Cat Scratch Disease (Cat Scratch Fever) Treatment & Management

Updated: Jul 24, 2017
  • Author: Stephen J Nervi, MD; Chief Editor: Michael Stuart Bronze, MD  more...
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Treatment

Approach Considerations

Controlled studies on treatment of catscratch disease (CSD) are lacking. Thus, treatment recommendations are based on case reports, reviews, a single controlled trial, and anecdotal data. Practice guidelines for the diagnosis and management of skin and soft-tissue infections, including CSD, have been established. [55]

For most patients with mild or moderate CSD, only conservative symptomatic treatment is recommended because the disease is self-limited. Administer antipyretics and analgesics as needed. Local heat may be applied to the involved lymph nodes.

Occasionally, lymph node aspiration is indicated for pain relief in patients with tender, fluctuant nodes. Use of antibiotics is controversial and not indicated for typical CSD in immunocompetent patients.

The role of corticosteroids in atypical CSD is somewhat controversial. Patients with neuroretinitis, encephalopathy with or without hemiplegia, and acute solid organ transplant rejection [56] have all been treated successfully with a combination of appropriate antibiotics and steroid therapy.

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Antibiotic Treatment

Antibiotics are not indicated in most cases of CSD, but they may be considered for severe or systemic disease. Reduction of lymph node size has been demonstrated with a 5-day course of azithromycin [57] and may be considered in patients with severe, painful lymphadenopathy; however, no reduction in the duration of symptoms has been shown. Immunocompromised patients should be treated with antibiotics because they are particularly susceptible to systemic disease and bacteremia

Margileth et al reported the results of therapy for catscratch antigen–proven CSD with 18 different antimicrobials in 268 adult and pediatric patients. [58] They concluded that the following 4 antibiotics were the most effective for patients with severe CSD:

  • Rifampin - Efficacy of 87%

  • Ciprofloxacin - Efficacy of 84%

  • Gentamicin intramuscularly - Efficacy of 73%

  • Trimethoprim/sulfamethoxazole (TMP-SMZ) - Efficacy of 58%

These agents were considered moderately to highly effective, producing reduction or resolution of lymphadenopathy, a declining erythrocyte sedimentation rate, and decreased inflammatory and constitutional symptoms within 3-10 days. Severe disease was defined as persistent high fever (>103.1°F [>39.5˚C]) with severe systemic signs (eg, malaise, fatigue, blindness, headache) and lymphadenitis.

A prospective, randomized, double-blind, placebo-controlled study by Bass et al showed that azithromycin administered for 5 days decreased lymph node volume as measured by ultrasonography within the first month of treatment. No other differences in clinical outcome were noted. [57] Musso et al [59] found that aminoglycosides were bactericidal and Ives et al [60] showed that clarithromycin and azithromycin were efficacious in CSD. (See Table 3, below.)

Table 3. Response to Medications (Open Table in a new window)

Ciprofloxacin

500 PO bid

Case Report

5 adults

"Dramatic improvement" in a few days; defined as resolution of symptoms (ie, malaise and pain)

Holley [61]

Gentamicin

5 mg/kg/d IV/IM

Case Report

3 febrile children; 2 with hepatitis, 1 with painful regional lymphadenopathy

Resolution of fever and systemic symptoms in 1-2 days

Bogue et al [62]

TMP-SMZ

6-8 mg TMP/kg/d PO

Uncontrolled retrospective study

60 patients with prolonged fever and systemic symptoms

58% effective, 7-day course (see above)

Margileth [41]

Rifampin 10-20 mg/kg/d PO/IV

Uncontrolled retrospective study

60 patients with prolonged fever and systemic symptoms

87% effective, 7- to 14-day course (see above)

Margileth [58]

Azithromycin

500 mg PO qd for 1 day, then 250 mg PO qd for 4 days

Prospective placebo-controlled, double-blind study

29 patients

80% of lymph node volume (as measured by ultrasonography) resolved in 30 days in 7 of 15 patients on azithromycin vs 1 of 15 control patients

Bass et al [57]

Although data are lacking, patients with catscratch disease who are treated should receive treatment for 10-14 days. Immunocompromised patients may require much longer courses of therapy. No specific dose recommendations are available for treating CSD.

Somewhat paradoxically, patients with AIDS and bacillary angiomatosis-peliosis frequently respond to a variety of commonly used antibiotics. Response to erythromycin, isoniazid, rifampin, doxycycline, and ethambutol is reported by Koehler et al. [63, 64] If an immunocompromised patient has treatment relapse, then prolonged treatment (4-6 mo) is recommended, although this is based on anecdotal data.

Bartonella henselae is generally resistant to penicillin, amoxicillin, and nafcillin.

Patients with neurologic bacillary angiomatosis or ocular manifestations have improved with antibiotic therapy and supportive care or with supportive care alone. In patients with thoracic and/or pulmonary disease, especially in association with prolonged fever and systemic symptoms, a trial of oral TMP-SMZ, ciprofloxacin, or azithromycin 2-3 times daily for 7-21 days is recommended. In the rare case of a severely ill patient, intramuscular gentamicin 5 mg/kg/d may be effective within 72 hours; continue treatment for 6-8 weeks.

Normal doses of rifampin are 10-20 mg/kg/d orally every 12-24 hours, not to exceed 600 mg/d. Rifampin can cause hepatitis, particularly with underlying liver damage. Gastrointestinal, hematologic, and neurologic adverse effects are reported.

Importantly, because of the potential risk of arthropathy, caution should be used if considering the use of fluoroquinolones in patients younger than 18 years. Ciprofloxacin is not approved for administration in children. Additional adverse effects include gastrointestinal symptoms, dizziness, rash, seizures, headache, confusion, and tremors.

TMP-SMZ doses can include 8-12 mg/kg/d orally of TMP and 40-60 mg/kg/d orally of SMX every 12 hours. TMP-SMZ can cause rashes and, occasionally, Stevens-Johnson syndrome. Anemia and neutropenia may occur, and a mild decrease in platelet count is common.

The dose of intravenous gentamicin is 3-7.5 mg/kg/d orally every 8 hours. Serious toxic effects from these drugs are not common. Gentamicin may cause nephrotoxicity and ototoxicity. Aminoglycoside therapy is recommended for endocarditis.

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Treatment of Lymph Node Suppuration

If suppuration occurs, lymph node aspiration may be required. Aspiration of suppurating nodes is both a diagnostic and therapeutic procedure. Repeated aspirations may be performed if pus reaccumulates and pain recurs.

Treat recurrence of suppuration by incision and drainage. Although incision and drainage has been discouraged because it leaves a scar and may result in a draining fistula, the risk of fistulous sinus tract formation is small. This has been reported only in cases of atypical mycobacterial lymphadenopathy mistaken for CSD.

Surgical excision of an enlarged node is indicated when the diagnosis is in question or when repeated aspirations fail to relieve the patient's pain. Excision of a persistent ocular granuloma may be required.

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Follow-up

Immunocompetent patients and immunocompromised patients without evidence of systemic disease may be followed on an outpatient basis. Depending on severity, immunocompromised patients or patients with atypical manifestations of CSD may require hospitalization. If admission is required, frequent monitoring of the adenitis is indicated to evaluate for suppurative complications.

Outpatients should be instructed to return for a follow-up evaluation to ensure resolution of lymphadenopathy in 2-4 months. Patients should return to care sooner if their condition worsens or the lymph node starts to suppurate. Closely follow up patients for 6 months or until the lymphadenopathy resolves.

Neurologic complications can occur up to 6 weeks after inoculation. Instruct parents to seek medical attention if they notice any abnormal behavior in their children.

If the lymphadenitis does not resolve or if it progressively enlarges, surgical biopsy may be indicated to rule out neoplastic causes and to definitively diagnose catscratch disease.

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Deterrence/Prevention

Pet quarantine, disposal, or euthanasia is unnecessary. The ability of the animal to transmit the organism is transient.

Although doxycycline treatment of cats is associated with decreased B henselae bacteremia, this treatment has not been shown to reduce the risk of cat-to-human transmission.

The natural history of feline infection and infectivity remains unknown. Feline B henselae bacteremia has been reported to last from weeks to months, with 100-fold fluctuations in bacteremic levels and intermittent negative cultures.

Given the established link between flea infection and B henselae transmission, common sense measures seem prudent (eg, avoiding stray cats, keeping pets free of fleas).

Children should be taught how to handle pets gently. Any scratch or bite, especially from a kitten, should be brought to the attention of parents and carefully followed up.

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Consultations

Emergent consultation is not usually required for those with catscratch disease. Consider emergent or outpatient consultation in cases of diagnostic uncertainty or with specific organ system involvement as indicated.

Consultation with an infectious disease specialist should be sought in cases of atypical catscratch disease or in cases of catscratch disease in immunocompromised patients. Consultation with a neurologist is indicated for patients with CNS involvement, and evaluation with an ophthalmologist may be needed in patients with any visual changes.

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