Trench Fever Treatment & Management

  • Author: Alfred Scott Lea, MD; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Jan 12, 2012
 

Medical Care

No well-designed, double-blinded, controlled trials have documented the best antibiotic regimen for B quintana infection and its associated syndromes (including trench fever) in immunocompetent patients. Most therapeutic recommendations are based on anecdotal clinical experience.

In the laboratory, B quintana seems to be sensitive to advanced-generation beta-lactams, chloramphenicol, macrolides, tetracyclines, fluoroquinolones (not ciprofloxacin), aminoglycosides, rifampin, and cotrimoxazole.[15, 21, 47] Microbiologic susceptibility studies may not accurately predict clinical efficacy since B quintana seems to respond clinically to bacteriostatic agents such as doxycycline, erythromycin, and azithromycin.[38] Only gentamicin is bactericidal in vitro.[48] Since gentamicin does not achieve bactericidal levels within human erythrocytes, it is not believed to be optimal for monotherapy but is regularly used in combination with doxycycline.

It is critical to use two antibiotics with good in vitro activity against B quintana for serious or complicated infections.[21] Successful treatment in immunocompromised patients is anecdotal, and most recommendations suggest longer treatment regimens combined with close clinical and microbiological follow-up.

The following are current recommendations for each of the identified clinical syndromes associated with B quintana in immunocompetent patients:

  • Trench fever/urban trench fever: Uncomplicated disease responds to doxycycline (100 mg PO twice daily for 28 d) and gentamicin (3 mg/kg IV daily for 14 d).[21] . Macrolides and ceftriaxone have also been shown to be effective.[6, 38, 14]
  • Chronic B quintana bacteremia: A small randomized study found that a combination of doxycycline (100 mg PO twice daily for 28 d) with gentamicin (3 mg/kg/d IV for 14 d) effectively eradicated bacteremia.[49, 21] In some cases, therapy of much longer duration (up to 4 y) has been required.[15] Serial cultures demonstrating eradication of the bacteremia are pivotal in determining duration of therapy.
  • Chronic lymphadenopathy: Erythromycin (500 mg PO 4 times a day for 3 mo) is the first-line therapy. Doxycycline (100 mg PO twice daily for 3 mo) is the alternative.[21, 6] Gentamicin (3 mg/kg IV daily for 14 d) can be added in difficult cases.
  • Bacillary angiomatosis: Erythromycin (500 mg PO 4 times a day for 3 mo) is the agent of choice.[21] Doxycycline (100 mg PO twice daily for 3 mo) is an effective alternative. Gentamicin (3 mg/kg/d IV for 14 d) can be added in refractory cases.[6] Fluoroquinolones and ceftriaxone have shown success in individual cases.
  • B quintana endocarditis: Doxycycline (100 mg PO twice daily for 6 wk) given in combination with gentamicin (3 mg/d IV daily for 14 d) is the regimen of choice.[21] Rocephin should be added to the regimen if culture results are negative. Most patients require valvular heart surgery.[36, 37]
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Surgical Care

Surgical biopsy may be used to establish a definitive diagnosis of B quintana endocarditis, lymphadenopathy, or bacillary angiomatosis, when necessary.

In addition to numerous descriptions of small numbers of patients with B quintana endocarditis, two large studies (both performed by the same group of investigators) have described the treatment and outcomes of the disease.[36, 37] Their findings have suggested that most cases require valvular cardiac surgery.

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Consultations

  • Consult with an infectious disease specialist for help with diagnosis and treatment.
  • Consult with a microbiology laboratory for help with blood and tissue specimen handling for optimal culture, serologic, and PCR-genomic testing.
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Diet

  • No dietary restrictions are necessary in patients with Bartonella infection, including trench fever and urban trench fever.
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Activity

  • No activity restrictions are necessary unless the patient has cardiac failure due to Bartonella endocarditis or its complications.
  • The patient should improve hygiene and living conditions.
  • Individuals should not donate blood or tissue if they are at risk for Bartonella infection.
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Contributor Information and Disclosures
Author

Alfred Scott Lea, MD  Associate Professor of Internal Medicine and Infectious Diseases, University of Texas Medical Branch School of Medicine

Alfred Scott Lea, MD is a member of the following medical societies: American Academy of Wound Management, American College of Physicians, American Medical Association, Harris County Medical Society, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Specialty Editor Board

Jeffrey M Zaks, MD  Clinical Associate Professor of Medicine, Wayne State University School of Medicine; Vice President, Medical Affairs, Chief Medical Officer, Department of Internal Medicine, Providence Hospital

Jeffrey M Zaks, MD is a member of the following medical societies: American College of Cardiology, American College of Healthcare Executives, American College of Physician Executives, and American Medical Association

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

Thomas M Kerkering, MD  Chief of Infectious Diseases, Virginia Tech Carilion School of Medicine

Thomas M Kerkering, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Public Health Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Medical Society of Virginia, and Wilderness Medical Society

Disclosure: Nothing to disclose.

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

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.

Additional Contributors

The author would like to thank A. Clinton White, MD, for his encouragement and suggestions during the composition of this article.

The authors and editors of eMedicine also gratefully acknowledge the contributions of previous author Eleftherios Mylonakis, MD, and previous coauthor Michael Forgione, MD, to the development and writing of this article.

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This illustration depicts a dorsal view of a female body louse, Pediculus humanus var. corporis. The human body louse P humanus var. corporis is a known vector responsible for the transmission of epidemic typhus, trench fever, and Asiatic relapsing fever. It also causes a dermatitic condition known as pediculosis. Courtesy of the CDC.
 
 
 
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