Treatment of Rocky Mountain spotted fever
- Daniel J Sexton, MD
Daniel J Sexton, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — Bacterial Infections
- Professor of Medicine
- Duke University Medical Center
- Micah T McClain, MD
Micah T McClain, MD
- Associate Professor of Medicine
- Division of Infectious Diseases
- Duke University Medical Center
Rocky Mountain spotted fever (RMSF) is a potentially lethal, but usually curable, tick-borne disease. It occurs throughout the United States, Canada, Mexico, Central America, and in parts of South America. The etiologic agent, Rickettsia rickettsii, is a gram-negative, obligate intracellular bacterium that causes a wide spectrum of clinical disease from mild to fulminant infection. Mortality from RMSF declined markedly in the last decade from 2.2 percent in 2000 to 0.3 percent in 2007, and has been essentially unchanged since that time [1,2].
The treatment of RMSF will be reviewed here. The basic biology of R. rickettsii, and the epidemiology, clinical manifestations, and diagnosis of RMSF are discussed separately. (See "Biology of Rickettsia rickettsii infection" and "Clinical manifestations and diagnosis of Rocky Mountain spotted fever".)
Our approach to treatment depends upon the certainty of disease and the severity of symptoms. Empiric therapy with doxycycline should be started if the diagnosis of Rocky Mountain spotted fever (RMSF) is suspected, even if the symptoms are mild.
Assessing likelihood of RMSF — A diagnosis of RMSF is likely in patients who present with fever, headache, and constitutional symptoms in the spring and summer months if:
●They are from an endemic area (see "Clinical manifestations and diagnosis of Rocky Mountain spotted fever", section on 'Epidemiology')
- Openshaw JJ, Swerdlow DL, Krebs JW, et al. Rocky mountain spotted fever in the United States, 2000-2007: interpreting contemporary increases in incidence. Am J Trop Med Hyg 2010; 83:174.
- Centers for Disease Control and Prevention. Rocky Mountain Spotted Fever, Statistics and Epidemiology. http://www.cdc.gov/rmsf/stats/ (Accessed on September 12, 2017).
- Marin-Garcia J, Gooch WM 3rd, Coury DL. Cardiac manifestations of Rocky Mountain spotted fever. Pediatrics 1981; 67:358.
- Rydkina E, Sahni A, Baggs RB, et al. Infection of human endothelial cells with spotted Fever group rickettsiae stimulates cyclooxygenase 2 expression and release of vasoactive prostaglandins. Infect Immun 2006; 74:5067.
- Holman RC, Paddock CD, Curns AT, et al. Analysis of risk factors for fatal Rocky Mountain Spotted Fever: evidence for superiority of tetracyclines for therapy. J Infect Dis 2001; 184:1437.
- Walker DH. Rocky Mountain spotted fever: a seasonal alert. Clin Infect Dis 1995; 20:1111.
- Walker DH, Kirkman HN. Rocky Mountain spotted fever and deficiency in glucose-6-phosphate dehydrogenase. J Infect Dis 1980; 142:771.
- Centers for Disease Control and Prevention (CDC). Consequences of delayed diagnosis of Rocky Mountain spotted fever in children--West Virginia, Michigan, Tennessee, and Oklahoma, May-July 2000. MMWR Morb Mortal Wkly Rep 2000; 49:885.
- Kirkland KB, Wilkinson WE, Sexton DJ. Therapeutic delay and mortality in cases of Rocky Mountain spotted fever. Clin Infect Dis 1995; 20:1118.
- Regan JJ, Traeger MS, Humpherys D, et al. Risk factors for fatal outcome from rocky mountain spotted Fever in a highly endemic area-Arizona, 2002-2011. Clin Infect Dis 2015; 60:1659.
- O'Reilly M, Paddock C, Elchos B, et al. Physician knowledge of the diagnosis and management of Rocky Mountain spotted fever: Mississippi, 2002. Ann N Y Acad Sci 2003; 990:295.
- American Academy of Pediatrics. Rocky Mountain Spotted Fever. In: Red Book: 2012 Report of the Committee on Infectious Diseases, 29th ed, Pickering LK (Ed), American Academy of Pediatrics, Elk Grove Village, IL 2012.
- Chapman AS, Bakken JS, Folk SM, et al. Diagnosis and management of tickborne rickettsial diseases: Rocky Mountain spotted fever, ehrlichioses, and anaplasmosis--United States: a practical guide for physicians and other health-care and public health professionals. MMWR Recomm Rep 2006; 55:1.
- Dalton MJ, Clarke MJ, Holman RC, et al. National surveillance for Rocky Mountain spotted fever, 1981-1992: epidemiologic summary and evaluation of risk factors for fatal outcome. Am J Trop Med Hyg 1995; 52:405.
- Cunha BA. Clinical features of Rocky Mountain spotted fever. Lancet Infect Dis 2008; 8:143.
- Centers for Disease Control and Prevention.Rocky Mountain Spotted Fever (RMSF); Symptoms, Diagnosis, and Treatment. https://www.cdc.gov/rmsf/symptoms/index.html (Accessed on June 06, 2017).
- Vennila V, Madhu V, Rajesh R, et al. Tetracycline-induced discoloration of deciduous teeth: case series. J Int Oral Health 2014; 6:115.
- Cohlan SQ, Bevelander G, Tiamsic T. Growth Inhibition of Prematures Receiving Tetracycline. Am J Dis Child 1963; 105:453.
- Cross R, Ling C, Day NP, et al. Revisiting doxycycline in pregnancy and early childhood--time to rebuild its reputation? Expert Opin Drug Saf 2016; 15:367.
- Cooper WO, Hernandez-Diaz S, Arbogast PG, et al. Antibiotics potentially used in response to bioterrorism and the risk of major congenital malformations. Paediatr Perinat Epidemiol 2009; 23:18.
- Biggs HM, Behravesh CB, Bradley KK, et al. Diagnosis and Management of Tickborne Rickettsial Diseases: Rocky Mountain Spotted Fever and Other Spotted Fever Group Rickettsioses, Ehrlichioses, and Anaplasmosis - United States. MMWR Recomm Rep 2016; 65:1.
- Lochary ME, Lockhart PB, Williams WT Jr. Doxycycline and staining of permanent teeth. Pediatr Infect Dis J 1998; 17:429.
- Todd SR, Dahlgren FS, Traeger MS, et al. No visible dental staining in children treated with doxycycline for suspected Rocky Mountain Spotted Fever. J Pediatr 2015; 166:1246.
- DuPont HL, Hornick RB, Dawkins AT, et al. Rocky Mountain spotted fever: a comparative study of the active immunity induced by inactivated and viable pathogenic Rickettsia rickettsii. J Infect Dis 1973; 128:340.
- DuPont HL, Hornick RB, Weiss CF, et al. Evaluation of chloramphenicol acid succinate therapy of induced typhoid fever and rocky mountain spotted fever. N Engl J Med 1970; 282:53.
- Breitschwerdt EB, Davidson MG, Aucoin DP, et al. Efficacy of chloramphenicol, enrofloxacin, and tetracycline for treatment of experimental Rocky Mountain spotted fever in dogs. Antimicrob Agents Chemother 1991; 35:2375.
- American Academy of Pediatrics (AAP). Red Book: 2012 Report of the Committee on Infectious Diseases, 29, Pickering LK, Baker CJ, Kimberlin DW, Long SS (Eds), American Academy of Pediatrics, Elk Grove, IL 2012.
- Wiest DB, Cochran JB, Tecklenburg FW. Chloramphenicol toxicity revisited: a 12-year-old patient with a brain abscess. J Pediatr Pharmacol Ther 2012; 17:182.
- Powell DA, Nahata MC. Chloramphenicol: new perspectives on an old drug. Drug Intell Clin Pharm 1982; 16:295.
- Archibald LK, Sexton DJ. Long-term sequelae of Rocky Mountain spotted fever. Clin Infect Dis 1995; 20:1122.
- Sun LR, Huisman TA, Yeshokumar AK, Johnston MV. Ongoing Cerebral Vasculitis During Treatment of Rocky Mountain Spotted Fever. Pediatr Neurol 2015; 53:434.
- Hayes SF, Burgdorfer W. Reactivation of Rickettsia rickettsii in Dermacentor andersoni ticks: an ultrastructural analysis. Infect Immun 1982; 37:779.
- Pretzman C, Daugherty N, Poetter K, Ralph D. The distribution and dynamics of Rickettsia in the tick population of Ohio. Ann N Y Acad Sci 1990; 590:227.
- Straily A, Drexler N, Cruz-Loustaunau D, et al. Notes from the Field: Community-Based Prevention of Rocky Mountain Spotted Fever - Sonora, Mexico, 2016. MMWR Morb Mortal Wkly Rep 2016; 65:1302.
- Assessing likelihood of RMSF
- Patients likely to have RMSF
- If the diagnosis is unlikely
- Importance of early therapy
- CHOICE OF ANTIBIOTIC
- Doxycycline as preferred agent
- - Non-pregnant adults
- - Pregnant women
- - Children
- Alternative agent
- Drug toxicity
- - Doxycycline
- - Chloramphenicol
- RESPONSE TO THERAPY
- DURATION OF TREATMENT
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS