Rickettsial Infection Treatment & Management

Updated: Nov 22, 2021
  • Author: Mobeen H Rathore, MD, CPE, FAAP, FIDSA; Chief Editor: Russell W Steele, MD  more...
  • Print

Medical Care

Specific therapy

Adequate antibiotic therapy initiated early in the first week of illness is highly effective and is associated with the best outcome. Fever usually subsides within 24-72 hours after starting antibiotic therapy. If fever fails to subside with the use of a suitable antibiotic, the diagnosis of rickettsial disease should be reconsidered. Treatment may be terminated 2-3 days after the patient is afebrile and at least 10 days of therapy has been given. [36]

Doxycycline is the drug of choice; it is preferred over other tetracyclines for treatment of rickettsial infections and, at such low dose and short duration, is rarely associated with staining of teeth in children younger than 8 years. [37, 10, 16]

Chloramphenicol may be used as an alternative. However, it is rarely used in the United States because of its potential bone marrow toxicity.

Recent data from Europe suggest that fluoroquinolones, such as ciprofloxacin and ofloxacin, may be effective in the treatment of certain rickettsioses. [25, 5] However quinolones, which are not FDA approved for use in children younger than 18 years, have been associated with clinical failures despite good in vitro activity.

Sulfonamides were found to have a harmful effect either by delaying the institution of proper antimicrobial therapy or by directly stimulating growth of the organisms. They are contraindicated in rickettsial infections. [4, 36]

Supportive therapy

Thrombocytopenia, hypoalbuminemia, hypotension, and coagulation defects require supportive management. Hyponatremia is best managed with maintenance fluids or even modest fluid restriction. Whether or not steroids are helpful in shortening the febrile period in Rocky Mountain spotted fever (RMSF) is controversial. [1, 38]

  • RMSF: Antibiotic treatment may be terminated 2-3 days after the patient is afebrile and at least 10 days of therapy has been given. Longer courses may be required in complicated illness. [36]

  • Rickettsialpox: Antibiotics are the mainstay of treatment. However, in infants and young children with mild illness, antibiotics may be withheld because the infection is self-limited.

  • Boutonneuse fever: Doxycycline remains the drug of first choice; however, the newer macrolide may be of interest. [10] Improvement usually occurs within 48 hours of therapy. Duration of therapy has not been definitively established; however, recommendations state that antibiotic treatment should continue for 24 hours after fever has abated.

  • Louse-borne (epidemic) typhus: Treatment is analogous to that of RMSF. The use of insecticides and pediculicides (eg, lindane, crotamiton, malathion) can be highly effective in reducing louse infestation and may serve as important adjuncts to specific therapy in curtailing louse-borne typhus epidemics.

  • Brill-Zinsser disease (ie, relapsing louse-borne typhus): Treatment is analogous to that of RMSF.

  • Murine (endemic or flea-borne) typhus: A single dose of doxycycline is the treatment of choice for this disease. Other tetracyclines and chloramphenicol are also effective agents. The control of rat fleas with insecticides followed by control of rat populations with rodenticides is an important adjunct measure to combat the spread of this disease.

  • Tsutsugamushi disease (ie, scrub typhus): Antibiotic treatment with tetracyclines or chloramphenicol, similar to that of the spotted fever group, is recommended. However, sporadic short antibiotic courses of doxycycline or chloramphenicol may be required to prevent relapses. [37]

  • Q fever

    • Acute disease responds to tetracyclines or chloramphenicol. Fluoroquinolones and the newer macrolides (eg, azithromycin) have also been used successfully for treatment of acute infection. Generally, relapses are rare. [5]

    • Chronic Q fever infections, on the other hand, require prolonged courses of antimicrobial therapy. In cases of endocarditis caused by chronic Q fever, combination therapy with hydroxychloroquine and doxycycline is the preferred treatment. Duration of therapy is 18-36 months depending on the serologic response. Several alternative combination regimens (eg, a fluoroquinolone with doxycycline or rifampin with doxycycline) have been proposed but not adequately studied yet. [31, 5]



Infectious disease subspecialists play a vital role in diagnosis confirmation, management, and exclusion of other illnesses on the differential.

Other subspecialists may be consulted, depending on the course of the illness (eg, cardiologist, pulmonologist, nephrologist, intensivist).



No dietary restriction is required in uncomplicated rickettsial infections.