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Relapsing Fever: Treatment & Medication
Updated: Apr 9, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
For decades, penicillins and tetracyclines have been the treatment of choice in relapsing fever. In vitro, Borrelia species are also susceptible to cephalosporins, macrolides, and chloramphenicol, although less data are available on these antibiotics.13 The efficacy of treatment can be demonstrated by noting clearance of spirochetes in the blood, usually occurring within 8 hours of administration of an effective antibiotic.13
- In adults with louse-borne relapsing fever (LBRF), treatment consists of a single dose of tetracycline, doxycycline, or erythromycin. Treatment of tick-borne relapsing fever (TBRF) is the same as that for LBRF, except the treatment duration is 7-10 days.
- In adults, intravenous therapy with doxycycline, erythromycin, tetracycline, chloramphenicol, or procaine penicillin G should be used when oral therapy is not tolerated.2
- Intravenous chloramphenicol is administered at 500 mg once in LBRF and 500 mg every 6 hours in TBRF.2 The oral preparation of chloramphenicol is unavailable in the United States.
- Procaine penicillin G2 may be administered at a single dose of 600,000 IU in patients with LBRF or 600,000 IU daily in patients with TBRF.2
- In children younger than 8 years and in pregnant or nursing women, erythromycin is preferred.2
- Antibiotic therapy can trigger a Jarisch-Herxheimer reaction, which is described in Complications. The reaction is more common in LBRF (about 80%)13 but also occurs in TBRF (54% in one series).13
- Meningitis is treated with either intravenous penicillin or ceftriaxone.4
Consultations
- Consultation with an infectious disease specialist may be helpful.
- A critical care specialist and/or pulmonologist should be consulted for patients with relapsing fever who are severely ill.
Activity
Activity is as tolerated in patients with relapsing fever.
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications. In louse-borne relapsing fever (LBRF), single-dose therapy is recommended, as only one relapse typically occurs. Therapy for tick-borne relapsing fever (TBRF) is extended to 7-10 days, as this form is characterized by multiple relapses.
Antibiotics
Borrelia species that cause relapsing fever are sensitive to antibiotic agents.
Doxycycline (Adoxa, Doryx, Monodox, Vibramycin, Vibratab)
Broad-spectrum, synthetically derived bacteriostatic antibiotic in the tetracycline class. Almost completely absorbed, concentrates in bile, and is excreted in urine and feces as a biologically active metabolite in high concentrations. Inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. May block dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Adult
Louse-borne relapsing fever: 100 mg PO single dose
Tick-borne relapsing fever: 100 mg PO q12h for 7-10 d
Pediatric
<8 years: Not recommended
>8 years: 100 mg PO q12h (tick-borne)
Bioavailability decreases minimally with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity (rare); administration during last half of pregnancy through 8 years can cause permanent dental discoloration
Erythromycin (E-Mycin, Eryc; Ery-Tab)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Adult
Louse-borne relapsing fever: 500 mg PO single dose
Tick-borne relapsing fever: 500 mg PO q6h for 7-10 d
Pediatric
Louse-borne relapsing fever: 500 mg PO single dose
Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis; may decrease effectiveness of oral contraceptives; increases sildenafil levels
Documented hypersensitivity; hepatic impairment
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in liver disease; estolate formulation may cause cholestatic jaundice; adverse GI effects are common; discontinue use if nausea, vomiting, abdominal colic occur; myasthenia gravis
Tetracycline (Sumycin, Achromycin V)
Treats gram-positive and gram-negative infections, as well as mycoplasmal, chlamydial, and rickettsial infections. Inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunit(s).
Adult
Louse-borne relapsing fever: 500 mg PO single dose
Tick-borne relapsing fever: 500 mg PO q6h for 7-10 d
Pediatric
<8 years: Not recommended
>8 years: 250 mg/kg/d PO q6h
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; may increase hypoprothrombinemic effects of anticoagulants
Documented hypersensitivity
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; use during tooth development (last half of pregnancy through 8 y) can cause permanent discoloration of teeth; Fanconi-like syndrome may occur with outdated tetracyclines
More on Relapsing Fever |
| Overview: Relapsing Fever |
| Differential Diagnoses & Workup: Relapsing Fever |
Treatment & Medication: Relapsing Fever |
| Follow-up: Relapsing Fever |
| Multimedia: Relapsing Fever |
| References |
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References
Barbour AG, Hayes SF. Biology of Borrelia species. Microbiol Rev. Dec 1986;50(4):381-400. [Medline].
Dworkin MS, Schwan TG, Anderson DE Jr, Borchardt SM. Tick-borne relapsing fever. Infect Dis Clin North Am. Sep 2008;22(3):449-68, viii. [Medline].
Wynns HL. The epidemiology of relapsing fever. In: Moulton FR. A Symposium on Relapsing Fever in the Americas. American Association for the Advancement of Science. Washington, DC: 1942:100-5.
Blevins SM, Greenfield RA, Bronze MS. Blood smear analysis in babesiosis, ehrlichiosis, relapsing fever, malaria, and Chagas disease. Cleve Clin J Med. Jul 2008;75(7):521-30. [Medline].
Moursund WH. Historical introduction to the symposium on relapsing fever. In: Moulton FR. A Symposium on Relapsing Fever in the Americas. American Association for the Advancement of Science. Washington, DC: 1942:1-6.
Barbour AG. Microbiology, pathogenesis, and epidemiology of relapsing fever. UpToDate. Available at http://www.uptodate.com/online/content/topic.do?topicKey=tickflea/11713&selectedTitle=2~15&source=search_result#references. Accessed November 25, 2008.
Fuchs PC, Oyama AA. Neonatal relapsing fever due to transplacental transmission of Borrelia. JAMA. Apr 28 1969;208(4):690-2. [Medline].
Thein M, Bunikis I, Denker K, Larsson C, Cutler S, Drancourt M, et al. Oms38 is the first identified pore-forming protein in the outer membrane of relapsing fever spirochetes. J Bacteriol. Nov 2008;190(21):7035-42. [Medline].
Gelderblom H, Schmidt J, Londoño D, Bai Y, Quandt J, Hornung R, et al. Role of interleukin 10 during persistent infection with the relapsing fever Spirochete Borrelia turicatae. Am J Pathol. Jan 2007;170(1):251-62. [Medline].
Londoño D, Marques A, Hornung RL, Cadavid D. Relapsing fever borreliosis in interleukin-10-deficient mice. Infect Immun. Dec 2008;76(12):5508-13. [Medline].
Centers for Disease Control and Prevention (CDC). Acute respiratory distress syndrome in persons with tickborne relapsing fever--three states, 2004-2005. MMWR Morb Mortal Wkly Rep. Oct 19 2007;56(41):1073-6. [Medline].
Brouqui P, Stein A, Dupont HT, Gallian P, Badiaga S, Rolain JM, et al. Ectoparasitism and vector-borne diseases in 930 homeless people from Marseilles. Medicine (Baltimore). Jan 2005;84(1):61-8. [Medline].
Barbour AG. Clinical features and management of relapsing fever. UpToDate. Available at http://www.uptodate.com/online/content/topic.do?topicKey=tickflea/11413#1. Accessed November 25, 2008.
Rhee KY, Johnson WD Jr. Borrelia species (relapsing fever). In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. Vol 2. 6th ed. Philadelphia, PA: Churchill Livingstone; 2005:2795-8.
Goubau PF. Relapsing fevers. A review. Ann Soc Belg Med Trop. 1984;64(4):335-64. [Medline].
Southern PM, Sanford JP. Relapsing fever: a clinical and microbiological review. Medicine. 1969;48:129-49.
Perine PL, Parry EH, Vukotich D, Warrell DA, Bryceson AD. Bleeding in louse-borne relapsing fever. I. Clinical studies in 37 patients. Trans R Soc Trop Med Hyg. 1971;65(6):776-81. [Medline].
Dennis DT, Awoke S, Doberstyn EB, Fresh JW. Bleeding in louse-borne relapsing fever in Ethiopia; clinical and laboratory features in 29 patients. East Afr Med J. Apr 1976;53(4):220-5. [Medline].
Parola P, Raoult D. Ticks and tickborne bacterial diseases in humans: an emerging infectious threat. Clin Infect Dis. Mar 15 2001;32(6):897-928. [Medline].
van Dam AP, van Gool T, Wetsteyn JC. Tick-borne relapsing fever imported from West Africa: diagnosis by quantitative buffy coat analysis and in vitro culture of Borrelia crocidurae. J Clin Microbiol. Jun 1999;37(6):2027-30. [Medline].
Kelly R. Cultivation of Borrelia hermsi. Science. Jul 30 1971;173(995):443-4. [Medline].
Schwan TG, Gage KL, Karstens RH, Schrumpf ME, Hayes SF, Barbour AG. Identification of the tick-borne relapsing fever spirochete Borrelia hermsii by using a species-specific monoclonal antibody. J Clin Microbiol. Apr 1992;30(4):790-5. [Medline].
Fukunaga M, Okada K, Nakao M, Konishi T, Sato Y. Phylogenetic analysis of Borrelia species based on flagellin gene sequences and its application for molecular typing of Lyme disease borreliae. Int J Syst Bacteriol. Oct 1996;46(4):898-905. [Medline].
Jiang J, Temenak JJ, Richards AL. Real-time PCR duplex assay for Rickettsia prowazekii and Borrelia recurrentis. Ann N Y Acad Sci. Jun 2003;990:302-10. [Medline].
Magnarelli LA, Anderson JF, Johnson RC. Cross-reactivity in serological tests for Lyme disease and other spirochetal infections. J Infect Dis. Jul 1987;156(1):183-8. [Medline].
Magnarelli LA, Meegan JM, Anderson JF, Chappell WA. Comparison of an indirect fluorescent-antibody test with an enzyme-linked immunosorbent assay for serological studies of Lyme disease. J Clin Microbiol. Aug 1984;20(2):181-4. [Medline].
[Best Evidence] Hasin T, Davidovitch N, Cohen R, Dagan T, Romem A, Orr N, et al. Postexposure treatment with doxycycline for the prevention of tick-borne relapsing fever. N Engl J Med. Jul 13 2006;355(2):148-55. [Medline].
Dworkin MS, Anderson DE Jr, Schwan TG. Tick-borne relapsing fever in the northwestern United States and southwestern Canada. Clin Infect Dis. Jan 1998;26(1):122-31. [Medline].
Scott R. Neurological complications of relapsing fever. Lancet. 1944;247:436-8.
Cadavid D, Barbour AG. Neuroborreliosis during relapsing fever: review of the clinical manifestations, pathology, and treatment of infections in humans and experimental animals. Clin Infect Dis. Jan 1998;26(1):151-64. [Medline].
Wengrower D, Knobler H, Gillis S, Chajek-Shaul T. Myocarditis in tick-borne relapsing fever. J Infect Dis. Jun 1984;149(6):1033. [Medline].
Further Reading
Keywords
relapsing fever, louse-borne relapsing fever, LBRF, tick-borne relapsing fever, TBRF, human body louse, Pediculus humanus, soft-bodied ticks, Ornithodoros species, species, Borrelia recurrentis, Borrelia turicatae, Borrelia hermsii, Borrelia parkeri, Borrelia duttonii, B recurrentis, B turicatae, B hermsii, B parkeri, B duttonii
Treatment & Medication: Relapsing Fever