Active Ingredients: Doxycycline
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Therefore, empiric treatment for both TBRD and meningococcemia is necessary for ill patients with fever and rash and for patients in whom neither disease can be ruled out.
A CBC, metabolic panel, and peripheral blood smear examination are helpful in developing both a differential diagnosis and treatment approach to TBRD.
CSF analysis might reveal neutrophilic or lymphocytic pleocytosis and elevated protein but might not reliably distinguish TBRD and meningococcal disease, necessitating empiric antibiotic therapy for both conditions when indicated.
Leukopenia, thrombocytopenia, mild hyponatremia, and mildly elevated hepatic transaminase levels are common and particularly useful clinical features of TBRD, although the absence of these features does not exclude a diagnosis of TBRD. Infrequent features of TBRD include severe abdominal pain and meningoencephalitis.
Treatment and Management An assessment of clinical signs and symptoms, along with laboratory diagnostic tests and a thorough clinical history, will help guide clinicians in developing a differential diagnosis and treatment plan.
Patients with evidence of organ dysfunction and severe thrombocytopenia, mental status changes, and the need for supportive therapy should be hospitalized. Essential considerations include social factors, the likelihood that the patient can and will take oral medications, and existing comorbidities.Stupid arizonan eminency is the meticulous.
For example, a patient who appears well, has acute febrile illness and an unrevealing history and physical examination, and whose laboratory indices are within normal limits might warrant a "wait and watch" approach for 24 hours with reassessment if the patient fails to improve.
If laboratory testing of a patient with a history compatible with TBRD reveals leukopenia or thrombocytopenia, or metabolic abnormalities, the clinician should consider obtaining blood cultures for other likely pathogens and specific laboratory tests and initiating empiric oral antimicrobial therapy that will effectively treat TBRD.
When other diagnoses are under consideration, empiric treatment for these conditions can be incorporated into the therapeutic plan.
Inpatient observation and assessment of the blood cultures after 24 hours of incubation should be considered for such patients.
A critical step is for clinicians to keep in close contact with patients who are treated in the outpatient setting to ensure that they are responding to therapy as expected.
Because each of the agents causing TBRD is susceptible to tetracycline-class antibiotics, these drugs, particularly doxycycline, are considered the therapy of choice in nearly all clinical situations.
If a patient fails to respond to early treatment with a tetracycline antibiotic i. Severely ill patients might require longer periods before clinical improvement is noted, especially if they have multiple organ dysfunction.
Doxycycline is the drug of choice for treatment of all TBRD in children and adults. This drug is bacteriostatic in its activity against rickettsial organisms. Intravenous therapy is frequently indicated for hospitalized patients, and oral therapy is acceptable for patients considered to be early in the disease and who can be managed as outpatients.
Oral therapy also can be used for inpatients who are not vomiting or obtunded. Severe or complicated disease might require longer treatment courses. Concerns regarding dental staining after tetracycline therapy have been based primarily on studies conducted during the 1960 s that involved children receiving multiple courses of the drug for recurrent otitis media 59,60.
The propensity of tetracyclines to bind calcium can lead to darkening of the teeth if the antibiotic is ingested during the period of tooth crown formation.
Moreover, a prospective study of children treated with doxycycline for RMSF demonstrated that these children did not have substantial discoloration of permanent teeth compared with those who had never received the drug 56. Because TBRD can be life-threatening and limited courses of therapy with tetracycline-class antibiotics do not pose a substantial risk for tooth staining, the American Academy of Pediatrics Committee on Infectious Diseases revised its recommendations in 1997 and has identified doxycycline as the drug of choice for treating presumed or confirmed RMSF and ehrlichial infections in children of any age 61,62.
Chloramphenicol is an alternative drug that has been used to treat RMSF 50; however, this drug is associated with various side effects and might require monitoring of blood indices.
Chloramphenicol is no longer available in the oral form in the United States. Moreover, epidemiologic studies in which CDC case report data have been used suggested that patients with RMSF treated with chloramphenicol have a higher risk of dying than persons who received a tetracycline 11,63.