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Relapsing Fever in Emergency Medicine Treatment & Management

  • Author: Bobak Zonnoor , MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
 
Updated: Jun 08, 2016
 

Approach Considerations

The antibiotics of choice in the treatment of relapsing fever penicillin and tetracyclines. There has been no evidence of acquired resistance to antibiotics.

The effectiveness of therapy can be assessed via serial testing of blood smears and observing the clearance of spirochetes from the blood. Most patients have undetectable spirochetes within 8 hours of the first dose of antibiotic.[18]

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Emergency Department Care

Emergency department care of patients with relapsing fever focuses on establishing the diagnosis and excluding other treatable infections with which it can be confused. As mentioned in Workup, thin and thick smears are usually the first tests performed for suspected relapsing fever.

Louse-borne relapsing fever

Louse-borne relapsing fever is treated with the following:

  • Tetracycline 500 mg PO as a single dose (12.5 mg/kg in children)
  • Doxycycline 200 mg PO as a single dose (5 mg/kg in children)
  • Intramuscular penicillin G procaine (400,000-800,000 units) as a single dose
  • If tetracyclines are contraindicated, erythromycin 500 mg as a single dose (12.5 mg/kg in children) [19]

The recurrence rate in patients receiving the above-mentioned therapy is less than 5%.

If the patient cannot tolerate oral administration, intravenous doxycycline 250 mg or 500 mg can be used.

Tetracycline is contraindicated in pregnant and nursing women and children younger than 9 years.

Tick-borne relapsing fever

Tick-borne relapsing fever is more sporadic than louse-borne relapsing fever.

The relapse rate of tick-borne relapsing fever after single dose of antibiotic is about 20% higher, which might result from probable invasion of the brain by spirochetes. Protected by the blood-brain barrier, spirochetes can reinvade the blood once antibiotic levels have fallen.

Treatment of tick-borne relapsing fever is the same as louse-borne relapsing fever, except the treatment duration is 7-10 days because the relapse rate is 20% after single-dose treatment.

Antibiotic choices for tick-borne relapsing fever include the following:

  • Tetracycline 500 mg PO every 6 hours for 7-10 days
  • Doxycycline 100 mg PO twice daily for 7-10 days
  • If tetracyclines are contraindicated, erythromycin 500 mg PO every 6 hours for 7-10 days
  • If CNS involvement is suspected, a beta-lactam antibiotic should be given intravenously: penicillin G (3 million units q4h for 7-10 days) or ceftriaxone 2 g IV once daily for 10-14 days or 1 g IV twice daily (for 10-14 days)

The efficacy of treatment can be measured by clearance of spirochetes in the blood, which usually occurs approximately 8 hours after antibiotic administration.[18]

For patients in endemic regions, postexposure treatment with doxycycline can be used.

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Consultations

Consultation with an infectious diseases specialist may be appropriate.

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Prevention

No vaccine is available for either louse-borne relapsing fever or tick-borne relapsing fever. Thus, decreasing exposure is the major mean of preventing relapsing fever.

Avoid sleeping in rodent-infested buildings (rodent nests may not be visible).

Use insect repellent containing DEET or permethrin to prevent tick bites.

For patients in endemic regions, postexposure treatment with doxycycline can be used.

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Contributor Information and Disclosures
Author

Bobak Zonnoor , MD Resident Physician, Department of Emergency Medicine, SUNY Downstate Medical Center, Kings County Hospital

Bobak Zonnoor , MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Richard H Sinert, DO Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Vice-Chair in Charge of Research, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians, Society for Academic Emergency Medicine

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.

Jon Mark Hirshon, MD, MPH, PhD Professor, Department of Emergency Medicine, University of Maryland School of Medicine

Jon Mark Hirshon, MD, MPH, PhD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Public Health Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, South Carolina Medical Association, Columbia Medical Society, South Carolina College of Emergency Physicians, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Chief Editor for Medscape.

Additional Contributors

Dan Danzl, MD Chair, Professor, Department of Emergency Medicine, University of Louisville Hospital

Dan Danzl, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Kentucky Medical Association, Society for Academic Emergency Medicine, Wilderness Medical Society

Disclosure: Nothing to disclose.

R Gentry Wilkerson, MD, FACEP, FAAEM Assistant Professor, Coordinator for Research, Department of Emergency Medicine, University of Maryland School of Medicine

R Gentry Wilkerson, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Nathaniel B Stephens, DO Resident Physician, Department of Emergency Medicine, University of South Florida, Tampa General Hospital

Nathaniel B Stephens, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, National Association of EMS Physicians, Emergency Medicine Residents' Association, Florida Osteopathic Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Jonathan A Edlow, MD, to the development and writing of this article.

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Relapsing fever can be tick- or louse-borne. Soft-bodied ticks of the genus Ornithodoros transmit tick-borne cases. Below is an image of such a tick. Unlike the hard-bodied ticks, the Ornithodoros feed briefly and can transmit disease within minutes. Photo courtesy of Julie Rawlings, MPH, Texas Department of Health.
Photomicrograph of a patient who presented to the ED with cyclical fevers and chills, which she developed while traveling in one of the recently formed Soviet Republics in 1990. A blood smear for malaria was obtained, and this is what the laboratory technician observed.
Cases of Tick-borne Relapsing Fever - United States, 1990-2011. Courtesy of the Centers for Disease Control and Prevention (CDC).
 
 
 
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