eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Scrub Typhus: Treatment & Medication

Author: Aracelis D Fernandez, MD, FAAP, Attending Physician, Assistant Professor of Pediatrics, Assistant Professor of Immunology an, Department of Pediatrics, Children's Hospital at Albany Medical Center
Coauthor(s): Rosemary Johann-Liang, MD, Medical Officer, Infectious Diseases and Pediatrics, Division of Special Pathogens and Immunological Drug Products, Center for Drug Evaluation and Research, Food and Drug Administration
Contributor Information and Disclosures

Updated: Jun 29, 2009

Treatment

Medical Care

  • Treatment of scrub typhus must be initiated early in the course of the disease, based on presumptive diagnosis, to reduce morbidity and mortality. Doxycycline and chloramphenicol are both effective in the treatment of scrub typhus. Tetracycline products are generally not recommended for use in children younger than 8 years because of dental discoloration. However, because of the potential toxicities associated with chloramphenicol, its use may be warranted in children younger than 8 years. Monitor chloramphenicol levels during therapy.
  • Seven days of antibiotic treatment is usually effective.
  • Meticulous supportive management is necessary to abort progression to disseminated intravascular coagulation (DIC) or circulatory collapse in severe cases.
  • Rifampin and azithromycin have been used successfully in areas where scrub typhus is resistant to the conventional therapy.
  • In a small Korean trial in children, roxithromycin, a macrolide antibiotic, was as effective as doxycycline and chloramphenicol in the treatment of scrub typhus.
  • Further studies are needed to improve antibiotic treatment of severe and resistant scrub typhus, as well as to improve treatment in children and pregnant women.

Medication

Antibiotics

Tetracycline derivatives are the mainstays of scrub typhus treatment.11


Tetracycline (Sumycin)

Inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunit(s).

Adult

250-500 mg PO q6h

Pediatric

Higher end of 25-50 mg/kg/d PO divided q6h; not to exceed 2 g/d

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

Documented hypersensitivity; severe hepatic dysfunction

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 one-half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines


Doxycycline (Bio-Tab, Doxy, Vibra-Tabs)

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

Adult

100-200 mg PO bid

Pediatric

5 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; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of PO contraceptives, causing breakthrough bleeding and increased risk of pregnancy

Documented hypersensitivity; severe hepatic dysfunction

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 one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines


Chloramphenicol (Chloromycetin)

Binds to 50 S bacterial-ribosomal subunits and inhibits bacterial growth by inhibiting protein synthesis.
PO chloramphenicol is no longer available in the United States.
Monitor serum levels closely and adjust dose to achieve therapeutic concentrations (ie, peak 10-20 mcg/mL, trough 5-10 mcg/mL).

Adult

50-100 mg/kg/d PO/IV divided q6h

Pediatric

50-100 mg/kg/d PO/IV divided q6h; not to exceed 4 g/d; monitor serum levels closely

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

Do not use in pregnancy near term because of potential development of gray baby syndrome (ie, circulatory collapse, cyanosis, acidosis, coma, and possibly death)
Use only for indicated infections, or as prophylaxis for bacterial infections; serious and fatal blood dyscrasias (aplastic anemia, hypoplastic anemia, thrombocytopenia, granulocytopenia) can occur; evaluate baseline and perform periodic blood studies approximately every 2 d while in therapy; discontinue upon appearance of reticulocytopenia, leukopenia, thrombocytopenia, anemia, or findings attributable to chloramphenicol; adjust dose in liver or kidney dysfunction

More on Scrub Typhus

Overview: Scrub Typhus
Differential Diagnoses & Workup: Scrub Typhus
Treatment & Medication: Scrub Typhus
Follow-up: Scrub Typhus
Multimedia: Scrub Typhus
References
Further Reading
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References

  1. [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;55:1-27. [Medline].

  2. Suputtamongkol Y, Suttinont C, Niwatayakul K, et al. Epidemiology and clinical aspects of rickettsioses in Thailand. Ann N Y Acad Sci. May 2009;1166:172-9. [Medline].

  3. Hendershot EF, Sexton DJ. Scrub typhus and rickettsial diseases in international travelers: a review. Curr Infect Dis Rep. Jan 2009;11(1):66-72. [Medline].

  4. Matsumura Y, Shimizu T. [Case of imported scrub typhus contracted in Myanmar]. Kansenshogaku Zasshi. May 2009;83(3):256-60. [Medline].

  5. Liu Y, Feng D, Suo J, et al. Clinical characteristics of the autumn-winter type scrub typhus cases in south of Shandong province, northern China. BMC Infect Dis. Jun 4 2009;9(1):82. [Medline].

  6. McGready R, Blacksell SD, Luksameetanasan R, Wuthiekanun V, Jedsadapanpong W, Day NP, et al. First Report of an Orientia tsutsugamushi Type TA716-Related Scrub Typhus Infection in Thailand. Vector Borne Zoonotic Dis. Jun 3 2009;[Medline].

  7. Sharma PK, Ramakrishnan R, Hutin YJ, et al. Scrub typhus in Darjeeling, India: opportunities for simple, practical prevention measures. Trans R Soc Trop Med Hyg. Mar 13 2009;[Medline].

  8. Kramme S, An le V, Khoa ND, et al. Orientia tsutsugamushi bacteremia and cytokine levels in Vietnamese scrub typhus patients. J Clin Microbiol. Mar 2009;47(3):586-9. [Medline].

  9. Phetsouvanh R, Blacksell SD, Jenjaroen K, Day NP, Newton PN. Comparison of indirect immunofluorescence assays for diagnosis of scrub typhus and murine typhus using venous blood and finger prick filter paper blood spots. Am J Trop Med Hyg. May 2009;80(5):837-40. [Medline].

  10. Paris DH, Aukkanit N, Jenjaroen K, Blacksell SD, Day NP. A highly sensitive quantitative real-time PCR assay based on the groEL gene of contemporary Thai strains of Orientia tsutsugamushi. Clin Microbiol Infect. May 2009;15(5):488-95. [Medline].

  11. Tsai CC, Lay CJ, Wang CL, Ho YH, Wang LS, Chen LK. Levofloxacin versus tetracycline antibiotics for the treatment of scrub typhus. Int J Infect Dis. Jun 3 2009;[Medline].

  12. Baxter JD. The typhus group. Clin Dermatol. May-Jun 1996;14(3):271-8. [Medline].

  13. Edwards MS, Feigen RD. Rickettsial diseases. In: Textbook of Pediatric Infectious Diseases. Vol 2. 2004:2508-9.

  14. Jensenius M, Fournier PE, Raoult D. Rickettsioses and the international traveler. Clin Infect Dis. Nov 15 2004;39(10):1493-9. [Medline].

  15. Raoult D. Scrub typhus. In: Mandell, Douglas and Bennett's Principles and Practice of Infectious Diseases. Vol 2. 2005:2309-10.

  16. Seong SY, Choi MS, Kim IS. Orientia tsutsugamushi infection: overview and immune responses. Microbes Infect. Jan 2001;3(1):11-21. [Medline].

  17. Sharma PK, Ramakrishnan R, Hutin YJ, et al. Scrub typhus in Darjeeling, India: opportunities for simple, practical prevention measures. Trans R Soc Trop Med Hyg. Mar 13 2009;[Medline].

  18. Watt G, Parola P. Scrub typhus and tropical rickettsioses. Curr Opin Infect Dis. Oct 2003;16(5):429-36. [Medline].

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Keywords

scrub typhus, chigger fever, tsutsugamushi fever, tsutsugamushi disease, akamushi disease, flood fever, inundation fever, island disease, island fever, Japanese river fever, kedani fever, mite typhus, shimamushi disease tropical typhus, Rickettsia tsutsugamushi, R tsutsugamushi, Rickettsia orientalis, R orientalis, Oriental tsutsugamushi, O tsutsugamushi, HIV infection, adult respiratory distress syndrome, ARDS, disseminated intravascular coagulation, DIC, treatment, diagnosis

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Contributor Information and Disclosures

Author

Aracelis D Fernandez, MD, FAAP, Attending Physician, Assistant Professor of Pediatrics, Assistant Professor of Immunology an, Department of Pediatrics, Children's Hospital at Albany Medical Center
Disclosure: Nothing to disclose.

Coauthor(s)

Rosemary Johann-Liang, MD, Medical Officer, Infectious Diseases and Pediatrics, Division of Special Pathogens and Immunological Drug Products, Center for Drug Evaluation and Research, Food and Drug Administration
Rosemary Johann-Liang, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, and Infectious Diseases Society of America
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

 
 
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