Relapsing Fever Treatment & Management

Updated: Mar 15, 2017
  • Author: Elina Bobkova, MD; Chief Editor: Michael Stuart Bronze, MD  more...
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Medical Care

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, 53]

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. [36, 54, 55] 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.

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]

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]

In children younger than 8 years and in pregnant or nursing women, 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. Antibiotic therapy can trigger a Jarisch-Herxheimer reaction, which is described in Complications. The reaction is more common in LBRF (about 80%) [30] but also occurs in TBRF (54% in one series). [30]

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.



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.