Relapsing Fever Treatment & Management

Updated: Oct 13, 2021
  • Author: Geneva E Guarin, MD, MBA; Chief Editor: Michael Stuart Bronze, MD  more...
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Medical Care

All patients diagnosed with relapsing fever should promptly receive antimicrobial therapy.

For decades, penicillins and tetracyclines have been the treatment of choice in relapsing fever. In vitro, Borrelia species are also susceptible to cephalosporins, macrolides, and chloramphenicol, although less data are available on these antibiotics. [30, 21] Borrelia species are relatively resistant to fluoroquinolones, sulfa drugs, rifampin, aminoglycosides, and metronidazole.

The efficacy of treatment can be demonstrated by noting clearance of spirochetes in the blood, usually occurring within 8 hours of administration of an effective antibiotic. [30, 62]

Without neurologic involvement:

In adults with louse-borne relapsing fever (LBRF), oral treatment consists of a single dose of tetracycline 500 mg, doxycycline 200 mg, or, when tetracyclines are contraindicated, erythromycin 500 mg.

Treatment of tickborne relapsing fever (TBRF) is the same as that for LBRF, except the treatment duration is 7-10 days owing to reported relapses of 20% or greater after single-dose treatment. [40, 63, 64] In oral treatment for TBRF, tetracycline 500 mg every 6 hours, doxycycline 100 mg twice daily, or, if tetracyclines are contraindicated, erythromycin 500 mg every 6 hours, can be used. Azithromycin is also an alternative macrolide that can be given.

In adults, intravenous therapy with doxycycline, erythromycin, tetracycline, or procaine penicillin G should be used when oral therapy is not tolerated. [2]

Procaine penicillin G [2] may be administered at a single dose of 600,000 IU in adult patients with LBRF or 600,000 IU daily in patients with TBRF. [2]

With neurologic involvement:

For TBRF with neurologic involvement, penicillin G 3 million units IV every 4 hours or ceftriaxone 2 g IV daily (or 1 g IV twice daily) are likely to work well, given that these regimens are efficacious for Lyme disease. [5]  

Pregnant women and young children:

In children younger than 8 years, erythromycin 12.5 mg/kg is preferred. [2] Older children can also take oral tetracycline 12.5 mg/kg, oral doxycycline 5 mg/kg, or intramuscular penicillin G procaine 200,000-400,000 units. There has been no serious adverse event associated with doxycyline use in pregnant women and children < 8 years of age. However, the risk is increased with concomitant use of other tetracyclines. Therefore, if neither a beta-lactam nor doxycyline is applicable, a macrolide is preferred.

Intravenous penicillin or a beta-lactam should be provided for 14 days regardless of CNS disease as there is a higher risk of mortality for both the mother and the fetus.

No treatment is currently defined for recently discovered B miyamotoi infection, and treatment as for Lyme disease is recommended, including treatment as for CNS Lyme disease in patients with neurologic B miyamotoi infection manifestations.

Antibiotic therapy can trigger a Jarisch-Herxheimer reaction. The reaction is more common in LBRF (about 80%) [30] but also occurs in TBRF (54% in one series). [30]



Consultation with an infectious disease specialist may be helpful.

A critical care specialist and/or pulmonologist should be consulted for patients with relapsing fever who are severely ill.



Activity is as tolerated in patients with relapsing fever.