eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Rickettsial Infection: Treatment & Medication

Author: Mobeen H Rathore, MD, CPE, FAAP, FIDSA, Chief of Division of Pediatric Infectious Diseases/Immunology, Associate Chairman of Department of Pediatrics, University of Florida College of Medicine at Jacksonville; Hospital Epidemiologist and Section Chief of Infectious Disease and Immunology, Wolfson Children's Hospital; Director of University of Florida Center for HIV/AIDS Research, Education and Service (UF CARES)
Coauthor(s): Nizar F Maraqa, MD, Assistant Professor of Pediatrics, Pediatric Infectious Diseases, University of Florida at Jacksonville
Contributor Information and Disclosures

Updated: May 11, 2009

Treatment

Medical Care

Specific therapy

Adequate antibiotic therapy initiated early in the first week of illness is highly effective and is associated with the best outcome. Fever usually subsides within 24-72 hours after starting antibiotic therapy. If fever fails to subside with the use of a suitable antibiotic, the diagnosis of rickettsial disease should be reconsidered. Treatment may be terminated 2-3 days after the patient is afebrile and at least 10 days of therapy has been given.22

Doxycycline is the drug of choice; it is preferred over other tetracyclines for treatment of rickettsial infections and, at such low dose and short duration, is rarely associated with staining of teeth in children younger than 8 years.23,8

Chloramphenicol may be used as an alternative. However, it is rarely used in the United States because of its potential bone marrow toxicity.

Recent data from Europe suggest that fluoroquinolones, such as ciprofloxacin and ofloxacin, may be effective in the treatment of certain rickettsioses.14,5 However quinolones, which are not FDA approved for use in children younger than 18 years, have been associated with clinical failures despite good in vitro activity.

Sulfonamides were found to have a harmful effect either by delaying the institution of proper antimicrobial therapy or by directly stimulating growth of the organisms. They are contraindicated in rickettsial infections.4,22

Supportive therapy

Thrombocytopenia, hypoalbuminemia, hypotension, and coagulation defects require supportive management. Hyponatremia is best managed with maintenance fluids or even modest fluid restriction. Whether or not steroids are helpful in shortening the febrile period in Rocky Mountain spotted fever (RMSF) is controversial.1

  • RMSF: Antibiotic treatment may be terminated 2-3 days after the patient is afebrile and at least 10 days of therapy has been given. Longer courses may be required in complicated illness.22
  • Rickettsialpox: Antibiotics are the mainstay of treatment. However, in infants and young children with mild illness, antibiotics may be withheld because the infection is self-limited.
  • Boutonneuse fever: Doxycycline remains the drug of first choice; however, the newer macrolide may be of interest.8 Improvement usually occurs within 48 hours of therapy. Duration of therapy has not been definitively established; however, recommendations state that antibiotic treatment should continue for 24 hours after fever has abated.
  • Louse-borne (epidemic) typhus: Treatment is analogous to that of RMSF. The use of insecticides and pediculicides (eg, lindane, crotamiton, malathion) can be highly effective in reducing louse infestation and may serve as important adjuncts to specific therapy in curtailing louse-borne typhus epidemics.
  • Brill-Zinsser disease (ie, relapsing louse-borne typhus): Treatment is analogous to that of RMSF.
  • Murine (endemic or flea-borne) typhus: A single dose of doxycycline is the treatment of choice for this disease. Other tetracyclines and chloramphenicol are also effective agents. The control of rat fleas with insecticides followed by control of rat populations with rodenticides is an important adjunct measure to combat the spread of this disease.
  • Tsutsugamushi disease (ie, scrub typhus): Antibiotic treatment with tetracyclines or chloramphenicol, similar to that of the spotted fever group, is recommended. However, sporadic short antibiotic courses of doxycycline or chloramphenicol may be required to prevent relapses.23
  • Q fever
    • Acute disease responds to tetracyclines or chloramphenicol. Fluoroquinolones and the newer macrolides (eg, azithromycin) have also been used successfully for treatment of acute infection. Generally, relapses are rare.5  
    • Chronic Q fever infections, on the other hand, require prolonged courses of antimicrobial therapy. In cases of endocarditis caused by chronic Q fever, combination therapy with hydroxychloroquine and doxycycline is the preferred treatment. Duration of therapy is 18-36 months depending on the serologic response. Several alternative combination regimens (eg, a fluoroquinolone with doxycycline or rifampin with doxycycline) have been proposed but not adequately studied yet.18,5

Consultations

  • Infectious disease subspecialists play a vital role in diagnosis confirmation, management, and exclusion of other illnesses on the differential.
  • Other subspecialists may be consulted, depending on the course of the illness (eg, cardiologist, pulmonologist, nephrologist, intensivist).

Diet

  • No dietary restriction is required in uncomplicated rickettsial infections.

Medication

Adequate antibiotic therapy initiated early is highly effective and associated with the best outcomes.

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.


Doxycycline (Bio-Tab, Doryx, Vibramycin)

DOC. Inhibits protein synthesis and, thus, bacterial growth by binding to 30S and, possibly, 50S ribosomal subunits of susceptible bacteria.

Adult

200 mg/d PO/IV divided bid

Pediatric

<45 kg: 5 mg/kg/d PO/IV divided bid; not to exceed 200 mg/d
>45 kg: Administer as in adults
Tetracyclines are not approved for and generally should not be given to children <8 y; however, experts agree that doxycycline as the drug of choice in these patients is justified and should be considered because it is highly effective and carries a low risk of dental staining at the recommended dose and duration

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 disfunction

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


Chloramphenicol (Chloromycetin)

Binds to 50S bacterial-ribosomal subunits and inhibits bacterial growth by inhibiting protein synthesis. Effective against gram-negative and gram-positive bacteria. It may not be as effective against rickettsia as doxycycline.
If administered on an outpatient basis, 30% of patients subsequently require hospitalization, compared with 11% of patients treated with tetracyclines.

Adult

50 mg/kg/d IV divided q6h; not to exceed 4 g/d

Pediatric

100 mg/kg/d IV divided qid; switch to 50-75 mg/kg PO qid when patient improves; not to exceed 4 g/d

Administered 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 chloramphenicol levels, presumably through hepatic enzyme induction; may increase effects of anticoagulants; may increase serum hydantoin levels, possibly resulting in toxicity; chloramphenicol levels may be increased or decreased

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

Use only for indicated infections, or as prophylaxis for bacterial infections; serious and fatal blood dyscrasias (eg, aplastic anemia, hypoplastic anemia, thrombocytopenia, granulocytopenia) can occur; evaluate baseline and perform periodic blood studies approximately every 2 d while in therapy; discontinue on appearance of 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)

More on Rickettsial Infection

Overview: Rickettsial Infection
Differential Diagnoses & Workup: Rickettsial Infection
Treatment & Medication: Rickettsial Infection
Follow-up: Rickettsial Infection
Multimedia: Rickettsial Infection
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Walker DH. Rickettsiae and rickettsial infections: the current state of knowledge. Clin Infect Dis. Jul 15 2007;45 Suppl 1:S39-44. [Medline].

  2. Jensenius M, Fournier P, Raoult D. Rickettsioses and the international traveler. Clin Infect Dis. 2004;34(10):1493-9. [Medline].

  3. Center of Disease Control and Prevention (CDC). Rickettsial Diseases. Infectious Disease Information. Available at http://www.cdc.gov/ncidod/dvrd/branch/vrzb.htm.

  4. Edwards MS, Feigin RD. Rickettsial diseases. In: Feigin RD, Cherry JD, Demmler GJ, Kaplan SL, eds. Textbook of Pediatric Infectious Diseases. 5th ed. WB Saunders Co; 2004:2497-2515/Chapter 195.

  5. Tissot-Dupont H, Raoult D. Q Fever. Infect Dis Clin N Am. Sept 2008;22:505-514. [Medline].

  6. Walker DH. Rickettsiae. In: Baron S, ed. Medical Microbiology. 4th ed. University of Texas Medical Branch; 1996:[Full Text].

  7. Azad AF. Pathogenic Rickettsiae as Bioterrorism Agents. Clin Infect Dis. Jul 15 2007;45 Suppl 1:S52-55. [Medline].

  8. Rovery C, Raoult D. Meditteranean Spotted Fever. Infect Dis Clin N Am. Sept 2008;22:515-530. [Medline].

  9. Dumler JS, Walker DH. Rocky Mountain spotted fever--changing ecology and persisting virulence. N Engl J Med. Aug 11 2005;353(6):551-3. [Medline].

  10. Graf PC, Chertien JP, Ung L, et al. Prevalence of serpositivity to spotted fever group rickettsiae and Anaplasma phagocytophilum in a large, dempgraphically diverse US sample. Clin Infect Dis. Jan 2008;46 (1):70-77. [Medline].

  11. Cowan G. Rickettsial diseases: the typhus group of fevers--a review. Postgrad Med J. May 2000;76(895):269-72. [Medline].

  12. Marshall GS. Rickettsia typhi seroprevalence among children in the Southeast United States. Tick-Borne Infections in Children Study (TICKS) Group. Pediatr Infect Dis J. Nov 2000;19(11):1103-4. [Medline].

  13. Fergie JE, Purcell K, Wanat D. Murine Typhus in South Texas children. Pediatr Infect Dis J. 2000;19(6):535-38. [Medline].

  14. Walker DH, Dumler JS. Emerging and reemerging rickettsial diseases. N Engl J Med. Dec 15 1994;331(24):1651-2. [Medline].

  15. Abramson JS, Givner LB. Rocky Mountain spotted fever. Pediatr Infect Dis J. Jun 1999;18(6):539-40. [Medline].

  16. Parola P, Davoust B, Raoult D. Tick- and flea-borne rickettsial emerging zoonoses. Vet Res. May-Jun 2005;36:469-492. [Medline].

  17. Ruiz-Contreras J, Gonzalez Montero R, Ramos Amador JT, et al. Q fever in children. Am J Dis Child. Mar 1993;147(3):300-2. [Medline].

  18. Nourse C, Allworth A, Jones A, et al. Three cases of Q fever osteomyelitis in children and a review of the literature. Clin Infect Dis. Oct 1 2004;39(7):e61-6. [Medline].

  19. Sexton DJ, Corey GR. Rocky Mountain "spotless" and "almost spotless" fever: a wolf in sheep's clothing. Clin Infect Dis. Sep 1992;15(3):439-48. [Medline].

  20. Demma LJ, Traeger MS, Nicholson et al. Rocky Mountain spotted fever from an unexpected tick vector in Arizona. N Engl J Med. Aug 11 2005;353(6):587-94. [Medline].

  21. Raoult D, Paddock CD. Rickettsia parkeri infection and other spotted fevers in the United States. N Eng J Med. 2005;353:626-7. [Medline].

  22. Raoult D, Drancourt M. Antimicrobial therapy of rickettsial diseases. Antimicrob Agents Chemother. Dec 1991;35(12):2457-62. [Medline].

  23. Purvis JJ, Edwards MS. Doxycycline use for rickettsial disease in pediatric patients. Pediatr Infect Dis J. Sep 2000;19(9):871-4. [Medline].

  24. Richards AL. Rickettsial Vaccines: the old and the new. Expert Rev Vaccines. October 2004;3:541-555. [Medline].

  25. 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].

  26. Fournier PE, Gouriet F, Brouqui P. Lymphangitis-associated rickettsiosis, a new rickettsiosis caused by Rickettsia sibirica mongolotimonae: seven new cases and review of the literature. Clin Infect Dis. May 15 2005;40(10):1435-44. [Medline].

  27. Jensenius M, Fournier P, Kelly P. African tick bite fever. Lancet Infect Dis. 2003;3(9):557-64. [Medline].

  28. Spach DH, Liles WC, Campbell GL, et al. Tick-borne diseases in the United States. N Engl J Med. Sep 23 1993;329(13):936-47. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

Rocky Mountain spotted fever, RMSF, rickettsialpox, boutonneuse fever, Mediterranean spotted fever, Kenya tick-bite fever, African tick typhus, India tick typhus, Israeli spotted fever, Marseille fever, epidemic louse-borne typhus, endemic murine typhus, Tsutsugamushi disease, scrub typhus, Q fever, Brill-Zinsser disease, relapsing louse-borne typhus, rickettsial infection, Rickettsiae, Rickettsia, rickettsialpox, catscratch disease, trench fever, hypoalbuminemia, osteomyelitis, chronic hepatitis, chronic vascular infection, endocarditis, pericarditis, myocarditis, treatment, diagnosis, atelectasis, pulmonary edema

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Mobeen H Rathore, MD, CPE, FAAP, FIDSA, Chief of Division of Pediatric Infectious Diseases/Immunology, Associate Chairman of Department of Pediatrics, University of Florida College of Medicine at Jacksonville; Hospital Epidemiologist and Section Chief of Infectious Disease and Immunology, Wolfson Children's Hospital; Director of University of Florida Center for HIV/AIDS Research, Education and Service (UF CARES)
Mobeen H Rathore, MD, CPE, FAAP, FIDSA is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, European Society for Paediatric Infectious Diseases, Florida Medical Association, Florida Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Society for Healthcare Epidemiology of America, Society for Pediatric Research, Southern Medical Association, and Southern Society for Pediatric Research
Disclosure: Nothing to disclose.

Coauthor(s)

Nizar F Maraqa, MD, Assistant Professor of Pediatrics, Pediatric Infectious Diseases, University of Florida at Jacksonville
Nizar F Maraqa, MD is a member of the following medical societies: American Academy of Pediatrics, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Medical Editor

José Rafael Romero, MD, Director of Pediatric Infectious Diseases Fellowship Program, Associate Professor, Department of Pediatrics, Combined Division of Pediatric Infectious Diseases, Creighton University/University of Nebraska Medical Center
José Rafael Romero, MD is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, New York Academy of Sciences, and Pediatric Infectious Diseases Society
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

Larry I Lutwick, MD, Professor of Medicine, State University of New York, Downstate Medical School; Director, Infectious Diseases, Veterans Affairs New York Harbor Health Care System, Brooklyn Campus
Larry I Lutwick, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
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.