Trench Fever Treatment & Management

Updated: Aug 17, 2016
  • Author: Sarah Perloff, DO, FACP; Chief Editor: Mark R Wallace, MD, FACP, FIDSA  more...
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Treatment

Approach Considerations

No well-designed, double-blinded, controlled trials have documented the best antibiotic regimen for B quintana infection and its associated syndromes (including trench fever) in immunocompetent patients. Most therapeutic recommendations are based on anecdotal clinical experience.

Pregnancy affects the appropriate choice of antibiotics for treatment. Teratogenic and congenital effects of maternal infection are unknown, as is the impact on pregnancy.

Initial management of severe Bartonella infections, including trench fever and urban trench fever, may require inpatient management. Generally, the consolidation phase of treatment can be provided on an outpatient basis.

An infectious disease specialist may be consulted for help with diagnosis and treatment. A microbiology laboratory may be consulted for help with blood and tissue specimen handling to ensure optimal culture, serologic, and PCR-genomic testing.

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Pharmacologic Therapy

In the laboratory, B quintana appears to be sensitive to advanced-generation beta-lactams, chloramphenicol, macrolides, tetracyclines, fluoroquinolones (though not ciprofloxacin), aminoglycosides, rifampin, and trimethoprim-sulfamethoxazole. [14, 48, 49]

Microbiologic susceptibility studies may not accurately predict clinical efficacy, in that B quintana seems to respond clinically to bacteriostatic agents such as doxycycline, erythromycin, and azithromycin. [23] Only gentamicin is bactericidal in vitro. [50] Because gentamicin does not achieve bactericidal levels within human erythrocytes, it is not believed to be optimal for monotherapy, but it is regularly used in combination with doxycycline.

For treatment of serious or complicated infections, it is critical to use combination therapy with two agents known to exhibit good in vitro activity against B quintana. [48] Based on reports of successful treatment in immunocompromised patients, which are mostly anecdotal, longer treatment regimens in conjunction with close clinical and microbiologic follow-up is recommended.

The following are current recommendations for each of the identified clinical syndromes associated with B quintana in immunocompetent patients:

  • Trench fever/urban trench fever – For uncomplicated disease, doxycycline 100 mg orally (PO) twice daily for 28 days and gentamicin 3 mg/kg/day intravenously (IV) for 14 days [48] ; macrolides and ceftriaxone are also effective [9, 23, 13]
  • Chronic B quintana bacteremia – Doxycycline 100 mg PO twice daily for 28 days and gentamicin 3 mg/kg/day IV for 14 days [51, 48] ; in some cases, longer therapy (up to 4 years) may be required [14] ; serial cultures demonstrating eradication of the bacteremia are pivotal in determining duration of therapy
  • Chronic lymphadenopathy – Erythromycin 500 mg PO 4 times daily for 3 months (first-line therapy) or doxycycline 100 mg PO twice daily for 3 months (alternative) [48, 9] ; in difficult cases, gentamicin 3 mg/kg/day IV for 14 days can be added
  • Bacillary angiomatosis – Erythromycin 500 mg PO 4 times daily for 3 months (first-line therapy) or doxycycline 100 mg PO twice daily for 3 months (alternative) [48] ; in refractory cases, gentamicin 3 mg/kg/day IV for 14 days can be added [9] ; fluoroquinolones and ceftriaxone may also be considered
  • B quintana endocarditis – Doxycycline 100 mg PO twice daily for 6 weeks plus gentamicin 3 mg/kg/day IV for 14 days [48] ; if culture results are negative, ceftriaxone should be added; however, a recent meta-analysis did not find this superior to other combinations [52] ; most patients require valvular heart surgery [41, 42]
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Surgical Intervention

Surgical biopsy may be used when necessary to establish a definitive diagnosis of B quintana endocarditis, lymphadenitis, or bacillary angiomatosis.

In addition to numerous descriptions of small numbers of patients with B quintana endocarditis, 2 large studies (both performed by the same group of investigators) have described the treatment and outcomes of the disease. [41, 42] The findings of these studies suggested that, in most cases of B quintana endocarditis, valvular cardiac surgery is required.

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Diet and Activity

No dietary restrictions are necessary in patients with Bartonella infection, including trench fever and urban trench fever.

No activity restrictions are necessary unless a patient has cardiac failure due to Bartonella endocarditis or its complications. Patients should take steps to improve their hygiene and living conditions. Individuals should avoid donating blood or tissue if they are at risk for Bartonella infection.

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Prevention

B quintana infection can be prevented via avoidance or rapid treatment of lice infestations, as follows: [14, 53, 54]

  • Providing facilities for bathing
  • Providing facilities for laundry
  • Insecticide application to or frequent boiling of bedding in shelters
  • Ivermectin treatment for lice infestation
  • Prompt diagnosis and treatment of ​B quintana infection to decrease the reservoir for this pathogen
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