From the Guidelines
The treatment of scrub typhus primarily involves antibiotics, with doxycycline being the first-line therapy, as it is the most effective option for reducing morbidity, mortality, and improving quality of life. For adults, the recommended regimen is doxycycline 100 mg twice daily for 7 days 1.
Key Considerations
- Alternatives include azithromycin 500 mg on day 1 followed by 250 mg daily for 4 more days, or chloramphenicol 500 mg four times daily for 7 days when doxycycline cannot be used.
- For pregnant women and children, azithromycin is preferred due to safety concerns with doxycycline.
- In severe cases with organ dysfunction, early treatment is crucial, and supportive care may be necessary.
- Patients typically show improvement within 48 hours of starting antibiotics, with fever resolution being a good indicator of treatment success.
- Delayed treatment increases the risk of complications such as respiratory distress, meningoencephalitis, and renal failure.
Evidence-Based Recommendations
- The most recent and highest quality study 1 recommends doxycycline as the drug of choice for treatment of all tickborne rickettsial diseases in children and adults.
- Empiric therapy should be initiated promptly in patients with a clinical presentation suggestive of a rickettsial disease.
- Doxycycline is recommended by the American Academy of Pediatrics and CDC as the treatment of choice for patients of all ages, including children aged <8 years, with a suspected tickborne rickettsial disease.
- Delay in treatment of tickborne rickettsial diseases can lead to severe disease and death 1.
From the FDA Drug Label
Doxycycline is indicated for the treatment of the following infections: ... typhus fever and the typhus group,
- Scrub typhus is a type of typhus fever.
- The drug label for doxycycline indicates it is used to treat typhus fever and the typhus group 2.
- Therefore, doxycycline can be used for the treatment of scrub typhus.
From the Research
Treatment Options for Scrub Typhus
- The recommended treatment regimen for scrub typhus is doxycycline 3.
- Alternative regimens include tetracycline, chloramphenicol, azithromycin, ciprofloxacin, rifampicin, and roxithromycin 3.
- Azithromycin is the recommended drug in pregnancy and for children 4.
- Minocycline and azithromycin are effective and safe for the treatment of mild scrub typhus, with minocycline being more active than azithromycin against O. tsutsugamushi infection acquired in northern China 5.
Comparison of Antibiotic Regimens
- Doxycycline compared to tetracycline may make little or no difference in resolution of fever within 48 hours and in time to defervescence 6.
- Macrolides compared to doxycycline may make little or no difference in the proportion of patients with resolution of fever within five days 6.
- Rifampicin is effective, but clinicians should not regard it as a first-line treatment option due to the risk of inducing resistance in undiagnosed tuberculosis 6.
Special Considerations
- Treatment of pregnant women with azithromycin was successfully done without relapse and with favorable pregnancy outcomes 3.
- Severe scrub typhus remains a challenging problem, and further study is needed on the efficacy of different antibiotics in its treatment 7.
- Further research should consist of additional adequately powered trials of doxycycline versus azithromycin or other macrolides, trials of other candidate antibiotics including rifampicin, and trials of treatments for severe scrub typhus 6.