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Introduction ⬇

Plague (enzootic infection of rats, squirrels, prairie dogs, and other rodents caused by the bacteria Yersinia pestis) can be found on every continent except Australia. Plague is transmitted by the bite of an infected flea or from direct contact from body fluid or tissues or inhaling droplets from an infected person or animal. Signs and symptoms include a sudden onset of fever, chills, generalized weakness, and buboes (swollen tender lymph nodes). Buboes typically develop in the axilla, cervical, or groin regions.

There are three clinical forms of the infection: bubonic (regional lymph node involvement), pneumonic (lung involvement), and septicemic (primarily after skin inoculation). Signs and symptoms include a sudden onset of fever, chills, generalized weakness, and buboes (swollen tender lymph nodes). Buboes typically develop in the axilla, cervical, or groin regions.

Bubonic plague has an incubation period of 2–6 days, with 80% of cases going on to become septicemic plague, which carries a 100% mortality rate if not treated. Septicemic plague occurs after a skin inoculation or progression of bubonic plague and, like pneumonic plague, if left untreated results in 100% mortality.

Procedure ⬆ ⬇

  1. Obtain specimens of blood, sputum, or a lymph node aspirate following standard precautions.

  2. Transport specimens per laboratory protocol.

Procedural Alert

Specimens should be taken prior to treatment if at all possible, but antibiotic treatment should not be delayed. Specimens should be processed using BSL-2 practices or BSL-3 if there is a high potential for aerosolization (e.g., centrifugation procedures). BSL-2 and BSL-3 practices include controlled access and decontamination of all waste and laboratory clothing before laundering.

Clinical Implications ⬆ ⬇

A positive culture for Y. pestis is evidence of the infection, and antibiotic treatment should begin immediately. If test results are negative but clinical manifestations still point to plague, further serologic testing should be done.

Clinical Alert

  1. Evidence of plague must be reported to the local, state, and federal authorities.

  2. Persons having close contact (<2 m) with an infected individual should receive postexposure antibiotic prophylaxis for 7 days.

Interventions ⬆ ⬇

Pretest Patient Care

  1. Explain necessity, purpose, and procedure of testing. Assess for and document signs and symptoms of infection (sudden onset of fever, chills, headache, weakness).

  2. There is limited evidence of person-to-person spread. Observe standard precautions for bubonic plague; observe droplet precautions for pneumonic plague.

  3. Follow guidelines in Chapter 1 for safe, effective, informed pretest care.

Posttest Patient Care

  1. Review test results; report and record findings. Modify the nursing care plan as needed. Counsel, monitor, and treat the patient appropriately. Evidence does not support that residual Y. pestis poses an environmental threat, and the organism does not survive long outside the host. For prophylaxis of bubonic or pneumonic plague, oral doxycycline, tetracycline, or trimethoprim/sulfamethoxazole should be considered.

  2. Notify the CDC if results are positive.

  3. Follow guidelines in Chapter 1 for safe, effective, informed posttest care.

Reference Values ⬆

Normal

Negative for the presence of Y. pestis

Titer <1:16 using passive hemagglutination on acute and convalescent serum

Titer >1:256 is presumptive of immunologic response.