eMedicine Specialties > Emergency Medicine > Infectious Diseases
Tick-Borne Diseases, Q Fever: Treatment & Medication
Updated: Dec 9, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Emergency Department Care
As with any patient with a febrile illness, the physician must exclude other potentially life-threatening diseases, which, in the case of tick-borne disease, involves presumptive antibiotic therapy.
- While specific antimicrobial therapy is indicated, most patients improve spontaneously. However, when Q fever is diagnosed, the administration of antibiotics is appropriate to prevent progression to chronic disease, which is far more resistant to treatment.
- Supportive care with fluids and antipyretics may improve patient comfort.
Consultations
In select cases, the emergency physician may consult an infectious disease specialist. In pregnant women, OB-GYN consultation may also be considered in some cases.
Medication
Despite the fact that most untreated patients improve, specific antibiotic therapy is indicated to help the patient improve faster and to reduce the likelihood of progression to chronic disease. Patients with Q fever who are misdiagnosed with legionellosis have responded well to intravenous erythromycin, which probably is effective for pregnant patients, although no controlled trials have been performed. Some investigators use lysosomal alkalinizing agents (eg, hydroxychloroquine) for patients with chronic Q fever to increase the effectiveness of antibiotics.
Treatment of pregnant women is complicated and infectious disease consultation should be sought by the emergency physician.
Treatment of chronic Q fever is beyond the scope of emergency medicine practice.
Antibiotics
Empiric antimicrobial therapy must be comprehensive, covering all likely pathogens in context of the clinical setting. Doxycycline is the drug of choice.
In one series of pregnant patients with Q fever, trimethoprim-sulfamethoxazole was used with some success.2
In the chronic setting, the addition of chloroquine to doxycycline may improve outcomes, although data are sparse.
Doxycycline (Bio-Tab, Doryx, Vibramycin)
DOC for Q fever. Interferes with bacterial cell wall synthesis during active multiplication, causing cell wall death and resultant bactericidal activity against susceptible bacteria.
Adult
Acute infection: 200 mg PO/IV immediately and 100 mg hs, followed by 100 mg bid for 3 d
Alternatives: 300 mg PO/IV immediately then 300 mg in 1 h, or 100 mg PO/IV bid for 7 d
Pediatric
<8 years: Not recommended
>8 years: 2-5 mg/kg/d PO/IV qd or divided bid; not to exceed 200 mg/d
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity (with prolonged exposure to sunlight or tanning equipment); reduce dose in renal impairment; consider determining drug serum levels in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can permanently discolor of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Tetracycline (Sumycin)
Treats susceptible bacterial infections of both gram-positive and gram-negative organisms, as well as infections caused by Mycoplasma, Chlamydia, and Rickettsia organisms. Inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Adult
250-500 mg PO q6h
Mild-to-moderate infections: 500 mg PO bid or 250 mg PO qid for 7-14 d
Severe infections: 500 mg PO qid for 7-14 d
Pediatric
<8 years: Not recommended
>8 years: 10-20 mg/lb/d (25-50 mg/kg) PO divided qid
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; tetracyclines can increase hypoprothrombinemic effects of anticoagulants
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity (with prolonged exposure to sunlight or tanning equipment); reduce dose in renal impairment; consider determining drug serum levels in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can permanently discolor teeth; Fanconilike syndrome may occur with outdated tetracyclines
Chloramphenicol (Chloromycetin)
Used in patients who do not tolerate tetracycline.
Adult
50-100 mg/kg/d PO/IV divided q6h for 10 d; not to exceed 4 g/d
Pediatric
50-75 mg/kg/d PO/IV divided q6h
Concurrently with barbiturates, chloramphenicol serum levels may decrease while barbiturate levels may increase, causing toxicity; manifestations of hypoglycemia may occur with sulfonylureas; rifampin may reduce serum levels, presumably because of hepatic enzyme induction; may increase effects of anticoagulants; may increase serum hydantoin levels, possibly resulting in toxicity; levels may be increased or decreased
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Use only for indicated infections or as prophylaxis for bacterial infections; serious and fatal blood dyscrasias (aplastic anemia, hypoplastic anemia, thrombocytopenia, granulocytopenia) can occur; perform baseline and periodic blood studies approximately every 2 d during therapy; discontinue with reticulocytopenia, leukopenia, thrombocytopenia, anemia, or findings attributable to chloramphenicol; adjust dose in liver or kidney dysfunction; caution in pregnancy at term or during labor because of potential toxic effects on fetus (gray syndrome)
Sulfamethoxazole and trimethoprim (Bactrim, Bactrim DS, Septra, Septra DS)
Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. This would be a drug to use in pregnant women after consultation with the patient's obstetrician and an infectious disease specialist.
Adult
160 mg TMP/800 mg SMZ PO q12h
Pediatric
Not established
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 persons; 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
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 because of 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 persons, 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
Antipyretics
Treatment of Q fever is symptomatic and supportive. Bed rest and mild analgesic-antipyretic therapy often are helpful in relieving the lethargy, malaise, and fever associated with the disease.
Aspirin (Bayer Aspirin, Bufferin, Anacin, Ascriptin)
Enhances dissipation of heat by vasodilating peripheral vessels, causing a decrease in body temperature. Also acts on hypothalamus heat-regulating center to reduce fever.
Adult
325-650 mg PO q4-6h; not to exceed 4 g/d
Pediatric
10-15 mg/kg/dose PO q4-6h; not to exceed 60-80 mg/kg/d
Effects may decrease with antacids and urinary alkalinizers; corticosteroids decrease salicylate serum levels; additive hypoprothrombinemic effects and increased bleeding time may occur with coadministration of anticoagulants; may antagonize uricosuric effects of probenecid and increase toxicity of phenytoin and valproic acid; doses >2 g/d may potentiate glucose-lowering effect of sulfonylurea drugs
Documented hypersensitivity; liver damage; hypoprothrombinemia; vitamin K deficiency; bleeding disorders; asthma; children (<16 y) with flu (association with Reye syndrome)
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May cause transient decrease in renal function and aggravate chronic kidney disease; avoid in severe anemia, history of blood coagulation defects, or anticoagulant therapy
Ibuprofen (Motrin, Nuprin, Advil, Ibuprin)
One of the few NSAIDs indicated for reduction of fever.
Adult
200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 30-70 mg/kg/d PO divided tid/qid; start with lower dose and titrate to maximum of 2.4 g/d
>12 years: Administer as in adults
Coadministration with aspirin increases risk of serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Acetaminophen (Aspirin Free Anacin, Tylenol, Feverall)
DOC for treatment of pain in patients with documented hypersensitivity to aspirin, NSAIDs, or upper GI disease and in those taking oral anticoagulants. Inhibits action of endogenous pyrogens on heat-regulating centers.
Adult
325-650 mg PO q4-6h or 1000 mg PO tid/qid; not to exceed 4 g/d
Alternative: 1000 mg PO tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses in 24 h
Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity; known G-6-P deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in chronic alcoholism with various doses; severe or recurrent pain or high or continued fever may indicate serious illness; may contain acetaminophen, and combined use may cause cumulative acetaminophen doses to exceed recommended maximum doses
More on Tick-Borne Diseases, Q Fever |
| Overview: Tick-Borne Diseases, Q Fever |
| Differential Diagnoses & Workup: Tick-Borne Diseases, Q Fever |
 Treatment & Medication: Tick-Borne Diseases, Q Fever |
| Follow-up: Tick-Borne Diseases, Q Fever |
| References |
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References
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Further Reading
Keywords
Q fever, tick-borne disease, Coxiella burnetii, C burnetii, fever, vector-borne disease, tick bite, acute Q fever, chronic Q fever, febrile illness
