eMedicine Specialties > Ophthalmology > Infectious Disease
Rocky Mountain Spotted Fever: Treatment & Medication
Updated: Oct 30, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Ophthalmic care: Supportive therapy according to the needs of individual patients is indicated.
- Moderate-to-severe uveitis may be treated with topical cycloplegics and corticosteroids, although no reliable information on efficacy is available.
- Artificial tears and ocular lubricating ointment may help relieve discomfort from periorbital edema and petechial conjunctivitis.
- Patients with RMSF usually do not present initially to an ophthalmologist. They are typically already under the care of an internist or infectious disease physician.
Consultations
An infectious disease specialist and/or internist are the appropriate primary physicians to manage these patients.
Activity
- Bed rest
- Activity as tolerated
- Avoid bright lights
Medication
Start IV tetracyclines as soon as possible with chloramphenicol as an alternative. Doxycycline is the drug of choice for oral treatment. Topical cycloplegics, such as cyclopentolate 1% (1 gtt bid/tid), reduce discomfort from uveitis. Topical ophthalmic steroids, such as prednisolone acetate 1% (1 drop bid/tid/qid), reduce ocular inflammation. Artificial tears and lubricating ointment may be used prn or frequently, depending on the amount of discomfort.
Antibiotics
Tetracyclines are the treatment of choice for adults and children older than 9 years. A course of doxycycline in children younger than 9 years is usually recommended because of better efficacy in treating this potentially life-threatening disease and no risk of aplastic anemia; doxycycline also binds less strongly to calcium than tetracycline does and, thus, is considered less likely to stain teeth. The American Academy of Pediatrics and the CDC recommend chloramphenicol for children younger than 9 years to avoid permanent staining of teeth.
Doxycycline (Doryx, Bio-Tab, Vibramycin)
Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Adult
200 mg PO/IV divided bid
Pediatric
<100 lb: 2 mg/lb divided bid PO/IV
>100 lb: 200 mg divided bid PO/IV
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Chloramphenicol (Chloromycetin)
Binds to 50 S bacterial-ribosomal subunits and inhibits bacterial growth by inhibiting protein synthesis. Effective against gram-negative and gram-positive bacteria.
Adult
Not recommended
Pediatric
50-75 mg/kg PO qid
Administered concurrently with barbiturates, chloramphenicol serum levels may decrease while barbiturate levels may increase causing toxicity; manifestations of hypoglycemia may occur with sulfonylureas; rifampin may reduce serum chloramphenicol levels, presumably through hepatic enzyme induction; may increase effects of anticoagulants; may increase serum hydantoin levels, possibly resulting in toxicity; chloramphenicol levels may be increased or decreased
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Use only for indicated infections, or as prophylaxis for bacterial infections; serious and fatal blood dyscrasias (aplastic anemia, hypoplastic anemia, thrombocytopenia, granulocytopenia) can occur; evaluate baseline and perform periodic blood studies approximately every 2 d while in therapy; discontinue upon appearance of reticulocytopenia, leukopenia, thrombocytopenia, anemia, or findings attributable to chloramphenicol; adjust dose in liver or kidney dysfunction; caution in pregnancy at term or during labor because of potential toxic effects on fetus (gray syndrome)
Cycloplegics
These agents relax any ciliary muscle spasm that can cause a deep aching pain and photophobia. Cycloplegic agents are also mydriatics, and the practitioner should make sure that the patient does not have glaucoma. This medication could provoke an acute angle-closure attack.
Cyclopentolate 1% (AK-Pentolate, Cyclogyl)
DOC in corneal abrasions. Blocks muscle of ciliary body and sphincter muscle of iris from responding to cholinergic stimulation, thus causing mydriasis and cycloplegia.
Induces mydriasis in 30-60 min and cycloplegia in 25-75 minutes. These effects last up to 24 hours.
Adult
1 gtt bid/tid in affected eye(s)
Pediatric
Administer as in adults; use 0.5% instead of 1% in infants
Decreases effects of carbachol and cholinesterase inhibitors
Documented hypersensitivity; narrow-angle glaucoma
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Exercise caution in patients (eg, elderly persons) where increased intraocular pressure may be present; can cause toxic anticholinergic systemic adverse effects (common in children especially infants) but incidence rare when used sparingly; compressing lacrimal sac by digital pressure for 1-3 min, following application, may minimize systemic absorption
Topical corticosteroids
Suppresses active disease, which is assumed to be due to inflammatory mechanisms.
Prednisolone acetate 1% (AK-Pred, Delta-Cortef, Econopred)
Decreases autoimmune reactions, possibly by suppressing key components of immune system.
Adult
1 gtt qd/qid in affected eye(s)
Pediatric
Administer as in adults
None reported
Documented hypersensitivity; viral, fungal, or tubercular infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hyperthyroidism, osteoporosis, cirrhosis, nonspecific ulcerative colitis, peptic ulcer, diabetes, and myasthenia gravis; may increase IOP; prolonged use may result in glaucoma
Loteprednol etabonate (Lotemax, Alrex)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability. Topical ester steroid drop with decreased risk of glaucoma. Available in 0.2% and 0.5% drops.
Adult
1 gtt tid up to q1h in both eyes; well shaken to suspend particles
Pediatric
Administer as in adults
None reported
Documented hypersensitivity; viral, fungal, or tubercular infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hypertension; known to cause cataract formation with chronic use; fungal invasion should be suspected in any persistent corneal ulceration where a corticosteroid has been used or is in use (fungal cultures should be taken when appropriate); may increase IOP; prolonged use may result in glaucoma
Nonsteroidal anti-inflammatory agents
Have analgesic and anti-inflammatory activities. Their mechanism of action is not known but may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.
Diclofenac (Voltaren)
Inhibits prostaglandin synthesis by decreasing activity of enzyme cyclooxygenase, which in turn decreases formation of prostaglandin precursors. May facilitate outflow of aqueous humor and decreases vascular permeability.
Adult
1 gtt in affected eye(s) qid or prn for pain and photophobia
Pediatric
Administer as in adults
Additive effect with systemic NSAIDs may occur
Documented hypersensitivity; avoid during pregnancy
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Corneal thinning may occur (Voltaren from CibaVision, Duluth, GA is not associated with this increased risk)
Ketorolac (Acular)
Available in preserved bottle as well as PF (preservative free) single dose unit (SDU) containers.
Adult
1 gtt in affected eye(s) qid or prn for pain and photophobia
Pediatric
Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Perform ophthalmologic studies in patients who develop eye complaints during therapy; discontinue therapy if changes are noted; changes may include blurred or diminished vision, corneal deposits and retinal disturbances, scotomata, changes in color vision, and macula degeneration
More on Rocky Mountain Spotted Fever |
| Overview: Rocky Mountain Spotted Fever |
| Differential Diagnoses & Workup: Rocky Mountain Spotted Fever |
 Treatment & Medication: Rocky Mountain Spotted Fever |
| Follow-up: Rocky Mountain Spotted Fever |
| References |
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References
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Further Reading
Keywords
Rocky Mountain spotted fever, RMSF, rickettsial disease, ticks, wood ticks, dog ticks,
