今日の臨床サポート

つつが虫病

著者: 山藤栄一郎 福島県立医科大学総合内科・臨床感染症学講座/北福島医療センター総合内科・感染症科

監修: 山本舜悟 京都市立病院 感染症科/京都大学 医療疫学(非常勤講師) 

著者校正/監修レビュー済:2021/08/04
患者向け説明資料

概要・推奨   

  1. 妊婦のつつが虫病患者にはアジスロマイシンの使用が推奨される(推奨度1R
  1. 小児のつつが虫病患者にはドキシサイクリンの使用が推奨される(推奨度1
  1. リファンピシンはドキシサイクリンより有熱期間を短縮する可能性があるが、わが国では耐性菌の問題はないため併用は推奨されない(推奨度3R
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  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧に
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧には ご契約が必 要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
山藤栄一郎 : 特に申告事項無し[2021年]
監修:山本舜悟 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行い、成人における症状・診断、小児への治療などを加筆した。

病態・疫学・診察

疾患情報  
  1. つつが虫病とは、ツツガムシリケッチア(Orientia tsutsugamushi)の感染によって、発熱・発疹・痂皮(刺し口)などの症状を来す人獣共通感染症である。つつが虫(ダニ)によって媒介され感染を起こす。
  1. つつが虫病の診断のポイントは、鑑別に挙げることである。鑑別に挙がらないと、非特異的な症状や検査所見のため、膨大な鑑別診断となる。
  1. 臨床的な診断基準は、発熱・発疹・痂皮(刺し口)を認めることである。しかし好発時期・地域によっては日本紅斑熱との鑑別が困難なこともある。
  1. 診断は主にコマーシャルベース、あるいは各都道府県衛生研究所で間接蛍光抗体法による血清診断で行われる。
  1. 病原体診断では末梢血中からのリケッチアの分離が行われるが、設備や時間がかかるため実用的でない。
  1. 全血や痂皮のPCRも有用な検査という報告もあるが、各都道府県の衛生研究所や一部の研究機関でしか行われていない。
問診・診察のポイント  
  1. つつが虫(ダニ)好発時期・地区の居住歴や旅行歴など、病歴が最も重要である(ダニの種類によって異なるので注意)。

今なら12か月分の料金で14ヶ月利用できます(個人契約、期間限定キャンペーン)

11月30日(火)までにお申込みいただくと、
通常12ヵ月の使用期間が2ヶ月延長となり、14ヵ月ご利用いただけるようになります。

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文献 

著者: Dong-Min Kim, Kyung Jun Won, Chi Young Park, Ki Dong Yu, Hyong Sun Kim, Tae Young Yang, Ji Hyun Lee, Hyun Kuk Kim, Hyeon-Je Song, Seung-Hyun Lee, Ho Shin
雑誌名: Am J Trop Med Hyg. 2007 May;76(5):806-9.
Abstract/Text Eschar is an important finding for the diagnosis of scrub typhus. The IFA test for possible scrub typhus was performed. The presence or absence of eschar was thoroughly examined. Among the 176 scrub typhus cases confirmed by IFA, 162 (92.0%) cases had eschar; 128 patients (79.5%) had eschars on the front of the body. Eschars were primarily detected in males within 30 cm below the umbilicus (19 patients, 35.8%). Distributions on the lower extremities and the front chest above the umbilicus were 22.6% (12 patients) and 20.8% (11 patients), respectively. A different pattern was seen in females. The most prevalent area was the front chest above the umbilicus, which accounted for 40.7% (44 patients) of all the detected eschars. Our study is the first report of a schematic diagram that shows the differences between the males and females with respect to eschar location in scrub typhus patients.

PMID 17488895  Am J Trop Med Hyg. 2007 May;76(5):806-9.
著者: Winsley Rose, Roshni J Rajan, Anu Punnen, Urmi Ghosh
雑誌名: J Trop Pediatr. 2016 Apr 27;. doi: 10.1093/tropej/fmw027. Epub 2016 Apr 27.
Abstract/Text BACKGROUND: Identifying an eschar in scrub typhus is useful for initiation of prompt and appropriate antibiotic therapy.
METHODS: The distribution of eschars in all children <15 years of age admitted with confirmed scrub typhus over a 5 year period is described.
RESULTS: Of 431 children admitted with scrub typhus, eschars were present in 176 (40.8%) children with the following distribution: head, face and neck, 33 (19.1%); axillae, 37 (21%); chest and abdomen, 21 (11.9%); genitalia, inguinal region and buttocks, 58 (33%); back, 8 (4.5%); upper extremities, 13 (7.4%); and lower extremities, 5 (2.8%). The commonest sites of eschars were scrotum (27 of 106; 25.5%) and axillae (15 of 106; 14.2%) in males and axillae (22 of 70; 31.4%) and groin (16 of 70; 22.9%) in females. Eschars were seen within skin folds in 100 of 176 (56.8%) children.
CONCLUSION: Children should be carefully examined for the presence of eschar especially in the skin folds of the genitalia, axillae and groin to make an early diagnosis of scrub typhus.

© The Author [2016]. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.
PMID 27122479  J Trop Pediatr. 2016 Apr 27;. doi: 10.1093/tropej/fmw02・・・
著者: Eiichiro Sando, Motoi Suzuki, Shungo Katoh, Hiromi Fujita, Masakatsu Taira, Makito Yaegashi, Koya Ariyoshi
雑誌名: Emerg Infect Dis. 2018 Sep;24(9):1633-1641. doi: 10.3201/eid2409.171436.
Abstract/Text Japanese spotted fever (JSF) and scrub typhus (ST) are endemic to Japan and share similar clinical features. To document the clinical and epidemiologic characteristics that distinguish these 2 rickettsial diseases, during 2004-2015 we recruited 31 JSF patients, 188 ST patients, and 97 nonrickettsial disease patients from the southern Boso Peninsula of Japan. JSF occurred during April-October and ST during November-December. Patients with JSF and ST were significantly older and more likely to reside in wooded areas than were patients with nonrickettsial diseases. Spatial analyses revealed that JSF and ST clusters rarely overlapped. Clinical findings more frequently observed in JSF than in ST patients were purpura, palmar/plantar rash, hyponatremia, organ damage, and delayed defervescence after treatment. Although their clinical features are similar, JSF and ST differ in seasonality, geographic distribution, physical signs, and severity. Because a considerable percentage of patients did not notice rash and eschar, many rickettsial diseases might be underdiagnosed in Japan.

PMID 30124190  Emerg Infect Dis. 2018 Sep;24(9):1633-1641. doi: 10.320・・・
著者: Stuart D Blacksell, Cherry Lim, Ampai Tanganuchitcharnchai, Suthatip Jintaworn, Pacharee Kantipong, Allen L Richards, Daniel H Paris, Direk Limmathurotsakul, Nicholas P J Day
雑誌名: J Clin Microbiol. 2016 Jun;54(6):1472-8. doi: 10.1128/JCM.02744-15. Epub 2016 Mar 23.
Abstract/Text The enzyme-linked immunosorbent assay (ELISA) has been proposed as an alternative serologic diagnostic test to the indirect immunofluorescence assay (IFA) for scrub typhus. Here, we systematically determine the optimal sample dilution and cutoff optical density (OD) and estimate the accuracy of IgM ELISA using Bayesian latent class models (LCMs). Data from 135 patients with undifferentiated fever were reevaluated using Bayesian LCMs. Every patient was evaluated for the presence of an eschar and tested with a blood culture for Orientia tsutsugamushi, three different PCR assays, and an IgM IFA. The IgM ELISA was performed for every sample at sample dilutions from 1:100 to 1:102,400 using crude whole-cell antigens of the Karp, Kato, and Gilliam strains of O. tsutsugamushi developed by the Naval Medical Research Center. We used Bayesian LCMs to generate unbiased receiver operating characteristic curves and found that the sample dilution of 1:400 was optimal for the IgM ELISA. With the optimal cutoff OD of 1.474 at a sample dilution of 1:400, the IgM ELISA had a sensitivity of 85.7% (95% credible interval [CrI], 77.4% to 86.7%) and a specificity of 98.1% (95% CrI, 97.2% to 100%) using paired samples. For the ELISA, the OD could be determined objectively and quickly, in contrast to the reading of IFA slides, which was both subjective and labor-intensive. The IgM ELISA for scrub typhus has high diagnostic accuracy and is less subjective than the IgM IFA. We suggest that the IgM ELISA may be used as an alternative reference test to the IgM IFA for the serological diagnosis of scrub typhus.

Copyright © 2016 Blacksell et al.
PMID 27008880  J Clin Microbiol. 2016 Jun;54(6):1472-8. doi: 10.1128/J・・・
著者: Dong-Min Kim, Hyun Lee Kim, Chi Young Park, Tae Young Yang, Ji Hyun Lee, Jong Tae Yang, Soo-Kyoung Shim, Seung-Hyun Lee
雑誌名: Clin Infect Dis. 2006 Nov 15;43(10):1296-300. doi: 10.1086/508464. Epub 2006 Oct 12.
Abstract/Text BACKGROUND: The aim of this study was to determine the diagnostic utility of performing eschar polymerase chain reaction (PCR) for the diagnosis of scrub typhus through a prospective comparison of eschar PCR results with indirect immunofluorescent antibody assay (IFA) results.
METHODS: We conducted a multicenter prospective study involving patients with possible scrub typhus. Whole-blood samples and eschars were obtained for serological evaluation and PCR. A new crust was formed several days later at the site of the removed eschar. The newly formed crust was taken for performance of the second eschar PCR. Additional blood samples and eschars were collected, if possible, at 1-week intervals for 1 month after antibiotic treatment.
RESULTS: We prospectively studied 135 patients with possible scrub typhus. Of these patients, 118 had scrub typhus confirmed on the basis of either a single indirect immunofluorescent specific immunoglobulin M titer against Orientia tsutsugamushi of > or = 1:10 or a > or = 4-fold increase in the follow-up titer. The results of nested PCR assay of the eschars demonstrated a sensitivity of 0.86 (95% confidence interval, 0.78-0.92) and a specificity of 1 (95% confidence interval, 0.05-1). Among the 50 patients who showed positive results of eschar PCR at admission, 46 (92%) also showed positive results for the follow-up PCR test of the newly formed eschar after the treatment with antibiotics.
CONCLUSIONS: The eschar PCR assay was useful as a rapid and reliable test to confirm the diagnosis of scrub typhus, even though the patients received treatment with appropriate antibiotics, such as macrolides, quinolones, and tetracycline, which are all active against Orientia and Rickettsia species.

PMID 17051495  Clin Infect Dis. 2006 Nov 15;43(10):1296-300. doi: 10.1・・・
著者: Andrew J Taylor, Daniel H Paris, Paul N Newton
雑誌名: PLoS Negl Trop Dis. 2015;9(8):e0003971. doi: 10.1371/journal.pntd.0003971. Epub 2015 Aug 14.
Abstract/Text BACKGROUND: Scrub typhus, a bacterial infection caused by Orientia tsutsugamushi, is increasingly recognized as an important cause of fever in Asia, with an estimated one million infections occurring each year. Limited access to health care and the disease's non-specific symptoms mean that many patients are undiagnosed and untreated, but the mortality from untreated scrub typhus is unknown. This review systematically summarizes the literature on the untreated mortality from scrub typhus and disease outcomes.
METHODOLOGY/PRINCIPAL FINDINGS: A literature search was performed to identify patient series containing untreated patients. Patients were included if they were symptomatic and had a clinical or laboratory diagnosis of scrub typhus and excluded if they were treated with antibiotics. The primary outcome was mortality from untreated scrub typhus and secondary outcomes were total days of fever, clinical symptoms, and laboratory results. A total of 76 studies containing 89 patient series and 19,644 patients were included in the final analysis. The median mortality of all patient series was 6.0% with a wide range (min-max) of 0-70%. Many studies used clinical diagnosis alone and had incomplete data on secondary outcomes. Mortality varied by location and increased with age and in patients with myocarditis, delirium, pneumonitis, or signs of hemorrhage, but not according to sex or the presence of an eschar or meningitis. Duration of fever was shown to be long (median 14.4 days Range (9-19)).
CONCLUSIONS: Results show that the untreated mortality from scrub typhus appears lower than previously reported estimates. More data are required to clarify mortality according to location and host factors, clinical syndromes including myocarditis and central nervous system disease, and in vulnerable mother-child populations. Increased surveillance and improved access to diagnostic tests are required to accurately estimate the untreated mortality of scrub typhus. This information would facilitate reliable quantification of DALYs and guide empirical treatment strategies.

PMID 26274584  PLoS Negl Trop Dis. 2015;9(8):e0003971. doi: 10.1371/jo・・・
著者: Nelson Lee, Margaret Ip, Bonnie Wong, Grace Lui, Owen Tak Yin Tsang, Jak Yiu Lai, Kin Wing Choi, Rebecca Lam, Tak Keung Ng, Jenny Ho, Yin Yan Chan, Clive S Cockram, Sik To Lai
雑誌名: Am J Trop Med Hyg. 2008 Jun;78(6):973-8.
Abstract/Text We retrospectively analyzed 92 cases of severe rickettsial infections in patients (median age = 49 years, 57% male, 37.0% with scrub typhus) in Hong Kong. Immunofluorescence assay was used for diagnostic confirmation. Identification of > or = 1 diagnostic sign (exposure history, rash, or eschar) was possible in 94.6% of the cases. Multivariate analysis suggested that pulmonary infiltrates (odds ratio [OR] = 25.2, 95% confidence interval [CI] = 3.9-160.9, P = 0.001) and leukocytosis (OR = 1.3, 95% CI = 1.0-1.5 per unit increase, P = 0.033) were independent predictors of admission to an intensive care unit (14.1%). Delayed administration of doxycycline was independently associated with major organ dysfunction (23.9%; oxygen desaturation, renal failure, severe jaundice, encephalopathy, cardiac failure) (OR = 1.2, 95% CI = 1.0-1.5 per day delay, P = 0.046; adjusted for age and rickettsia biogroup) and prolonged hospitalization > 10 days (25%) (OR = 1.4, 95% CI = 1.1-1.9 per day delay, P = 0.014). Treatment with fluoroquinolone/clarithromycin did not correlate with clinical outcomes (P > 0.05). Early empirical doxycycline therapy should be considered if clinico-epidemiologic signs of rickettsial infections are present.

PMID 18541779  Am J Trop Med Hyg. 2008 Jun;78(6):973-8.
著者: G Watt, P Kantipong, K Jongsakul, P Watcharapichat, D Phulsuksombati, D Strickman
雑誌名: Lancet. 2000 Sep 23;356(9235):1057-61. doi: 10.1016/S0140-6736(00)02728-8.
Abstract/Text BACKGROUND: Some strains of scrub typhus in northern Thailand are poorly responsive to standard antirickettsial drugs. We therefore did a masked, randomised trial to compare rifampicin with standard doxycycline therapy for patients with scrub typhus.
METHODS: Adult patients with strictly defined, mild scrub typhus were initially randomly assigned 1 week of daily oral treatment with 200 mg doxycycline (n=40), 600 mg rifampicin (n=38), or doxycycline with rifampicin (n=11). During the first year of treatment, the combined regimen was withdrawn because of lack of efficacy and the regimen was replaced with 900 mg rifampicin (n=37). Treatment outcome was assessed by fever clearance time (the time for oral temperature to fall below 37.3 degrees C).
FINDINGS: About 12,800 fever patients were screened during the 3-year study to recruit 126 patients with confirmed scrub typhus and no other infection, of whom 86 completed therapy. Eight individuals received the combined regimen that was discontinued after 1 year. The median duration of pyrexia was significantly shorter (p=0.01) in the 24 patients treated with 900 mg daily rifampicin (fever clearance time 22.5 h) and in the 26 patients who received 600 mg rifampicin (fever clearance time 27.5 h) than in the 28 patients given doxycycline monotherapy (fever clearance time 52 h). Fever resolved in a significantly higher proportion of patients within 48 h of starting rifampicin (900 mg=79% [19 of 24], 600 mg=77% [20 of 26]) than in patients treated with doxycycline (46% [13 of 28]; p=0.02). Severe gastrointestinal events warranted exclusion of two patients on doxycyline. There were two relapses after doxycycline therapy, but none after rifampicin therapy.
INTERPRETATION: Rifampicin is more effective than doxycycline against scrub-typhus infections acquired in northern Thailand, where strains with reduced susceptibility to antibiotics can occur.

PMID 11009140  Lancet. 2000 Sep 23;356(9235):1057-61. doi: 10.1016/S01・・・
著者: Yeon-Sook Kim, Hwan-Jung Yun, Soo Kyoung Shim, Sun Hoe Koo, Sun Young Kim, Samyong Kim
雑誌名: Clin Infect Dis. 2004 Nov 1;39(9):1329-35. doi: 10.1086/425008. Epub 2004 Oct 11.
Abstract/Text BACKGROUND: Scrub typhus is one of the most important endemic infections in the Asia-Pacific region. Although tetracyclines or chloramphenicol are the recommended drugs of choice for the treatment of scrub typhus, reports of doxycycline-resistant strains have prompted a search for alternative treatments.
METHODS: We conducted a prospective, open-label, randomized trial from September 2002 through November 2003 to compare azithromycin with doxycycline for the treatment of mild scrub typhus. The time to defervescence was assessed to compare the efficacy of the 2 treatment regimens.
RESULTS: A total of 93 patients were randomly assigned to receive either a single 500-mg dose of azithromycin or a 1-week course of daily oral 200-mg dose of doxycycline. Cure was achieved in 47 (100%) of 47 patients in the azithromycin-treated group and in 43 (93.5%) of 46 patients in the doxycycline-treated group (P=.117). The median time to defervescence was 21 h for the azithromycin-treated group and 29 h for the doxycycline-treated group (P=.097). There were no serious adverse events during the study. No relapses occurred in either group during a 1-month follow-up period.
CONCLUSION: The single 500-mg dose of azithromycin was as effective as the 1-week course of daily 200-mg doses of doxycycline for the treatment of mild scrub typhus acquired in South Korea.

PMID 15494910  Clin Infect Dis. 2004 Nov 1;39(9):1329-35. doi: 10.1086・・・
著者: B A Cunha, J Baron, C B Cunha
雑誌名: Eur J Clin Microbiol Infect Dis. 2018 Jan;37(1):15-20. doi: 10.1007/s10096-017-3081-x. Epub 2017 Aug 17.
Abstract/Text Doxycycline and, to a lesser extent, minocycline, have been used for decades to treat various serious systemic infections, but many physicians remain unfamiliar with their spectrum, interpretation of susceptibility results, pharmacokinetic/pharmacodynamic (PK/PD) properties, optimal dosing regimens, and their activity against MRSA, VRE, and multidrug-resistant (MDR) Gram-negative bacilli, e.g., Acinetobacter sp. This article reviews the optimal use of doxycycline and minocycline to treat a variety of infections and when minocycline is preferred instead of doxycycline.

PMID 28819873  Eur J Clin Microbiol Infect Dis. 2018 Jan;37(1):15-20. ・・・
著者: Wiwit Tantibhedhyangkul, Emmanouil Angelakis, Narongchai Tongyoo, Paul N Newton, Catrin E Moore, Rattanaphone Phetsouvanh, Didier Raoult, Jean-Marc Rolain
雑誌名: Int J Antimicrob Agents. 2010 Apr;35(4):338-41. doi: 10.1016/j.ijantimicag.2009.11.019.
Abstract/Text Scrub typhus is a public health concern for a population of over a billion humans, with an estimated incidence of one million cases/year in endemic areas. Although doxycycline remains the standard therapy, fluoroquinolones have been used successfully in a few patients. However, there is also clinical evidence that fluoroquinolones are ineffective in the treatment of scrub typhus. To clarify this matter, we determined the in vitro susceptibility of Orientia tsutsugamushi strain Kato to ciprofloxacin and ofloxacin and sequenced the quinolone resistance-determining region (QRDR) of the gyrA gene, the target of fluoroquinolones, of 18 fresh isolates from the Lao PDR. Orientia tsutsugamushi strain Kato was resistant to ciprofloxacin and ofloxacin in vitro (minimum inhibitory concentration=8 microg/mL). All sequences obtained, including those from the two available genomes of O. tsutsugamushi (strains Boryong and Ikeda), had a Ser83Leu mutation in their QRDR domain that is known to be associated with fluoroquinolone resistance. These findings re-emphasise the usefulness of in silico analysis for the prediction of antibiotic resistance and suggest that fluoroquinolones should not be used in the treatment of scrub typhus.

(c) 2009 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved.
PMID 20138477  Int J Antimicrob Agents. 2010 Apr;35(4):338-41. doi: 10・・・
著者: Hee-Chang Jang, Su-Mi Choi, Mi-Ok Jang, Joon-Hwan Ahn, Uh-Jin Kim, Seung-Ji Kang, Jong-Hee Shin, Hyon E Choy, Sook-In Jung, Kyung-Hwa Park
雑誌名: J Korean Med Sci. 2013 May;28(5):667-71. doi: 10.3346/jkms.2013.28.5.667. Epub 2013 May 2.
Abstract/Text The use of quinolone for treatment of rickettsial diseases remains controversial. Recent clinical studies suggest that quinolone is not as effective as others in patients with rickettsial diseases including scrub typhus, although the mechanism is not well understood. In this study, we evaluated the mutation in gyrA associated with quinolone resistance. We prospectively enrolled scrub typhus patients, collected blood samples and clinical data from October, 2010 to November, 2011. Among the 21 patients enrolled, one initially received ciprofloxacin for 3 days but was switched to doxycycline due to clinical deterioration. We obtained the gyrA gene of Orientia tsutsugamushi from 21 samples (20 Boryong strain, 1 Kato strain) and sequenced the quinolone resistance-determining region. All of 21 samples had the Ser83Leu mutation in the gyrA gene, which is known to be associated with quinolone resistance. This suggests that quinolones may be avoided for the treatment of serious scrub typhus.

PMID 23678256  J Korean Med Sci. 2013 May;28(5):667-71. doi: 10.3346/j・・・
著者: Yeon-Sook Kim, Hyo Jin Lee, Meayoung Chang, Sung Kyong Son, Yun Ee Rhee, Soo Kyong Shim
雑誌名: Am J Trop Med Hyg. 2006 Nov;75(5):955-9.
Abstract/Text Although scrub typhus is uncommon in pregnant women, when present, it can have serious repercussions for the mother and developing fetus. Since it is uncommon, the clinical impact of scrub typhus on pregnancy has not been elucidated and an effective and safe therapeutic regimen has not been validated. The medical records of pregnant women whose scrub typhus were treated at Chungnam National University Hospital were reviewed and their clinical outcomes were evaluated. A review of the literature was also performed on pregnant women with scrub typhus and their clinical outcomes. Eight pregnant women with scrub typhus were treated successfully with a single 500-mg dose of azithromycin, and no relapses were reported. They all delivered healthy babies at term, without congenital or neonatal complications. In the reviews, azithromycin was effective against scrub typhus and had favorable pregnancy outcomes. Ciprofloxacin and cefuroxime failed to treat scrub typhus and fetal loss resulted. A single 500-mg dose of azithromycin may be a reasonable treatment regimen for pregnant women with scrub typhus. Ciprofloxacin might not be advisable for the treatment of scrub typhus during pregnancy. Scrub typhus itself seems to have serious adverse effects on pregnancy if not appropriately controlled.

PMID 17123995  Am J Trop Med Hyg. 2006 Nov;75(5):955-9.
著者: Kriangsak Phimda, Siriwan Hoontrakul, Chuanpit Suttinont, Sompong Chareonwat, Kitti Losuwanaluk, Sunee Chueasuwanchai, Wirongrong Chierakul, Duangjai Suwancharoen, Saowaluk Silpasakorn, Watcharee Saisongkorh, Sharon J Peacock, Nicholas P J Day, Yupin Suputtamongkol
雑誌名: Antimicrob Agents Chemother. 2007 Sep;51(9):3259-63. doi: 10.1128/AAC.00508-07. Epub 2007 Jul 16.
Abstract/Text Leptospirosis and scrub typhus are important causes of acute fever in Southeast Asia. Options for empirical therapy include doxycycline and azithromycin, but it is unclear whether their efficacies are equivalent. We conducted a multicenter, open, randomized controlled trial with adult patients presenting with acute fever (<15 days), without an obvious focus of infection, at four hospitals in Thailand between July 2003 and January 2005. Patients were randomly allocated to receive either a 7-day course of doxycycline or a 3-day course of azithromycin. The cure rate, fever clearance time, and adverse drug events were compared between the two study groups. A total of 296 patients were enrolled in the study. The cause of acute fever was determined for 151 patients (51%): 69 patients (23.3%) had leptospirosis; 57 patients (19.3%) had scrub typhus; 14 patients (4.7%) had murine typhus; and 11 patients (3.7%) had evidence of both leptospirosis and a rickettsial infection. The efficacy of azithromycin was not inferior to that of doxycycline for the treatment of both leptospirosis and scrub typhus, with comparable fever clearance times in the two treatment arms. Adverse events occurred more frequently in the doxycycline group than in the azithromycin group (27.6% and 10.6%, respectively; P = 0.02). In conclusion, doxycycline is an affordable and effective choice for the treatment of both leptospirosis and scrub typhus. Azithromycin was better tolerated than doxycycline but is more expensive and less readily available.

PMID 17638700  Antimicrob Agents Chemother. 2007 Sep;51(9):3259-63. do・・・
著者: Holly M Biggs, Casey Barton Behravesh, Kristy K Bradley, F Scott Dahlgren, Naomi A Drexler, J Stephen Dumler, Scott M Folk, Cecilia Y Kato, R Ryan Lash, Michael L Levin, Robert F Massung, Robert B Nadelman, William L Nicholson, Christopher D Paddock, Bobbi S Pritt, Marc S Traeger
雑誌名: MMWR Recomm Rep. 2016 May 13;65(2):1-44. doi: 10.15585/mmwr.rr6502a1. Epub 2016 May 13.
Abstract/Text Tickborne rickettsial diseases continue to cause severe illness and death in otherwise healthy adults and children, despite the availability of low-cost, effective antibacterial therapy. Recognition early in the clinical course is critical because this is the period when antibacterial therapy is most effective. Early signs and symptoms of these illnesses are nonspecific or mimic other illnesses, which can make diagnosis challenging. Previously undescribed tickborne rickettsial diseases continue to be recognized, and since 2004, three additional agents have been described as causes of human disease in the United States: Rickettsia parkeri, Ehrlichia muris-like agent, and Rickettsia species 364D. This report updates the 2006 CDC recommendations on the diagnosis and management of tickborne rickettsial diseases in the United States and includes information on the practical aspects of epidemiology, clinical assessment, treatment, laboratory diagnosis, and prevention of tickborne rickettsial diseases. The CDC Rickettsial Zoonoses Branch, in consultation with external clinical and academic specialists and public health professionals, developed this report to assist health care providers and public health professionals to 1) recognize key epidemiologic features and clinical manifestations of tickborne rickettsial diseases, 2) recognize that doxycycline is the treatment of choice for suspected tickborne rickettsial diseases in adults and children, 3) understand that early empiric antibacterial therapy can prevent severe disease and death, 4) request the appropriate confirmatory diagnostic tests and understand their usefulness and limitations, and 5) report probable and confirmed cases of tickborne rickettsial diseases to public health authorities.

PMID 27172113  MMWR Recomm Rep. 2016 May 13;65(2):1-44. doi: 10.15585/・・・

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