eMedicine Specialties > Infectious Diseases > Bacterial Infections
Q Fever: Treatment & Medication
Updated: Nov 18, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- Acute Q fever
- Symptoms of acute Q fever usually resolve spontaneously within 2 weeks, but antibiotic treatment has been shown to reduce the duration of disease, especially if initiated within 3 days of illness onset. The optimal duration of treatment has not been adequately studied. Antibiotics are given for 14-21 days, usually in an outpatient setting.
- Doxycycline has been the agent most frequently investigated.8 It is currently the treatment of choice.
- Fluoroquinolones can be used as alternatives. Ofloxacin and pefloxacin have been used with success in patients. Ciprofloxacin demonstrated higher MIC values than other fluoroquinolones and doxycycline. Levofloxacin showed bacteriostatic activity in vitro.8
- Fluoroquinolones may offer a theoretical advantage in meningoencephalitis since they possess better cerebrospinal fluid penetration. A more recent literature review demonstrated that the choice of antimicrobial therapy (doxycycline vs fluoroquinolones) did not affect resolution of acute disease or severity of neurologic sequelae.3
- Macrolides, especially azithromycin and clarithromycin, can be used as alternatives, but some strains of C burnetii show resistance.3
- Trimethoprim-sulfamethoxazole (TMP-SMX) has also been used.3,4
- No reliable regimen is available for children (<8 y) or pregnant women. Macrolides or TMP-SMX may be options in these populations.6,3
- Adjuvant corticosteroid treatment has been used in antimicrobial-nonresponsive hepatitis.
- Chronic Q fever
- Chronic C burnetii infections are very difficult to treat. A prolonged combined antimicrobial regimen is recommended. Hospitalization may be warranted for intractable heart failure.
- No drug used alone has been shown to be bactericidal against C burnetii. Therefore, prolonged combination therapy is recommended because of the high rate of relapse with treatment of shorter duration. No consensus on the ideal duration of therapy has been reached, but serial measurement of antibody titers should likely be used as a guide to duration of therapy.
- The most current recommendation for endocarditis is combination treatment with doxycycline and hydroxychloroquine for at least 18 months. An alternative option is combination of doxycycline and a fluoroquinolone for at least 3-4 years. Other proposed alternatives include doxycycline or fluoroquinolones with rifampin therapy, although significant drug interactions could limit these regimens.3
- The use of hydroxychloroquine is based on the assumption that it will elevate the pH within the phagolysosome vacuole of the monocyte, where C burnetii resides. This might affect the metabolism of the organism, rendering it more susceptible to the effects of doxycycline.
- Endovascular complications should also be treated with doxycycline and hydroxychloroquine in combination, although the optimal regimen is not well defined.3
- Osteoarticular infections should also be treated with prolonged antimicrobial combination therapy, along with surgical debridement. A regimen of doxycycline and hydroxychloroquine, with or without rifampin, has been suggested.3
Surgical Care
- Valvular replacement is indicated for intractable heart failure. C burnetii can persist on endocardial tissue even after valve replacement; therefore, antibiotics should be continued following surgery.
- Surgical treatment can affect survival in endovascular complications such as mycotic aneurysm or vascular graft infections.3
- Surgical debridement is also recommended for osteoarticular infections.3
Consultations
- Infectious disease specialist
- Cardiothoracic, vascular, and orthopedic surgeons in selected cases
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Antibiotics
Drugs are used that provide in vivo or in vitro activity in C burnetii infections .
Doxycycline (Vibramycin)
First-line agent for both acute and chronic diseases. Bacteriostatic drug that interferes with bacterial protein synthesis by binding to 30S ribosome.
Adult
Acute Q fever: 100 mg PO bid for 14 d
Chronic Q fever: 100 mg PO bid for at least 3 y when combined with ofloxacin (or pefloxacin); 100 mg PO bid for at least 18 mo when combined with hydroxychloroquine
Pediatric
<8 years: Contraindicated
>8 years: 2-4 mg/kg/d PO divided q 12 h
Antacids, milk, iron- or zinc-containing medications, didanosine, and sucralfate minimally diminish absorption; Tegretol and chronic ethanol ingestion decrease effects; reduces action of oral contraceptives; may potentiate effect of anticoagulants; BUN augmentation reported when used with diuretics
Documented hypersensitivity; pregnant women
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Adverse effects include photosensitivity (rare) and permanent tooth discoloration in children due to enamel hypoplasia
Ofloxacin (Floxin)
An alternative to doxycycline in acute Q fever. A derivative of pyridine carboxylic acid with broad-spectrum bactericidal effect.
Adult
Acute Q fever: 200 mg PO q8h for 14-21 d
Chronic Q fever: 200 mg PO tid with doxycycline for at least 3 y
Pediatric
Not established
Antacids, sucralfate, and iron- or zinc-containing medications diminish absorption; increases risk of seizures when used with AINS drugs
Documented hypersensitivity; pregnant women
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
Dosage adjustment is required in renal failure; adverse effects include nausea, vomiting, abdominal discomfort and diarrhea, mild headache and dizziness, allergic rash, and photosensitivity; avoid in nursing mother (excreted in breast milk)
Rifampin (Rifadin, Rifadin IV, Rimactane)
Used to treat all forms of tuberculosis in combination with at least one other antituberculous drug. Inhibits RNA synthesis in bacteria by binding to beta subunit of DNA-dependent RNA polymerase, which in turn blocks RNA transcription. Cross-resistance has only been shown with other rifamycins; combination therapy with doxycycline should be continued for chronic Q fever for at least 18 mo.
Adult
600 mg PO/IV qd
Pediatric
10-20 mg/kg PO/IV; not to exceed 600 mg/d
Induces microsomal enzymes, which may decrease effects of acetaminophen, oral anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, oral contraceptives, corticosteroids, mexiletine, cyclosporine, digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin; blood pressure may increase with coadministration of enalapril; coadministration with isoniazid or pyrazinamide may result in higher rate of hepatotoxicity than with either agent alone (discontinue one or both agents if alterations in LFTs occur)
Documented hypersensitivity
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
Obtain CBCs and baseline clinical chemistries prior to and throughout therapy; in liver disease, weigh benefits against risk of further liver damage; interruption of therapy and high-dose intermittent therapy are associated with thrombocytopenia that is reversible if therapy is discontinued as soon as purpura occurs; if treatment is continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur
Sulfamethoxazole and Trimethoprim (Bactrim, Bactrim DS, Septra, Septra DS)
Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.
Adult
160 mg TMP-800 mg SMX PO q12h (1 double strength tab q12h)
Pediatric
<2 months: Do not administer
>2 months: 10-12 mg/kg/d, based on TMP, PO divided bid (50-60 mg/kg/d, based on SMX, divided bid)
May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Documented hypersensitivity; megaloblastic anemia due to folate deficiency; age <2 mo
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
Do not use during last trimester of pregnancy due to potential toxicity to newborn (eg, jaundice, hemolytic anemia, kernicterus)
Dosage adjustments (adult adjustments)
CrCl (mL/min) 80-50: Recommended IV dose q18h
CrCl 50-10: Recommended IV dose q24h
CrCl <10: Not recommended
HD: 4-5 mg/kg after HD
During peritoneal dialysis: 0.16-0.8 g q48h
Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBCs frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, chronic alcoholics, elderly, those receiving anticonvulsant therapy, or those with malabsorption syndrome); hemolysis may occur in G-6-PD deficient individuals; AIDS patients may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation
Azithromycin (Zithromax)
Acts by binding to 50S ribosomal subunit of susceptible microorganisms and blocks dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Nucleic acid synthesis is not affected.
Concentrates in phagocytes and fibroblasts as demonstrated by in vitro incubation techniques. In vivo studies suggest that concentration in phagocytes may contribute to drug distribution to inflamed tissues.
Treats mild-to-moderate microbial infections.
Plasma concentrations are very low, but tissue concentrations are much higher, giving it value in treating intracellular organisms. Has a long tissue half-life.
Adult
Day 1: 500 mg PO
Days 2-5: 250 mg PO qd; may need to repeat if symptoms do not resolve
Pediatric
<6 months: Not established
>6 months:
Day 1: 10 mg/kg PO once; not to exceed 500 mg/d
Days 2-5: 5 mg/kg PO qd; not to exceed 250 mg/d
May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Site reactions can occur with IV route; bacterial or fungal overgrowth may result from prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function or prolonged QT intervals
Antimalarial drugs
These agents are used for their alkalinizing action within the phagolysosomal compartment of monocyte, where C burnetii resides.
Hydroxychloroquine (Plaquenil)
Used in chronic Q fever, with doxycycline, which is more effective. Fewer relapses than with doxycycline and ofloxacin. Treatment duration can be shortened.
Adult
200 mg PO tid with doxycycline for at least 18 mo; dosage reduction to 200 mg PO bid or qd if gastrointestinal intolerance develops
Pediatric
Not established
Serum levels increase with cimetidine; magnesium trisilicate may decrease absorption
Documented hypersensitivity to drug or 4-aminoquinoline compounds; preexisting retinopathy
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
Use with caution in hepatic or renal disease; adverse effects include retinopathy, corneal opacities, rash, pigmentation changes, alopecia, photosensitivity, nausea, diarrhea, abdominal pain; should be avoided in porphyria or psoriasis
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| Differential Diagnoses & Workup: Q Fever |
 Treatment & Medication: Q Fever |
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Further Reading
Keywords
Q fever, query fever, Coxiella burnetii, C burnetii, Rickettsia burnetii, R burnetii, Rickettsia diaporica, R diaporica, zoonosis, zoonotic transmission, farm animals, livestock, bacterial infection, farm infection, chronic Q fever, chronic fatigue syndrome
