eMedicine Specialties > Infectious Diseases > Bacterial Infections

Relapsing Fever: Treatment & Medication

Author: Kauser Akhter, MD, Clinical Assistant Professor, Internal Medicine, Florida State University College of Medicine; Infectious Diseases Faculty Practice, Orlando Health
Coauthor(s): 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; 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
Contributor Information and Disclosures

Updated: Apr 9, 2009

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

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

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

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  3. 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.

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  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.

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  12. 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].

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  14. 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.

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Further Reading

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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

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Contributor Information and Disclosures

Author

Kauser Akhter, MD, Clinical Assistant Professor, Internal Medicine, Florida State University College of Medicine; Infectious Diseases Faculty Practice, Orlando Health
Disclosure: Nothing to disclose.

Coauthor(s)

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, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Medical Editor

John M Leedom, MD, Professor of Medicine, Keck School of Medicine, University of Southern California; Chief, Division of Infectious Diseases, Department of Internal Medicine, Los Angeles County, University of Southern California Medical Center
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, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Joseph F John Jr, MD, FACP, FIDSA, FSHEA, Clinical Professor of Medicine, Molecular Genetics and Microbiology, Medical University of South Carolina; Associate Chief of Staff for Education, Ralph H Johnson Veterans Affairs Medical Center
Disclosure: BioMerieux Honoraria Review panel membership; Cubist Honoraria Review panel membership; Pfizer Honoraria Speaking and teaching; Merck Stock dividends stock holdings

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD, Professor, Stewart G Wolf Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center
Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physician Executives, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Association of Professors of Medicine, Association of Program Directors in Internal Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

 
 
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