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Pediatric Rocky Mountain Spotted Fever Treatment & Management

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

Approach Considerations

Early treatment is critical to the outcome in Rocky Mountain spotted fever (RMSF) and must be started on the basis of clinical diagnosis.[2] Consider the possibility of RMSF and promptly begin antibiotic treatment in any patient with potential tick exposure who develops fever, myalgia, or headache, even if they do not have a rash.

Never delay treatment while awaiting a confirmatory laboratory diagnosis or the development of a rash. The best outcomes are achieved when treatment is started within 4 days of symptom onset, and the classic petechial rash may not appear until day 6.

Doxycycline

Doxycycline is considered to be first line treatment for both adults and children and should be started as soon as RMSF is suspected.[11] The use of any other antibiotics has been associated with a higher risk of death (see Table 2, below).

Doxycycline treatment is most effective at preventing death if it is begun within the first 5 days after symptoms begin. As a result doxycycline treatment should be started before the return of lab results and before manifestation of severe symptoms, such as petechiae. If the patient is treated within the first 5 days of disease, fever generally subsides within 24-72 hours.[11]

The recommended dosage of doxycycline is 2.2 mg/kg body weight twice daily for children less than 45 kg (100 lb). For adults, the dosage is 100 mg every 12 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.

The recommended dosage of doxycycline for RMSF has not been shown to cause staining of permanent teeth.[12]

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. Staining of teeth caused by one or more courses of tetracyclines (particularly doxycycline) is negligible.

Some authors have advocated the use of adjunctive corticosteroids, but the specific therapeutic benefits of these drugs are not known. Physicians should be aware that sulfonamide treatment given empirically in a febrile child can worsen Rocky Mountain spotted fever.

Other supportive measures (eg, intravenous administration of fluids, oxygenation, correction of electrolyte impairments, management of disseminated intravascular coagulation) should be provided according to the patient's clinical situation.

Patients with Rocky Mountain spotted fever should be treated in consultation with an infectious disease specialist.

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Deterrence and Prevention

Avoidance of tick-infested areas is the first line of defense against Rocky Mountain spotted fever. If tick-infested areas cannot be avoided, wearing light-colored shirts and trousers that fit tightly around the waist and ankles can minimize the risk of being bitten.

Exposed areas of the skin should be covered with insect repellents containing N -N -diethyl-M -toluamide (DEET). In children, insect repellents should be used carefully on exposed skin. Application to the face and hands should be avoided.

After people leave an endemic area, they should inspect their bodies for attached ticks, with particular attention on areas containing hair.

If ticks are found, any of several commercial removal devices should be used if possible. Otherwise, ticks should be removed by grasping them with fine tweezers at the point of attachment and by pulling them out slowly and steadily. The aim is to remove the tick's mouthparts from the site of insertion without damaging the body of the tick.

After the tick is removed, the skin should be disinfected. Check to make sure that the head of the tick is not still embedded.

Some have recommended keeping the removed tick in a jar along with a dampened paper towel in the refrigerator for a month. This way, if the person later develops symptoms, the tick may be used to help identify what (if any) infection it may have transmitted.

Burning the tick, smothering it in alcohol or petroleum jelly (or another substance), or twisting or rubbing it off is not recommended. These methods have not been shown to decrease the time the tick remains embedded. In addition, they may pose of risk breaking the body of the tick open and releasing bacteria that were otherwise contained within it.

After a tick bite occurs, use of antimicrobial prophylaxis has no role in the prevention of Rocky Mountain spotted fever.

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Table: Specific Recommended Treatment

Table 2. Doxycycline Treatment for RMSF (Open Table in a new window)

  • 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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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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