Brand name: Sumycin
Drug class: Tetracyclines
VA class: AM250
CAS number: 60-54-8

Medically reviewed by Drugs.com on Apr 10, 2024. Written by ASHP.

Introduction

Antibacterial; antibiotic derived from Streptomyces aureofaciens^{b c d} or produced semisynthetically from oxytetracycline.^b

Uses for Tetracycline

Respiratory Tract Infections

Treatment of respiratory tract infections caused by Mycoplasma pneumoniae.^{c d 104}

Treatment of respiratory tract infections caused by Haemophilus influenzae, Streptococcus pneumoniae, or Klebsiella.^{c d 104} Should only be used for treatment of infections caused by these bacteria when in vitro susceptibility tests indicate the organism is susceptible.^{c d a}

Acne

Adjunctive treatment of moderate to severe inflammatory acne.^{a c d} Not indicated for treatment of noninflammatory acne.^a

Actinomycosis

Treatment of actinomycosis caused by Actinomyces israelii;^{104 114 c d} oral tetracyclines (usually doxycycline or tetracycline) used as follow-up after initial parenteral penicillin G.¹¹⁴

Amebiasis

Adjunct to amebicides for treatment of acute intestinal amebiasis.^{c d} Tetracyclines not included in current recommendations for treatment of amebiasis caused by Entamoeba.^{112 114}

Anthrax

Alternative to doxycycline for postexposure prophylaxis to reduce the incidence or progression of disease following suspected or confirmed exposure to aerosolized Bacillus anthracis spores (inhalational anthrax).¹²² Initial drug of choice for such prophylaxis is ciprofloxacin or doxycycline;^{114 122 123 127} doxycycline is the preferred tetracycline because of ease of administration and proven efficacy in monkey studies.¹²²

Alternative to doxycycline for treatment of inhalational anthrax when a parenteral regimen is not available (e.g., supply or logistic problems because large numbers of individuals require treatment in a mass casualty setting).^{c d 122 123} A multiple-drug parenteral regimen (ciprofloxacin or doxycycline and 1 or 2 other anti-infectives predicted to be effective) is preferred for treatment of inhalational anthrax that occurs as the result of exposure to anthrax spores in the context of biologic warfare or bioterrorism.^{122 123 i}

Balantidiasis

Treatment of balantidiasis^{† [off-label]} caused by Balantidium coli; drug of choice.^{112 114}

Bartonella Infections

Treatment of bartonellosis caused by Bartonella bacilliformis.^{c d}

Brucellosis

Treatment of brucellosis;^{104 114 c d} tetracyclines (usually doxycycline or tetracycline) considered drugs of choice.^{104 114} Used in conjunction with other anti-infectives (e.g., streptomycin or gentamicin and/or rifampin),¹¹⁴ especially for severe infections or when there are complications (e.g., endocarditis, meningitis, osteomyelitis).¹¹⁴

Burkholderia Infections

Treatment of glanders^{† [off-label]} caused by Burkholderia mallei.^{104 m} Experience is limited regarding treatment of human cases; optimum regimens not identified.^{123 m} Some clinicians suggest streptomycin used in conjunction with tetracycline or chloramphenicol or imipenem monotherapy.¹⁰⁴ Other clinicians suggest that, pending results of in vitro susceptibility tests, regimens used for treatment of melioidosis can be used for initial empiric treatment of glanders.¹²³ Doxycycline is the preferred tetracycline for treatment of melioidosis caused by susceptible B. pseudomallei.^{123 m}

Campylobacter Infections

Treatment of infections caused by Campylobacter.^{c d} Tetracyclines (usually doxycycline) are alternatives,¹¹⁴ not drugs of choice for C. jejuni.^{104 114}

Chancroid

Treatment of chancroid caused by Haemophilus ducreyi.^{c d} Not included in CDC recommendations for treatment of chancroid;¹⁰¹ CDC and others recommend azithromycin, ceftriaxone, ciprofloxacin, or erythromycin.^{101 102}

Chlamydial Infections

Treatment of uncomplicated urethral, endocervical, or rectal infections caused by Chlamydia trachomatis.^{c d 102} Doxycycline is the preferred tetracycline for treatment of these infections, including presumptive treatment of chlamydial infections in patients with gonorrhea.¹⁰¹

Treatment of trachoma and inclusion conjunctivitis caused by C. trachomatis.^{c d 104} Consider that anti-infectives may not eliminate C. trachomatis in all cases of chronic trachoma.^{c d}

Treatment of lymphogranuloma venereum (genital, inguinal, or anorectal infections) caused by C. trachomatis.^{c d 102 104} Doxycycline is the preferred tetracycline for these infections.^{101 114}

Treatment of psittacosis (ornithosis) caused by C. psittaci.^{100 104 114 c d} Doxycycline and tetracycline are drugs of choice.^{100 114} For initial treatment of severely ill patients, use IV doxycycline.¹⁰⁰

Clostridium Infections

Alternative for treatment of infections caused by Clostridium.^{c d} Tetracyclines are alternatives to metronidazole or penicillin G for adjunctive treatment of C. tetani infections.¹⁰⁴

Dientamoeba fragilis Infections

Treatment of Dientamoeba fragilis infections.¹¹² Drugs of choice are iodoquinol, paromomycin, tetracycline, or metronidazole.¹¹²

Enterobacteriaceae Infections

Treatment of infections caused by susceptible Escherichia coli, Enterobacter aerogenes, Klebsiella, or Shigella.^{c d} Only use for treatment of infections caused by these common gram-negative bacteria when other appropriate anti-infectives are contraindicated or ineffective^a and when in vitro susceptibility tests indicate the organism is susceptible.^{a c d}

Fusobacterium Infections

Alternative to penicillin G for the treatment of infections caused by Fusobacterium fusiforme (Vincent's infection).^{c d}

Gonorrhea and Associated Infections

Alternative for treatment of uncomplicated gonorrhea caused by susceptible Neisseria gonorrhoeae.^{c d} Tetracyclines are considered inadequate therapy and are not recommended by CDC for treatment of gonorrhea.^{101 a}

Empiric treatment of epididymitis most likely caused by N. gonorrhoeae or C. trachomatis; used in conjunction with IM ceftriaxone.¹⁰²

Granuloma Inguinale (Donovanosis)

Treatment of granuloma inguinale (donovanosis) caused by Calymmatobacterium granulomatis.^{c d} Doxycycline is the tetracycline recommended as drug of choice by CDC.¹⁰¹

Helicobacter pylori Infection and Duodenal Ulcer Disease

Treatment of Helicobacter pylori infection and duodenal ulcer (active or a history of duodenal ulcer);^{104 e} eradication of H. pylori has been shown to reduce the risk of duodenal ulcer recurrence.^{104 e}

Used in a multiple-drug regimen that includes tetracycline, metronidazole, and bismuth subsalicylate and a histamine H₂-receptor antagonist.^e If initial 14-day regimen does not eradicate H. pylori, a retreatment regimen that does not include metronidazole should be used.^e

Leptospirosis

Tetracyclines are alternatives to penicillin G for treatment of leptosporosis^{† [off-label]}.¹⁰⁴ Doxycycline is the preferred tetracycline for treatment or prevention of these infections.^l

Listeria Infections

Alternative for treatment of listeriosis caused by Listeria monocytogenes.^{c d} Not usually considered a drug of choice or alternative for these infections.^{104 114}

Malaria

Treatment of uncomplicated malaria^{† [off-label]} caused by chloroquine-resistant Plasmodium falciparum or chloroquine-resistant P. vivax and when the plasmodial species has not been identified.^{112 129}

CDC and others state treatments of choice for uncomplicated chloroquine-resistant P. falciparum malaria are a regimen of oral quinine in conjunction with oral doxycycline, tetracycline, or clindamycin or a regimen of atovaquone and proguanil.^{112 129} A regimen of quinine and doxycycline (or tetracycline) generally preferred over quinine and clindamycin,¹²⁹ except for young children or pregnant women who should not receive tetracyclines.¹²⁹ Quinine in conjunction with tetracycline (or doxycycline) also a regimen of choice for chloroquine-resistant P. vivax malaria.^{112 129}

Treatment of severe malaria caused by P. falciparum^{† [off-label]};^{112 129} used in conjunction with IV quinidine gluconate initially and then oral quinine when an oral regimen is tolerated.^{112 129}

Active only against asexual erythrocytic forms of Plasmodium (not exoerythrocytic stages) and cannot prevent delayed primary attacks or relapse of P. vivax malaria or provide a radical cure; primaquine usually also is indicated to eradicate hypnozoites and prevent relapse in patients treated for P. vivax malaria.^{112 129}

Assistance with diagnosis or treatment of malaria available from the CDC Malaria Epidemiology Branch by contacting the CDC Malaria Hotline at 770-488-7788 from 8:00 a.m. to 4:30 p.m. Eastern Standard Time or CDC Emergency Operation Center at 770-488-7100 after hours, on weekends, and holidays.¹²⁹

Nocardiosis

Tetracyclines are alternatives to co-trimoxazole for treatment of nocardiosis^† caused by Nocardia.^{104 114}

Nongonococcal Urethritis

Treatment of nongonococcal urethritis (NGU) caused by Ureaplasma urealyticum, C. trachomatis, or Mycoplasma.^{c d 104} Doxycycline usually is the tetracycline of choice for NGU.^{101 102}

Consider that some cases of recurrent urethritis following tetracycline treatment may be caused by tetracycline-resistant U. urealyticum.¹⁰¹

Pasteurella multocida Infections

Treatment of infections caused by Pasteurella multocida^†.^{104 114} Tetracyclines (usually doxycycline) are alternatives to penicillin G.^{104 114}

Plague

Treatment of plague caused by Yersinia pestis,^{c d 104 114 124} including naturally occurring or endemic bubonic, septicemic, or pneumonic plague and plague that occurs following exposure to Y. pestis in the context of biologic warfare or bioterrorism.¹²⁴ Regimen of choice is streptomycin or gentamicin;^{104 114 123 124} alternatives are doxycycline, tetracycline, ciprofloxacin, or chloramphenicol.^{123 124} For plague meningitis, some experts recommend that chloramphenicol be included in the treatment regimen.¹²³

Postexposure prophylaxis following a high-risk exposure to Y. pestis^† (e.g., household, hospital, or other close contact with an individual who has pneumonic plague; laboratory exposure to viable Y. pestis; confirmed exposure in the context of biologic warfare or bioterrorism).^{123 124} Doxycycline may be drug of choice;^{114 123 124} alternatives are tetracycline, ciprofloxacin, or chloramphenicol.¹²³ Prophylaxis not required for asymptomatic contacts of individuals with bubonic plague, but observe such contacts for 1 week and initiate treatment if symptoms occur.¹²³

Rat-bite Fever

Treatment of rat-bite fever^† caused by Streptobacillus moniliformis or Spirillum minus.^{104 114} Tetracyclines (usually doxycycline) are alternatives to penicillin G.^{104 114}

Relapsing Fever

Treatment of relapsing fever caused by Borrelia recurrentis.^{104 c d} Tetracyclines are drugs of choice.¹⁰⁴

Rickettsial Infections

Treatment of rickettsial infections including Rocky Mountain spotted fever, typhus fever and the typhus group, Q fever, rickettsialpox, and tick fevers caused by Rickettsiae.^{114 123 c d} Doxycycline is the drug of choice for most rickettsial infections.^{114 a j}

Syphilis

Alternative to penicillin G for treatment of primary, secondary, latent, or tertiary syphilis (not neurosyphilis) in nonpregnant adults and adolescents hypersensitive to penicillins.^{101 114 c d} Use tetracyclines only if compliance and follow-up can be ensured since efficacy not well documented.¹⁰¹

Tularemia

Treatment of tularemia caused by Francisella tularensis, including naturally occurring or endemic tularemia and tularemia that occurs following exposure to F. tularensis in the context of biologic warfare or bioterrorism.^{104 114 123 c d f} Drugs of choice are streptomycin or gentamicin; alternatives are tetracyclines (usually doxycycline), ciprofloxacin, or chloramphenicol.^{104 114 f} Risk of relapse and primary treatment failure may be higher with the alternatives.^f

Postexposure prophylaxis of tularemia^† following a high-risk laboratory exposure to F. tularensis (e.g., spill, centrifuge accident, needlestick injury) or in individuals exposed to the organism in the context of biologic warfare or bioterrorism.^{123 f} Drugs of choice are doxycycline, tetracycline, or ciprofloxacin.^{123 f} Postexposure prophylaxis usually not recommended after exposure to natural or endemic tularemia (e.g., tick bite, rabbit or other animal exposure) and is unnecessary in close contacts of tularemia patients since human-to-human transmission does not occur.^f

Vibrio Infections

Treatment of cholera caused by Vibrio cholerae.^{104 114 c d h} Doxycycline and tetracycline are drugs of choice; used as an adjunct to fluid and electrolyte replacement in moderate to severe disease.^{104 114 c d h}

Treatment of severe V. parahaemolyticus^† infection when anti-infective therapy is indicated in addition to supportive care.^h

Treatment of infections caused by V. vulnificus^†.¹⁰⁴ Optimum anti-infective therapy has not been identified; a tetracycline or third generation cephalosporin (e.g., cefotaxime, ceftazidime) is recommended.^{104 g h} Because the case fatality rate associated with V. vulnificus is high, initiate anti-infective therapy promptly if indicated.^g

Yaws

Alternative to penicillin G for treatment of yaws caused by Treponema pertenue.^{104 c d}

Yersinia Infections

Treatment of plague or postexposure prophylaxis of plague^†.^{c d 104 114 123 124} (See Plague in Uses.)

Treatment of GI infections caused by Yersinia enterocolitica^† or Y. pseudotuberculosis^†.¹¹⁴ These GI infections usually are self-limited, but IDSA, AAP, and others recommend anti-infectives for severe infections or when septicemia or other invasive disease occurs.¹¹⁴ Some clinicians suggest the role of oral anti-infectives in management of enterocolitis, pseudoappendicitis syndrome, or mesenteric adenitis caused by Yersinia needs further evaluation.¹¹⁴

Related/similar drugs

prednisone, amoxicillin, omeprazole, pantoprazole, doxycycline, ciprofloxacin, cephalexin

Tetracycline Dosage and Administration

Administration

Oral Administration

Administer orally.^{c d}

Administer capsules and tablets with adequate amounts of fluid to reduce the risk of esophageal irritation and ulceration.^{c d}

Dosage

Available as tetracycline^d and tetracycline hydrochloride;^c dosage expressed in terms of tetracycline hydrochloride.^{c d}

Pediatric Patients

General Pediatric Dosage

Oral

Children >8 years of age: 25–50 mg/kg daily in 4 divided doses.^c

Balantidiasis†

Oral

Children ≥8 years of age: 40 mg/kg daily (up to 2 g) in 4 divided doses given for 10 days.^{112 114}

Brucellosis

Oral

Children ≥8 years of age: 30–40 mg/kg daily (up to 2 g) in 4 divided doses.¹¹⁴ Duration of treatment usually is 4–6 weeks; more prolonged treatment may be necessary for severe infections or when there are complications.¹¹⁴

If infection is severe or if endocarditis, meningitis, or osteomyelitis are present, administer IM streptomycin or gentamicin during the first 7–14 days of tetracycline therapy.^{114 c d} Rifampin can be administered concomitantly (with or without an aminoglycoside) to decrease the risk of relapse.¹¹⁴

Dientamoeba fragilis Infection†

Oral

Children ≥8 years of age: 40 mg/kg daily (up to 2 g) in 4 divided doses given for 10 days.¹¹²

Malaria†

Treatment of Uncomplicated Chloroquine-resistant P. falciparum Malaria†

Oral

Children ≥8 years of age: 6.25 mg/kg 4 times daily given for 7 days; used in conjunction with oral quinine sulfate (10 mg/kg 3 times daily given for 3 days if infection was acquired in Africa or South America or for 7 days if acquired in Southeast Asia).^{112 129}

Treatment of Uncomplicated P. vivax Malaria†

Oral

Children ≥8 years of age: 6.25 mg/kg 4 times daily given for 7 days; used in conjunction with oral quinine sulfate (10 mg/kg 3 times daily given for 3 days if infection was acquired in Africa or South America or for 7 days if acquired in Southeast Asia).¹²⁹

In addition, a 14-day regimen of oral primaquine (0.6 mg/kg once daily) also may be indicated to provide a radical cure and prevent delayed attacks or relapse of P. vivax malaria.¹²⁹

Treatment of Severe P. falciparum Malaria†

Oral

Children ≥8 years of age: 6.25 mg/kg 4 times daily given for 7 days; used in conjunction with IV quinidine gluconate (followed by oral quinine sulfate) given for a total duration of 3–7 days.¹²⁹ If an IV tetracycline is necessary initially, use IV doxycycline until oral therapy can be tolerated.¹²⁹

Plague

Treatment of Pneumonic Plague

Oral

Children >8 years of age: 25–50 mg/kg daily in 4 divided doses^b given for ≥10–14 days.^{123 124}

Prompt initiation of treatment (within 18–24 hours of symptom onset) is essential.^{123 124} A parenteral regimen (e.g., IM streptomycin, IM or IV gentamicin, IV doxycycline) is preferred for initial treatment; an oral regimen may be substituted when the patient's condition improves or if a parenteral regimen is unavailable.^{123 124}

Postexposure Prophylaxis following High-risk Exposure†

Oral

Children >8 years of age: 25–50 mg/kg daily in 2 or 4 equally divided doses.^b

Duration of prophylaxis following exposure to plague aerosol or a patient with suspected pneumonic plague is 7 days^{123 124} or the duration of exposure risk plus 7 days.¹²³

Syphilis

Primary or Secondary Syphilis

Oral

Children >8 years of age: 500 mg 4 times daily given for 14 days.^{101 102 114}

Latent Syphilis or Tertiary Syphilis (Except Neurosyphilis)

Oral

Children >8 years of age: 500 mg 4 times daily given for 14 days for early latent syphilis (duration <1 year) or 500 mg 4 times daily given for 28 days for late latent syphilis (duration≥1 year), latent syphilis of unknown duration, or tertiary syphilis.^{101 102 114}

Vibrio Infections

Cholera

Oral

Children >8 years of age: 50 mg/kg daily in 4 divided doses given for 3 days.¹¹⁴

Adults

General Adult Dosage

Oral

1–2 g daily in 2–4 divided doses.^{c d}

500 mg twice daily or 250 mg 4 times daily may be adequate for mild to moderate infections; severe infections may required 500 mg 4 times daily.^{c d}

Respiratory Tract Infections

Mycoplasma pneumoniae Infections

Oral

1–2 g daily in 2–4 equally divided doses.^b Duration of treatment usually is 1–4 weeks.^b

Acne

Oral

1 g daily given in divided doses; when improvement occurs in 1–2 weeks, decrease slowly to a maintenance dosage of 125–500 mg daily.^{b c d} Continue maintenance dosage until clinical improvement allows discontinuation of the drug.^b

Actinomycosis

Oral

1–2 g daily for 6–12 months as follow-up to penicillin G.^b

Anthrax

Postexposure Prophylaxis following Exposure in the Context of Biologic Warfare or Bioterrorism

Oral

500 mg every 6 hours given for ≥60 days.¹²²

Optimum duration of postexposure prophylaxis after an inhalation exposure to B. anthracis spores is unclear,^{123 k} but prolonged postexposure prophylaxis usually required.^{122 123} A duration of 60 days may be adequate for a low-dose exposure, but a duration >4 months may be necessary to reduce the risk following a high-dose exposure.^k CDC recommends that postexposure prophylaxis following a confirmed exposure (including in laboratory workers with confirmed exposures to B. anthracis cultures) be continued for 60 days.^{122 123} The US Working Group on Civilian Biodefense and the US Army Medical Research Institute of Infectious Diseases (USAMRIID) recommends that postexposure prophylaxis be continued for at least 60 days in individuals who are not fully immunized against anthrax and when anthrax vaccine is unavailable or cannot be used for postexposure vaccination.¹²³

Treatment of Inhalational Anthrax

Oral

500 mg every 6 hours.¹²²

Initial parenteral regimen preferred; use oral regimen for initial treatment only when a parenteral regimen is not available (e.g., supply or logistic problems because large numbers of individuals require treatment in a mass casualty setting).^{122 i} Continue for total duration of ≥60 days if inhalational anthrax occurred as the result of exposure to anthrax spores in the context of biologic warfare or bioterrorism.^{102 123 i}

Balantidiasis†

Oral

500 mg 4 times daily given for 10 days.¹¹²

Brucellosis

Oral

500 mg 4 times daily given for 3 weeks.^{c d}

If infection is severe or if endocarditis, meningitis, or osteomyelitis are present, administer IM streptomycin or gentamicin during the first 7–14 days of tetracycline therapy.^{114 c d} Rifampin can be administered concomitantly to decrease the risk of relapse (with or without an aminoglycoside).¹¹⁴

Burkholderia Infections†

Melioidosis†

Oral

2–3 g daily given for 1–3 months.^b In severe cases, some clinicians recommend concomitant chloramphenicol during the first month.^b In patients with extrapulmonary suppurative lesions, continue tetracycline therapy for 6–12 months.^b

Campylobacter Infections

Campylobacter fetus Infections

Oral

1–2 g daily given for 10 days.^b

Chancroid

Oral

1–2 g daily given for 2–4 weeks.^b

Chlamydial Infections

Uncomplicated Urethral, Endocervical, or Rectal Infections

Oral

500 mg 4 times daily given for ≥7 days.^{102 c d}

Psittacosis (Ornithosis)

Oral

500 mg 4 times daily given for ≥10–14 days after defervescence.¹⁰⁰

Dientamoeba fragilis Infection†

Oral

500 mg 4 times daily for 10 days.¹¹²

Gonorrhea and Associated Infections

Uncomplicated Gonorrhea

Oral

500 mg 4 times daily given for 7 days.^{c d} No longer recommended for gonorrhea by CDC or other experts.^{101 102}

Empiric Treatment of Epididymitis†

Oral

500 mg 4 times daily given for 10 days; as follow-up to a single dose of IM ceftriaxone.¹⁰²

Granuloma Inguinale (Donovanosis)

Oral

1–2 g daily given for 2–4 weeks.^b

Helicobacter pylori Infection and Duodenal Ulcer Disease

Oral

500 mg in conjunction with metronidazole (250 mg) and bismuth subsalicylate (525 mg) 4 times daily (at meals and at bedtime) for 14 days; these drugs should be given concomitantly with usual dosage of an H₂-receptor antagonist.¹¹⁰

Leptospirosis†

Oral

1–2 g daily given for 5–7 days.^b

Malaria†

Treatment of Uncomplicated Chloroquine-resistant P. falciparum Malaria†

Oral

250 mg 4 times daily given for 7 days; used in conjunction with quinine sulfate (650 mg 3 times daily given for 3 days if malaria was acquired in Africa or South America or for 7 days if acquired in Southeast Asia).^{112 129}

Treatment of Uncomplicated P. vivax Malaria†

Oral

250 mg 4 times daily given for 7 days; used in conjunction with oral quinine sulfate (650 mg 3 times daily given for 3 days if malaria was acquired in Africa or South America or for 7 days if acquired in Southeast Asia).¹²⁹

In addition, a 14-day regimen of oral primaquine (30 mg once daily) also may be indicated to provide a radical cure and prevent delayed attacks or relapse of P. vivax malaria.¹²⁹

Treatment of Severe P. falciparum Malaria†

Oral

250 mg 4 times daily for 7 days; used in conjunction with IV quinidine gluconate (followed by oral quinine sulfate) given for a total duration of 3–7 days.¹²⁹ If an IV tetracycline is necessary initially, use IV doxycycline until oral therapy can be tolerated.¹²⁹

Plague

Treatment

Oral

2–4 g daily in 4 divided doses^b given for ≥10–14 days.^{b 123}

Prompt initiation of treatment (within 18–24 hours of symptom onset) is essential.^{123 124} A parenteral regimen (e.g., IM streptomycin, IM or IV gentamicin, IV doxycycline) is preferred for initial treatment; an oral regimen may be substituted when the patient's condition improves or if a parenteral regimen is unavailable.^{123 124}

Postexposure Prophylaxis following High-risk Exposure†

Oral

1–2 g daily in 2 or 4 divided doses.¹²³

Duration of prophylaxis following exposure to plague aerosol or a patient with suspected pneumonic plague is 7 days^{123 124} or the duration of exposure risk plus 7 days.¹²³

Relapsing Fever

Oral

1–2 g daily until afebrile for 7 days.^b A single 500-mg dose may be effective in some patients.^b

Rickettsial Infections

Oral

1–2 g daily in 2–4 divided doses.^b Duration of treatment usually is ≥3–7 days or until patients has been afebrile for approximately 2–3 days.^b

Q Fever

Oral

500 mg every 6 hours given for ≥14 days for treatment of acute Q fever.¹²³

For prophylaxis against Q fever^†, 500 mg every 6 hours given for ≥5–7 days may prevent clinical disease if initiated 8–12 days after exposure; such prophylaxis is not effective and may only prolong the onset of disease if given immediately (1–7 days) after exposure.¹²³

Syphilis

Primary or Secondary Syphilis

Oral

500 mg 4 times daily given for 14 days recommended by CDC and others.^{101 102} Manufacturer recommends a total dosage of 30–40 g in equally divided doses given over 10–15 days.^{c d}

Latent Syphilis or Tertiary Syphilis (Except Neurosyphilis)

Oral

500 mg 4 times daily given for 14 days for early latent syphilis (duration <1 year) or 500 mg 4 times daily given for 28 days for late latent syphilis (duration≥1 year), latent syphilis of unknown duration, or tertiary syphilis.^{101 102}

Tularemia

Treatment

Oral

500 mg 4 times daily¹²³ given for ≥14–21 days.^{123 f} Relapse may occur as long as 6 months after treatment with tetracycline; however, retreatment with the same dosage usually is curative.^b

Postexposure Prophylaxis following High-risk Exposure†

Oral

500 mg 4 times daily.¹²³

Initiate postexposure prophylaxis within 24 hours of exposure and continue for ≥14 days.^{123 f}

Vibrio Infections

Cholera

Oral

1–2 g daily given for 2–3 days.^b 500 mg 4 times daily for 3 days also has been recommended.¹⁰³

Yaws

Oral

1–2 g daily given for 10–14 days.^b

Prescribing Limits

Pediatric Patients

Malaria

Treatment of Severe P. falciparum Malaria†

Oral

Children ≥8 years of age: Maximum 1g daily.¹²⁹

Special Populations

Renal Impairment

Adjust dosage by decreasing doses or increasing dosing interval.^{c d}

Cautions for Tetracycline

Contraindications

• Known hypersensitivity to any tetracycline.^{c d}

• Helidac Therapy (kit containing tetracycline, metronidazole, bismuth subsalicylate) contraindicated in pregnant or nursing women, pediatric patients, patients with hepatic or renal impairment, patients with known allergy to aspirin or salicylates, and those with known hypersensitivity to any component of the kit.^e

Warnings/Precautions

Warnings

Dental and Bone Effects

Use during tooth development (e.g., pregnancy, children <8 years of age) may cause permanent yellow-gray to brown discoloration of teeth and enamel hypoplasia.^{c d} Effects are most common following long-term use, but may occur following repeated short-term use.^{c d}

Tetracyclines form a stable calcium complex in any bone-forming tissue.^{c d} Reversible decrease in fibula growth rate has occurred in young animals receiving oral tetracycline.^{c d}

Use not recommended in children <8 years of age unless other appropriate drugs are ineffective or are contraindicated or unless the benefits in certain indications (e.g., anthrax) outweigh the risks.^{114 c d} (See Pediatric Use under Cautions.)

Fetal/Neonatal Morbidity

Animal studies indicate possible fetal toxicity (e.g., retardation of skeletal development) and embryotoxicity.^{c d} If used during pregnancy or if patient becomes pregnant while receiving tetracycline, patient should be apprised of the potential hazard to the fetus.^{c d} (See Pregnancy under Cautions.)

Renal Effects

Tetracyclines have antianabolic effects and may increase BUN.^{c d}

In patients with impaired renal function, high serum tetracycline concentrations may result in azotemia, hyperphosphatemia, and acidosis.^{c d} Excessive drug accumulation and possible liver toxicity may occur if usual dosage is used patients with renal impairment.^{c d} (See Renal Impairment under Dosage and Administration.)

Do not use tetracycline preparations past their expiration dates.^{c d} Outdated tetracycline preparations are highly nephrotoxic and have, on occasion, produced a Fanconi-like syndrome.^{c d}

Laboratory Monitoring

Periodically assess organ system function, including renal, hepatic and hematopoietic, during long-term therapy.^{c d}

Helidac Therapy

When the kit containing tetracycline, metronidazole, and bismuth subsalicylate (Helidac Therapy) is used for the treatment of H. pylori infection and duodenal ulcer disease, the cautions, precautions, and contraindications associated with metronidazole and bismuth subsalicylate must be considered in addition to those associated with tetracycline.^e

Sensitivity Reactions

Photosensitivity Reactions

Photosensitivity, manifested by an exaggerated sunburn reaction, reported with tetracyclines.^{c d}

Photosensitivity reactions may develop within a few minutes to several hours after sun exposure and usually persist 1–2 days after discontinuance of the drug.^a Most reactions result from accumulation of tetracyclines in skin and are phototoxic in nature; photoallergic reactions may also occur.^a

Discontinue drug at first evidence of skin erythema.^{c d}

Hypersensitivity Reactions

Oral suspension contains sulfites, which may cause allergic-type reactions (including anaphylaxis and life-threatening or less severe asthmatic episodes) in certain susceptible individuals.^d

Cross-sensitization occurs among the various tetracyclines.^{c d}

General Precautions

Superinfection

Possible emergence and overgrowth of nonsusceptible bacteria or fungi.^{c d} Discontinue drug and institute appropriate therapy if superinfection occurs.^{c d}

Nervous System Effects

Possibility of bulging fontanels in infants and benign intracranial hypertension (pseudotumor cerebri) in adults.^{c d} Effects usually resolve when drug discontinued, but possibility for permanent sequelae exists.^{c d}

Selection and Use of Anti-infectives

To reduce development of drug-resistant bacteria and maintain effectiveness of tetracycline and other antibacterials, use only for treatment or prevention of infections proven or strongly suspected to be caused by susceptible bacteria.^{c d}

When selecting or modifying anti-infective therapy, use results of culture and in vitro susceptibility testing.^{c d} In the absence of such data, consider local epidemiology and susceptibility patterns when selecting anti-infectives for empiric therapy.^{c d}

Because many strains of Acinetobacter, Bacteroides, Enterobacter, E. coli, Klebsiella, Shigella, S. pyogenes (group A β-hemolytic streptococci), S. pneumoniae, enterococci, and α-hemolytic streptococci are resistant to tetracycline, in vitro susceptibility tests should be performed if the drug is used for treatment of infections caused by these bacteria.^{c d}

Incision and drainage or other surgical procedures should be performed in conjunction with tetracycline therapy when indicated.^{c d}

Specific Populations

Pregnancy

Category D.^{c d} (See Fetal/Neonatal Morbidity under Cautions.)

Should not be used in pregnant women unless, in the judgement of the clinician, it is essential for the welfare of the patient and benefits outweigh the risks.^{c d}

CDC and others state tetracyclines can be used when necessary for treatment of inhalational anthrax in pregnant women.^{122 i} Since adverse effects on developing teeth and bones are dose-related, CDC suggests the drug might be used for a short period (7–14 days) before 6 months of gestation;ⁱ some clinicians recommend periodic liver function testing if used in pregnant women.¹²²

Malaria infection in pregnant women is associated with high risks of maternal and perinatal morbidity and mortality (e.g., miscarriage, premature delivery, low birth weight, congenital infection and/or perinatal death)¹²⁹ CDC recommends prompt treatment with quinine and clindamycin for pregnant women with uncomplicated chloroquine-resistant P. falciparum malaria or with quinine alone for those with uncomplicated P. vivax malaria.¹²⁹ However, CDC states a regimen of quinine in conjunction with doxycycline (or tetracycline) may be used for treatment of uncomplicated malaria in pregnant women in rare circumstances (e.g., if other treatment options are not available or not tolerated) if benefits outweigh risks.¹²⁹

Lactation

Distributed into milk; discontinue nursing or the drug.^{c d}

AAP states maternal use of tetracyclines usually is compatible with breast-feeding since absorption of the drugs by nursing infants is negligible.¹¹⁴

Pediatric Use

Should not be used in children <8 years of age unless other appropriate drugs are ineffective or are contraindicated.^{c d 114} (See Dental and Bone Effects under Cautions.)

CDC states that children <8 years of age with uncomplicated chloroquine-resistant P. falciparum malaria, uncomplicated P. vivax malaria, or severe P. falciparum malaria may receive a regimen that includes a tetracycline if other treatment options are not available or not tolerated and if potential benefits outweigh risks.¹²⁹

Safety and efficacy of the kit containing tetracycline, metronidazole, and bismuth subsalicylate (Helidac Therapy) for treatment of H. pylori infection and duodenal ulcer disease have not been established in pediatric patients.^e

Geriatric Use

Insufficient experience in those ≥65 years of age to determine whether they respond differently than younger adults to concomitant use of tetracycline, metronidazole, and bismuth subsalicylate (Helidac Therapy) for treatment of H. pylori infection and duodenal ulcer disease.^e Age-related decreases in hepatic, renal, and/or cardiac function and concomitant disease and drug therapy should be considered.^e

Renal Impairment

High serum tetracycline concentrations may result in azotemia, hyperphosphatemia, and acidosis.^{c d} Excessive drug accumulation and possible liver toxicity may occur if usual dosage is used patients with renal impairment.^{c d}

Dosage adjustment necessary in patients with impaired renal function.^{c d} Serum tetracycline concentrations should be monitored if therapy is prolonged.^{c d}

Because usual dosage of doxycycline can be used in patients with impaired renal function, it may preferred when a tetracycline is indicated in a patient with impaired renal function.^b

Common Adverse Effects

GI effects (anorexia, epigastric distress, nausea, vomiting, diarrhea); rash; dose-related BUN increases.^{c d}

Drug Interactions

Specific Drugs

Tetracycline Pharmacokinetics

Absorption

Bioavailability

75–80% absorbed from GI tract in fasting adults;^b peak serum concentrations attained within 2–4 hours.^{b c d}

Food

GI absorption reduced by ≥50% by food and/or milk.^b

Divalent and trivalent cations, including aluminum, calcium, iron, magnesium, and zinc may decrease oral absorption as a result of chelation with the drug.^b

Distribution

Extent

Widely distributed into body tissues and fluids.^{a c d}

Only small amounts diffuse into CSF.^a

Readily crosses the placenta^a and is distributed into milk.^{a c d}

Plasma Protein Binding

20–67%.^{a c d}

Elimination

Metabolism

Does not appear to be metabolized.^a

Elimination Route

Eliminated in urine by glomerular filtration; 48–60% of a dose excreted in urine as active drug.^b Also eliminated in bile and feces.^{a c d}

Half-life

Adults with normal renal function: 6–12 hours.^b

Special Populations

Patients with severe hepatic impairment or biliary obstruction: Serum concentrations and half-life may be increased.^a

Severe renal impairment: 57–120 hours.^b

Stability

Storage

Oral

Tablets

Room temperature in tight, light-resistant container.^c Avoid excessive heat.^c

Suspension

<30°C in tight container; protect from light.^d

Tetracycline Combinations

Kit containing tetracycline, metronidazole, and bismuth subsalicylate: 20–25°C.^e

Actions and Spectrum

• Usually bacteriostatic,^{a c d} but may be bactericidal in high concentrations or against highly susceptible organisms.^a

• Inhibits protein synthesis^{c d} in susceptible organisms by reversibly binding to 30S and 50S ribosomal subunits.^a

• The complete mechanisms by which tetracyclines reduce acne lesions have not been fully elucidated.^a The effects appear to result in part from the antibacterial activity of the drugs, but other mechanisms also are involved.^a

• Spectrum of activity includes many gram-positive and -negative bacteria and various other organisms (e.g., Rickettsia, Chlamydia, Mycoplasma, spirochetes).^{a c d} Inactive against fungi and viruses.^a

• Gram-positive aerobes and anaerobes: Active against Actinomyces israelii, Bacillus anthracis, Clostridium perfringens, C. tetani, Nocardia, Propionibacterium acnes, and some streptococci.^{a c d} Many strains of S. pyogenes and Enterococci are resistant.^{a c d}

• Gram-negative aerobes and anaerobes: Active against Bartonella bacilliformis, Brucella, Calymmatobacterium granulomatis, Francisella tularensis, Haemophilus ducreyi, H. influenzae, Neisseria gonorrhoeae, Vibrio cholerae, Y. enterocolitica, and Y. pestis.^{a c d} Many strains of Acinetobacter, E. aerogenes, E. coli, Klebsiella, and Shigella and nearly all strains of Proteus and Pseudomonas are resistant.^{a c d}

• Other organisms: Active against Rickettsia, Coxiella burnetii, Chlamydia psittaci, C. trachomatis, Helicobacter pylori, Mycoplasma hominis, M. pneumoniae, Ureoplasma urealyticum, Borrelia burgdorferi, B. recurrentis, Leptospira, Treponema pallidum, T. pertenue, and Mycobacterium fortuitum.^{a c d} Active against asexual erythrocytic forms of Plasmodium falciparum, but is not gametocidal and not active against exoerythrocytic forms of P. falciparum.^a

• Complete cross-resistance usually occurs between tetracycline and other tetracyclines (demeclocycline, doxycycline, minocycline, oxytetracycline).^{a c d}

Advice to Patients

• Advise patients that antibacterials (including tetracycline) should only be used to treat bacterial infections and not used to treat viral infections (e.g., the common cold).^{c d}

• Importance of completing full course of therapy, even if feeling better after a few days.^{c d}

• Advise patients that skipping doses or not completing the full course of therapy may decrease effectiveness and increase the likelihood that bacteria will develop resistance and will not be treatable with tetracycline or other antibacterials in the future.^{c d}

• Importance of drinking sufficient quantities of fluids when taking capsules or tablets to reduce the risk of esophageal irritation and ulceration.^c

• Advise patients that tetracycline absorption is reduced when taken with foods, especially those containing calcium, and doses should be taken 1 hour before or 2 hours after meals and/or milk.^b

• Advise patients that tetracycline may decrease effectiveness of oral contraceptives and that alternative nonhormonal contraceptive measures should be used.^a

• Advise patients to avoid excessive sunlight or artificial UV light and to discontinue the drug at the first sign of skin erythema;^{a c d} consider use of sunscreen or sunblock.^a

• Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.^{c d} (See Fetal/Neonatal Morbidity under Cautions.)

• Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, and any concomitant illnesses.^{c d}

• Importance of informing patients of other important precautionary information. (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

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