study rigorously compared 10 days of oral ciprofloxacin monotherapy to the standard sequential aminoglycoside-ciprofloxacin regimen. Researchers tracked therapy failure rates – defined as death, persistent fever, development of secondary lung plague, or the need for alternative treatment – up to day 11. The results were striking: therapy failure occurred in 9.0% of patients receiving ciprofloxacin alone, compared to 8.1% in the control group. Mortality rates were comparable, hovering around 4% in both groups, and secondary lung plague cases were equally rare.
“The lack of high-quality evidence and the disadvantages of the aminoglycosides – such as the parenteral administration, potentially serious side effects and a low intracellular penetration – prompted us to initiate a randomized study,” explained Dr. Rindra V. Randremanana of the Institut Pasteur de Madagascar, lead author of the study. Importantly, the side effect profiles of both treatment approaches were also similar, with no serious adverse events directly attributed to the medication.
From Streptomycin to a Potential New Standard
The history of plague treatment is a testament to medical innovation. Sulfonamides offered early relief in the 1930s, but were ineffective against pneumonic plague (lung plague). The 1948 discovery of streptomycin, the first effective antibiotic against all forms of plague, marked a major breakthrough. For decades, streptomycin was the gold standard. Ciprofloxacin gained approval in the US in 2015 under the “Animal Rule” – a pathway for approval based on animal data when human trials are impractical – but its use remained “off-label” in Europe until now.
What This Means for the Future of Plague Control
The implications of this study are far-reaching. A purely oral treatment regimen simplifies logistics, reduces healthcare costs, and minimizes the risk of adverse effects associated with injections. This is particularly crucial in resource-limited settings where access to healthcare is already strained. The findings support a shift towards a more practical and cost-effective approach to bubonic plague treatment, potentially saving countless lives. As Dr. Randremanana and colleagues conclude, “Purely oral ciprofloxacin therapy over 10 days is not inferior to sequential aminoglycoside-ciprofloxacin therapy in the treatment of the bubonic plague,” paving the way for a more accessible and effective response to this ancient and persistent threat. This research is a beacon of hope in the ongoing fight against infectious diseases worldwide, and a powerful example of how rigorous scientific investigation can translate into tangible improvements in global health outcomes.
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