eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease
Catscratch Disease: Treatment & Medication
Updated: Apr 28, 2009
- Overview
- Differential Diagnoses & Workup
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Treatment
Medical Care
The need for and value of what constitutes appropriate therapy in persons with catscratch disease (CSD) has not been well studied. In most immunocompetent patients, catscratch disease is self-limited, and symptoms resolve in 2-4 months. Antibiotic in vitro activity against B henselae does not correlate well with in vivo response. Practice guidelines for the diagnosis and management of skin and soft-tissue infections have been established.6
Effective antibiotics used in treating catscratch disease include rifampin, ciprofloxacin, trimethoprim-sulfamethoxazole (TMP-SMX), and gentamicin. Clarithromycin, azithromycin, and tetracycline are likely to be effective. Although data are lacking, patients with catscratch disease who are treated should receive treatment for 10-14 days. Immunocompromised patients may require much longer courses of therapy. No specific dose recommendations are available for treating catscratch disease.
- Normal doses of rifampin are 10-20 mg/kg/d orally every 12-24 hours, not to exceed 600 mg/d. Rifampin can cause hepatitis, particularly with underlying liver damage. Gastrointestinal, hematologic, and neurologic adverse effects are reported.
- Ciprofloxacin is not approved for administration in children. Ciprofloxacin, as with other quinolones, has been implicated in damaging cartilage in immature animals. These concerns have reduced the use of this class of drugs in pediatric patients. Adverse effects include gastrointestinal symptoms, dizziness, rash, seizures, headache, confusion, and tremors.
- TMP-SMX doses can include 8-12 mg/kg/d orally of TMP and 40-60 mg/kg/d orally of SMX every 12 hours. TMP-SMX can cause rashes and, occasionally, Stevens-Johnson syndrome. Anemia and neutropenia may occur, and a mild decrease in platelet count is common.
- The dose of intravenous gentamicin is 3-7.5 mg/kg/d orally every 8 hours. Serious toxic effects from these drugs are not common. Gentamicin may cause nephrotoxicity and ototoxicity. Aminoglycoside therapy is recommended for endocarditis.
- Do not administer sulfa drugs in patients with glucose-6-phospate dehydrogenase (G-6-PD) deficiency. Sulfa crystals may be deposited in the renal system if the patient is not adequately hydrated. Drug fever, serum sickness, and hepatitis are infrequent reactions.
Medication
Most immunocompetent patients completely recover from catscratch disease (CSD) without antibiotic therapy. Involvement of organ systems other than the lymph nodes, especially the neurologic system, or prolonged disease may be reason for antibiotic use.
Antibiotics
B henselae, a gram-negative bacillus, is sensitive to various antibiotics in vitro. Few clinical studies are available, but not all of the antibiotics to which the organism is sensitive in vitro are effective in vivo.
Rifampin (Rifadin, Rimactane)
Very broad-spectrum antibiotic. Available data suggest that Bartonella species are sensitive to rifampin in vitro and that the drug may work in vivo. Inhibits RNA synthesis in bacteria by binding to beta subunit of DNA-dependent RNA polymerase, which in turn blocks RNA transcription.
Adult
600 mg/d PO for 2-3 wk
Pediatric
10-20 mg/kg/d PO qd or divided q12h; not to exceed 600 mg/d
Induction of microsomal enzymes resulting from use may decrease therapeutic effects of acetaminophen, PO anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, clofibrate, PO contraceptives, corticosteroids, cyclosporine, digitoxin, disopyramide, estrogens, hydantoins, methadone, mexiletine, quinidine, sulfones, sulfonylureas, theophyllines, tocainide, and digoxin; significant increase in blood pressure has been reported in patients receiving enalapril and rifampin concurrently; isoniazid and rifampin coadministration may result in higher rate of hepatotoxicity than with either agent alone
Documented hypersensitivity
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
May cause GI symptoms (heartburn, anorexia, nausea, vomiting, jaundice, diarrhea, cramps), hematologic symptoms (thrombocytopenia, leukopenia, decreased hemoglobin), neurologic findings (headache, ataxia, dizziness, poor concentration, mental confusion, behavior changes, muscular weakness, pains in extremities, generalized numbness), ocular disturbances, menstrual disturbances, and elevation in BUN and uric acid levels; report any severe flulike symptoms; take on empty stomach; may discolor urine, tears, sweat, or other body fluids; use with caution in patients with underlying disease
Trimethoprim-sulfamethoxazole (Bactrim, Septra)
First-line drug for PO therapy against B henselae. Inhibits bacterial synthesis of dihydrofolic acid by competing with PABA. TMP blocks production of tetrahydrofolic acid by inhibiting enzyme dihydrofolate reductase. This combination blocks 2 consecutive steps in bacterial biosynthesis of essential nucleic acids and proteins. In vitro, bacterial resistance develops more slowly with this combination than with either drug alone.
Adult
160 mg TMP/800 mg SMX PO q12h
Pediatric
<2 months: Contraindicated
>2 months: Based on 8-12 mg/kg/d of TMP PO q12h
Phenytoin's hepatic clearance may be decreased and half-life may be prolonged
Documented hypersensitivity; megaloblastic anemia due to folate deficiency; age <2 mo
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
Stevens-Johnson syndrome and toxic epidermal necrolysis; discontinue at first appearance of skin rash or any sign of adverse reaction; rash, sore throat, fever, arthralgia, cough, shortness of breath, pallor, purpura, or jaundice may be early indications of serious reactions; hepatic necrosis; aplastic anemia; agranulocytosis; hemolysis may occur in G-6-PD deficient individuals (frequently dose-related); exercise caution in patients diagnosed with renal or hepatic impairment; maintain adequate fluid intake to prevent crystalluria and stone formation
Gentamicin (Garamycin)
Can be used in patients requiring parenteral therapy. Inhibits protein synthesis by irreversibly binding to bacterial 30S and 50S ribosomes.
Adult
Moderate infections: 1.5-1.8 mg/kg/dose parenterally; not to exceed 6 mg/kg/d
Dosing intervals based on CrCl:
>60 mL/min: q8h
40-60 mL/min: q12h
20-40 mL/min: q24h
10-20 mL/min: q48h
<10 mL/min: q72h
Pediatric
<5 years: 2.5 mg/kg/dose IV/IM q8h
>5 years: 1.5-2.5 mg/kg/dose IV/IM q8h
Potentiates effects of neuromuscular blockers; amphotericin B, cyclosporine, cephalosporins, and furosemide may increase risk of renal toxicity
Documented hypersensitivity
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
Potentially nephrotoxic; patients that have renal impairment, receive high doses, or receive drug over a long period are at increased risk for nephrotoxicity; ototoxicity; monitor levels to minimize risk of toxicity and to optimize therapy
Ciprofloxacin (Cipro)
Quinolone; must be used with caution in children. Only use when benefits outweigh potential complications and when patient's family understands potential risks.
Adult
250-750 mg PO q12h
Pediatric
<18 years: Not approved
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may interfere with GI absorption of fluoroquinolones, resulting in decreased serum levels; administer antacids 2-4 h before or after fluoroquinolone; may increase effects of anticoagulants; monitor PT; may increase nephrotoxic effect of cyclosporine; may reduce phenytoin serum levels, producing decrease in therapeutic effects; cimetidine may interfere with elimination of fluoroquinolones; probenecid may reduce ciprofloxacin renal clearance by 50% and increase serum concentration by 50%; digoxin serum levels may be increased when used concurrently with ciprofloxacin (monitor digoxin levels)
Documented hypersensitivity
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
Associated with damaged cartilage in immature animals; seizures have been reported; other neurologic adverse effects include light-headedness, hallucinations, tremors, restlessness, and confusion
More on Catscratch Disease |
| Overview: Catscratch Disease |
| Differential Diagnoses & Workup: Catscratch Disease |
 Treatment & Medication: Catscratch Disease |
| Follow-up: Catscratch Disease |
| Multimedia: Catscratch Disease |
| References |
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References
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Further Reading
Keywords
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