eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Ehrlichiosis: Treatment & Medication

Author: Nicholas John Bennett, MB, BCh, PhD, Fellow in Pediatric Infectious Disease, Department of Pediatrics, State University of New York Upstate Medical University
Coauthor(s): Joseph Domachowske, MD, Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York-Upstate Medical University; Walid Abuhammour, MD, FAAP, Associate Professor of Pediatrics, Michigan State University; Director of Pediatric Infectious Disease, Department of Pediatrics, Hurley Medical Center
Contributor Information and Disclosures

Updated: Jun 2, 2009

Treatment

Medical Care

Early treatment is critical. Consider the possibility of ehrlichiosis when patients have a febrile illness and history of recent tick exposure.

  • Doxycycline remains the drug of choice for persons with ehrlichiosis.
  • Current data recommend continuation of treatment until the patient has been afebrile for at least 3 days and for a minimum of 5-7 days.
  • Guidelines for the diagnosis and management of tick-borne diseases have been established by the Centers for Disease Control and Prevention (CDC).7

Consultations

  • Treat patients with ehrlichiosis in consultation with an infectious diseases specialist.

Medication

The American Academy of Pediatrics recommends doxycycline as first-line therapy for suspected or proven human granulocytic anaplasmosis (HGA) and human monocytic ehrlichiosis (HME).  Ordinarily, tetracyclines are not administered to children younger than 8 years; however, chloramphenicol is the alternative treatment option and is associated with aplastic anemia.  Additionally, oral chloramphenicol is no longer available in the United States. Chloramphenicol has also been associated with treatment failures and is inactive against A phagocytophilum in vitro .
Several case reports have detailed successful treatment of mild, non–life-threatening anaplasmosis (not ehrlichiosis) with rifampin in patients in whom doxycycline was contraindicated (eg, allergy, pregnancy).

Antibiotics

Doxycycline is considered the DOC for ehrlichiosis. Use rifampin only as an alternative treatment for mild anaplasmosis if doxycycline is contraindicated. For these indications, age younger than 8 years is not considered a contraindication for doxycycline.


Doxycycline (Bio-Tab, Vibramycin, Doxy)

Usually bacteriostatic. Inhibits protein synthesis by binding to 30S and 50S ribosomal subunits.

Adult

100 mg PO/IV bid

Pediatric

4.4 mg/kg/d PO/IV divided bid; not to exceed 200 mg/d

Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can increase hypoprothrombinemic effects of anticoagulants; can decrease effects of PO contraceptives, causing breakthrough bleeding and increased risk of pregnancy

Documented hypersensitivity; severe hepatic dysfunction; doxycycline is the only tetracycline that does not require a dose reduction in renal failure

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; consider drug serum level determinations in prolonged therapy; use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines


Rifampin (Rifadin)

Inhibits RNA synthesis in bacteria by binding to beta subunit of DNA-dependent RNA polymerase, which, in turn, blocks RNA transcription.

Adult

300 mg PO/IV bid; not to exceed 600 mg/d

Pediatric

10 mg/kg PO/IV bid; not to exceed 600 mg/d

Induces microsomal enzymes, which may decrease effects of acetaminophen, PO anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, PO contraceptives, corticosteroids, mexiletine, cyclosporine, digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin; blood pressure may increase with coadministration of enalapril; coadministration with isoniazid or pyrazinamide may result in higher rate of hepatotoxicity than with either agent alone (discontinue one or both agents if alterations in LFT findings occur)

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

Obtain CBC counts and baseline clinical chemistries prior to and throughout therapy; in liver disease, weigh benefits against risk of further liver damage; interruption of therapy and high-dose intermittent therapy are associated with thrombocytopenia that is reversible if therapy is discontinued as soon as purpura occurs; if treatment is continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur

More on Ehrlichiosis

Overview: Ehrlichiosis
Differential Diagnoses & Workup: Ehrlichiosis
Treatment & Medication: Ehrlichiosis
Follow-up: Ehrlichiosis
Multimedia: Ehrlichiosis
References
[ CLOSE WINDOW ]

References

  1. Schneider JG. Human ehrlichiosis: a case study. Clin Lab Sci. Winter 2009;22(1):3-8. [Medline].

  2. Ganguly S, Mukhopadhayay SK. Tick-borne ehrlichiosis infection in human beings. J Vector Borne Dis. Dec 2008;45(4):273-80. [Medline].

  3. Buller RS, Arens M, Hmiel SP, et al. Ehrlichia ewingii, a newly recognized agent of human ehrlichiosis. N Engl J Med. Jul 15 1999;341(3):148-55. [Medline].

  4. Anaplasma phagocytophilum transmitted through blood transfusion--Minnesota, 2007. MMWR Morb Mortal Wkly Rep. Oct 24 2008;57(42):1145-8. [Medline].

  5. McQuiston JH, Paddock CD, Holman RC, Childs JE. The human ehrlichioses in the United States. Emerg Infect Dis. Sep-Oct 1999;5(5):635-42. [Medline].

  6. Demma LJ, Holman RC, McQuiston JH, Krebs JW, Swerdlow DL. Human monocytic ehrlichiosis and human granulocytic anaplasmosis in the United States, 2001-2002. Ann N Y Acad Sci. Oct 2006;1078:118-9. [Medline].

  7. [Guideline] Chapman AS, Bakken JS, Folk SM, et al. Diagnosis and management of tickborne rickettsial diseases: Rocky Mountain spotted fever, ehrlichioses, and anaplasmosis--United States: a practical guide for physicians and other health-care and public health professionals. MMWR Recomm Rep. Mar 31 2006;55(RR-4):1-27. [Medline]. [Full Text].

  8. Bakken JS, Krueth J, Wilson-Nordskog C, et al. Clinical and laboratory characteristics of human granulocytic ehrlichiosis. JAMA. Jan 17 1996;275(3):199-205. [Medline].

  9. Committee on Infectious Diseases. Ehrlichiosis. In: Red Book. 2006:281-4.

  10. Dumler JS, Barbet AF, Bekker CP, et al. Reorganization of genera in the families Rickettsiaceae and Anaplasmataceae in the order Rickettsiales: unification of some species of Ehrlichia with Anaplasma, Cowdria with Ehrlichia and Ehrlichia with Neorickettsia, descriptions of six new species combinations and designation of Ehrlichia equi and 'HGE agent' as subjective synonyms of Ehrlichia phagocytophila. Int J Syst Evol Microbiol. Nov 2001;51(Pt 6):2145-65. [Medline].

  11. Dumler JS, Choi KS, Garcia-Garcia JC, et al. Human granulocytic anaplasmosis and Anaplasma phagocytophilum. Emerg Infect Dis. Dec 2005;11(12):1828-34. [Medline].

  12. Glushko GM. Human ehrlichiosis. Postgrad Med. Jun 1997;101(6):225-30. [Medline].

  13. Jacobs RF, Schutze GE. Ehrlichiosis in children. J Pediatr. Aug 1997;131(2):184-92. [Medline].

  14. Laudicina RJ, Hilger AE. Human ehrlichiosis: a case review. Clin Lab Sci. 1997;10(3):149-66.

  15. Ogden NH, Woldehiwet Z, Hart CA. Granulocytic ehrlichiosis: an emerging or rediscovered tick-borne disease?. J Med Microbiol. Jun 1998;47(6):475-82. [Medline].

  16. Schaffner W, Standaert SM. Ehrlichiosis--in pursuit of an emerging infection. N Engl J Med. Jan 25 1996;334(4):262-3. [Medline].

  17. Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. Nov 1 2006;43(9):1089-134. [Medline]. [Full Text].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

ehrlichiosis, human monocytic ehrlichiosis, HME, human granulocytic ehrlichiosis, HGE, human granulocytic anaplasmosis, HGA, tick-borne disease, Rickettsiae, Ehrlicia, Anaplasma, anaplasmosis, coccobacilli, Ehrlichia chaffeensis, Anaplasma phagocytophilum, human monocytic ehrlichiosis, HME, human granulocytic anaplasmosis, HGA, human granulocytic ehrlichiosis, HGE, Lyme disease, Ehrlichia phagocytophilum, Ehrlichia equi, Ehrlichia ewingii, Amblyomma americanum, Ixodes scapularis, Ixodes pacificus, Ixodes ricinus, Ixodes persulcatus, Rocky Mountain spotted fever, myalgia, arthralgia, malaise, photophobia

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Nicholas John Bennett, MB, BCh, PhD, Fellow in Pediatric Infectious Disease, Department of Pediatrics, State University of New York Upstate Medical University
Nicholas John Bennett, MB, BCh, PhD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Pediatrics
Disclosure: Nothing to disclose.

Coauthor(s)

Joseph Domachowske, MD, Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York-Upstate Medical University
Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Walid Abuhammour, MD, FAAP, Associate Professor of Pediatrics, Michigan State University; Director of Pediatric Infectious Disease, Department of Pediatrics, Hurley Medical Center
Walid Abuhammour, MD, FAAP is a member of the following medical societies: American Medical Association and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Medical Editor

Michael D Nissen, MBBS, BMedSc, FRACP, FRCPA, Associate Professor in Biomolecular, Biomedical Science & Health, Griffith University; Director of Infectious Diseases and Unit Head of Queensland Paediatric Infectious Laboratory, Sir Albert Sakzewski Viral Research Centre, Royal Children's Hospital
Michael D Nissen, MBBS, BMedSc, FRACP, FRCPA is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, Pediatric Infectious Diseases Society, Royal Australasian College of Physicians, and Royal College of Pathologists of Australasia
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Joseph Domachowske, MD, Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York-Upstate Medical University
Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Phi Beta Kappa
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.