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Relapsing Fever Treatment & Management

  • Author: Kauser Akhter, MD; Chief Editor: Michael Stuart Bronze, MD  more...
Updated: Dec 10, 2014

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.[16, 14] Borrelia species are relatively resistant to fluoroquinolones, sulfa drugs, rifampin, aminoglycosides, and metronidazole.

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.[16, 37]

In adults with louse-borne relapsing fever (LBRF), oral treatment consists of a single dose of tetracycline 500 mg, doxycycline 200 mg, or, when tetracyclines are contraindicated, erythromycin 500 mg.

Treatment of tick-borne relapsing fever (TBRF) is the same as that for LBRF, except the treatment duration is 7-10 days owing to reported relapses of 20% or greater after single-dose treatment.[22, 38, 39] In oral treatment for TBRF, tetracycline 500 mg every 6 hours, doxycycline 100 mg twice daily, or, if tetracyclines are contraindicated, erythromycin 500 mg every 6 hours, can be used.

In adults, intravenous therapy with doxycycline, erythromycin, tetracycline, or procaine penicillin G should be used when oral therapy is not tolerated.[2]

Procaine penicillin G[2] may be administered at a single dose of 600,000 IU in adult patients with LBRF or 600,000 IU daily in patients with TBRF.[2]

For TBRF with neurologic involvement, penicillin G 3 million units IV every 4 hours or ceftriaxone 2 g IV daily (or 1 g IV twice daily) are likely to work well, given that these regimens are efficacious for Lyme disease.[4]

In children younger than 8 years and in pregnant or nursing women, erythromycin 12.5 mg/kg is preferred.[2] Older children can also take oral tetracycline 12.5 mg/kg, oral doxycycline 5 mg/kg, or intramuscular penicillin G procaine 200,000-400,000 units. Antibiotic therapy can trigger a Jarisch-Herxheimer reaction, which is described in Complications. The reaction is more common in LBRF (about 80%)[16] but also occurs in TBRF (54% in one series).[16]

No treatment is currently defined for recently discovered B miyamotoi infection, and treatment as for Lyme disease is recommended, including treatment as for CNS Lyme disease in patients with neurologic B miyamotoi infection manifestations.



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 is as tolerated in patients with relapsing fever.

Contributor Information and Disclosures

Kauser Akhter, MD Assistant Professor, Department of Internal Medicine, Florida State University College of Medicine; Associate Program Director, Infectious Diseases Fellowship Program, Orlando Health

Disclosure: Nothing to disclose.


Pierre A Dorsainvil, MD Medical Director, HIV Specialist, Palm Beach County Main Detention Center; Consulting Staff, Department of Internal Medicine, Division of Infectious Diseases, Lake Ida Medical Center

Disclosure: Nothing to disclose.

Burke A Cunha, MD Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Joseph F John, Jr, MD, FACP, FIDSA, FSHEA Clinical Professor of Medicine, Molecular Genetics and Microbiology, Medical University of South Carolina College of Medicine; Associate Chief of Staff for Education, Ralph H Johnson Veterans Affairs Medical Center

Joseph F John, Jr, MD, FACP, FIDSA, FSHEA is a member of the following medical societies: Charleston County Medical Association, Infectious Diseases Society of America, South Carolina Infectious Diseases Society

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, Oklahoma State Medical Association, Southern Society for Clinical Investigation, Association of Professors of Medicine, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

John M Leedom, MD Professor Emeritus of Medicine, Keck School of Medicine of the University of Southern California

John M Leedom, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, American Society for Microbiology, Infectious Diseases Society of America, International AIDS Society, Phi Beta Kappa

Disclosure: Nothing to disclose.

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Peripheral blood smear in relapsing fever. (Image originally printed in 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. Reprinted with permission from the Cleveland Clinic.)
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