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Pediatric Rocky Mountain Spotted Fever Medication

  • Author: Nicholas John Bennett, MBBCh, PhD, MA(Cantab), FAAP; Chief Editor: Russell W Steele, MD  more...
 
Updated: Oct 25, 2015
 

Medication Summary

The best outcomes in Rocky Mountain spotted fever (RMSF) are achieved when treatment is started within 4 days of symptom onset. Doxycycline is the antibiotic of choice.

Chloramphenicol was previously recommended for the treatment of children younger than 9 years. In national surveillance data, however, patients treated with chloramphenicol were more likely to die than those treated with a tetracycline. Chloramphenicol poses a risk of permanent aplastic anemia and should be avoided if at all possible.

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Antibiotic Agents

Class Summary

Tetracyclines are the drugs of choice. Although tetracyclines should not be routinely prescribed to children younger than 8 years, the benefits far exceed the risks in RMSF. Doxycycline is the agent of choice because the risk of dental staining is less with this agent than with other tetracyclines.

Doxycycline (Adoxa, Doxy 100, Vibramycin, Monodox)

 

Doxycycline is the drug of choice for RMSF. It is a broad-spectrum, synthetically derived bacteriostatic antibiotic in the tetracycline class. When given orally, it is almost completely absorbed.

It concentrates in bile and is excreted in urine and feces as a biologically active metabolite in high concentrations. This agent is the only tetracycline that does not need dosing adjustment in renal failure.

Doxycycline inhibits protein synthesis and, therefore, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. It may block dissociation of peptidyl transfer RNA (tRNA) from ribosomes, arresting RNA-dependent protein synthesis.

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Contributor Information and Disclosures
Author

Nicholas John Bennett, MBBCh, PhD, MA(Cantab), FAAP Assistant Professor of Pediatrics, Co-Director of Antimicrobial Stewardship, Medical Director, Division of Pediatric Infectious Diseases and Immunology, Connecticut Children's Medical Center

Nicholas John Bennett, MBBCh, PhD, MA(Cantab), FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics

Disclosure: Received research grant from: Cubist Pharmaceuticals, Durata Therapeutics, and Biota Pharmaceutical<br/>Received income in an amount equal to or greater than $250 from: HealthyCT insurance<br/>Medico legal consulting for: Various.

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, Phi Beta Kappa

Disclosure: Received research grant from: Pfizer;GlaxoSmithKline;AstraZeneca;Merck;American Academy of Pediatrics<br/>Received income in an amount equal to or greater than $250 from: Sanofi Pasteur;Astra Zeneca;Novartis<br/>Consulting fees for: Sanofi Pasteur; Novartis; Merck; Astra Zeneca.

Walid Abuhammour, MD, MBA, FAAP Professor of Pediatrics, Michigan State University College of Medicine; Director of Pediatric Infectious Disease, Department of Pediatrics, Al Jalila Children's Hospital

Walid Abuhammour, MD, MBA, FAAP is a member of the following medical societies: American Medical Association, Infectious Diseases Society of America, Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

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, Southern Medical Association

Disclosure: Nothing to disclose.

References
  1. McQuiston JH, Guerra MA, Watts MR, Lawaczeck E, Levy C, Nicholson WL, et al. Evidence of exposure to spotted fever group rickettsiae among Arizona dogs outside a previously documented outbreak area. Zoonoses Public Health. 2011 Mar. 58(2):85-92. [Medline].

  2. 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. 2006 Mar 31. 55(RR-4):1-27. [Medline]. [Full Text].

  3. Openshaw JJ, Swerdlow DL, Krebs JW, et al. Rocky mountain spotted fever in the United States, 2000-2007: interpreting contemporary increases in incidence. Am J Trop Med Hyg. 2010 Jul. 83(1):174-82. [Medline]. [Full Text].

  4. Centers for Disease Control and Prevention. Rocky Mountain Spotted Fever - Statistics and Epidemiology. Available at http://www.cdc.gov/rmsf/stats/. Accessed: January 27, 2013.

  5. Holman RC, McQuiston JH, Haberling DL, Cheek JE. Increasing incidence of Rocky Mountain spotted fever among the American Indian population in the United States. Am J Trop Med Hyg. 2009 Apr. 80(4):601-5. [Medline].

  6. Adjemian JZ, Krebs J, Mandel E, McQuiston J. Spatial clustering by disease severity among reported Rocky Mountain spotted fever cases in the United States, 2001-2005. Am J Trop Med Hyg. 2009 Jan. 80(1):72-7. [Medline].

  7. Folkema AM, Holman RC, McQuiston JH, Cheek JE. Trends in clinical diagnoses of Rocky Mountain spotted fever among American Indians, 2001-2008. Am J Trop Med Hyg. 2012 Jan. 86(1):152-8. [Medline]. [Full Text].

  8. McQuiston JH, Wiedeman C, Singleton J, Carpenter LR, McElroy K, Mosites E, et al. Inadequacy of IgM antibody tests for diagnosis of Rocky Mountain Spotted Fever. Am J Trop Med Hyg. 2014 Oct. 91 (4):767-70. [Medline].

  9. Maller VG, Agarwal AK, Choudhary AK. Diffusion imaging findings in Rocky Mountain spotted fever encephalitis: a case report. Emerg Radiol. 2012 Jan. 19(1):79-81. [Medline].

  10. Crapp S, Harrar D, Strother M, Wushensky C, Pruthi S. Rocky Mountain spotted fever: 'starry sky' appearance with diffusion-weighted imaging in a child. Pediatr Radiol. 2012 Apr. 42(4):499-502. [Medline].

  11. Centers for Disease Control and Prevention. Rocky Mountain Spotted Fever. Available at http://www.cdc.gov/rmsf/symptoms/index.html#treatment. Accessed: July 22, 2011.

  12. Todd SR, Dahlgren FS, Traeger MS, Beltrán-Aguilar ED, Marianos DW, Hamilton C, et al. No visible dental staining in children treated with doxycycline for suspected Rocky Mountain Spotted Fever. J Pediatr. 2015 May. 166 (5):1246-51. [Medline].

 
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Geographic distribution of Rocky Mountain spotted fever incidence in 2010, cases per million: Courtesy of the US Centers for Disease Control and Prevention.
Table 1. Human Disease Around the World Caused by Spotted Fever Group Rickettsiae.
Organism Disease or Presentation Geographic Location
Rickettsia rickettsii Rocky Mountain spotted fever North, Central and South America
Rickettsia conorii Mediterranean spotted fever, boutonneuse fever, Israeli spotted fever, Astrakhan fever, Indian tick typhus Europe, Asia, Africa, India, Israel, Sicily, Russia, Europe, Asia, Africa, India, Israel, Sicily, Russia
Rickettsia akari Rickettsialpox Worldwide
Rickettsia sibirica Siberian tick typhus, North Asian tick typhus Siberia, People's Republic of China, Mongolia, Europe
Rickettsia australis Queensland tick typhus Australia
Rickettsia honei Flinders Island spotted fever, Thai tick typhus Australia, South Eastern Asia
Rickettsia africae African tick-bite fever Sub Saharan Africa, Caribbean
Rickettsia japonica Japanese or Oriental spotted fever Japan
Rickettsia felis Cat flea rickettsiosis, flea borne typhus Worldwide
Rickettsia slovaca Necrosis, erythema, lymphadenopathy Europe
Rickettsia heilongjaiangensis Mild spotted fever China, Asian region of Russia
Rickettsia parkeri Mild spotted fever US
Table 2. Doxycycline Treatment for RMSF
  • Doxycycline is first-line treatment for both adults and children; antibiotics other than doxycycline increase the risk of death [11]
  • Dosage : for children < 45 kg (100 lb): 2.2 mg/kg body weight given twice a day
  • Dosage for adults: 100 mg every 12 hours
  • Treatment is most effective at preventing death if doxycycline is started within the first 5 days of symptoms; if treatment occurs within 5 days fever generally subsides within 24-72 hours
  • Patients should be treated for at least 3 days after the fever subsides and until there is evidence of clinical improvement; standard duration of treatment is 7-14 days - "Fever plus 3, at least a week"
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