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Anaplasmosis

• Human granulocytic anaplasmosis, suspected or symptomatic

• Preferred regimen: Doxycycline 100 mg orally bid (or intravenously for those patients unable to take an oral medication) for 10 days
• Alternative regimen: Rifampin 300 mg orally bid for 7–10 days (For patients with mild illness due to HGA who are not optimally suited for doxycycline treatment because of a history of drug allergy, pregnancy, or age <8 years)
• Pediatric regimen: Doxycycline 4 mg/kg per day in 2 divided doses (maximum of 100 mg per dose) given orally (or intravenously for children unable to take an oral medication); Rifampin 10 mg/kg bid for children (maximum of 300 mg per dose) (For children age <8 years without Lyme disease)

NOTE (1): Children ≥8 years of age may be treated with a 10-day course of Doxycycline; For severely ill children <8 years of age without concomitant Lyme disease, the panel recommended an abbreviated treatment course of 4–5 days

NOTE (2): If the patient has concomitant Lyme disease, then Amoxicillin 50 mg/kg per day in 3 divided doses (maximum of 500 mg per dose) OR Cefuroxime axetil 30 mg/kg per day in 2 divided doses (maximum of 500 mg per dose) should be initiated at the conclusion of the course of Doxycycline to complete a 14-day total course of antibiotic therapy

NOTE: Rifampin is not effective therapy for Lyme disease, patients coinfected with B. burgdorferi should also be treated with Amoxicillin OR Cefuroxime axetil

Brucellosis

• Uncomplicated brucellosis in adults and children eight years of age and older

• Preferred regimen: Doxycycline 100 mg bid for six weeks OR Tetracycline 500 mg every six hours orally administered for at least six weeks
• NOTE: Streptomycin 1 g/day intramuscularly administered for the first two to three weeks of therapy OR Gentamicin 5mg/kg/day intravenously or intramuscularly for 7-10 days in combination with Doxycycline administered for six weeks
• Alternative regimen (1): Doxycycline 200 mg/day orally AND Rifampicin 600–900 mg/day orally, both drugs administered for six weeks
• Alternative regimen (2): Fluoroquinolones
• NTOE: Quinolones should always be used in combination with other drugs, such as Doxycycline or Rifampicin
• Alternative regimen (3): TMP/SMZ in a fixed ratio of 1:5 (80 mg TMP/400 mg SMZ)
• NOTE: TMP/SMZ should always be used in combination with another agent, such as Doxycycline, Rifampicin or Streptomycin

• Complications of brucellosis

• Spondylitis

• Preferred regimen: Continuation of Doxycycline for eight weeks or more; Surgical drainage is rarely necessary.

• Neurobrucellosis

• Preferred regimen: Rifampicin OR Trimethoprim/sulfamethoxazole, be added to the standard regimen of Doxycycline AND Streptomycin for 6-8 weeks, and possibly longer, depending on the clinical response

• Brucella endocarditis

• Preferred regimen: Doxycycline AND an Aminoglycoside for at least eight weeks, and therapy should be continued for several weeks after surgery when valve replacement is necessary
• NOTE: Rifampicin OR Trimethoprim/sulfamethoxazole are used for their ability to penetrate cell membranes

• For children less than eight years of age

• Preferred regimen: TMP/SMZ 8/40 mg/ kg/day bid orally administered for six weeks AND Streptomycin 30 mg/kg/day once daily intramuscularly administered for three weeks OR Gentamicin 5 mg/kg/day once daily intravenously or intramuscularly administered for 7-10 days
• Alternative regimen (1): TMP/SMZ AND Rifampicin 15 mg/kg/day orally each administered for 6 weeks

• Alternative regimen (2): Rifampicin AND an Aminoglycoside

Ehrlichiosis

• Ehrlichiosis, suspected

• Preferred regimen: Doxycycline 100 mg every 12 hours for 7-14 days
• Alternative regimen: Chloramphenicol OR Rifampin
• Pediatric regimen: Doxycycline 2.2 mg/kg body weight given twice a day (Children under 45 kg (100 lbs)) for 7-14 days
• NOTE: Patients should be treated for at least 3 days after the fever subsides and until there is evidence of clinical improvement

Tularemia

• For treatment and prophylaxis

• Preferred regimen: Gentamicin 5 mg/kg daily, divided into two doses
• Alternative regimen (1): Streptomycin intramuscular 2 g daily, divided in two doses, for 10 days
• Alternative regimen (2): Ciprofloxacin 800–1000 mg daily, divided into two doses intravenously or orally, for 10–14 days
• Alternative regimen (3): Doxycycline, 200 mg daily, divided in two, orally for at least 15 days
• Pediatric regimen: Gentamicin 5–6 mg/kg divided into two or three doses for at least 10 days; Streptomycin 15 mg/kg twice daily (up to 2 g daily) for at least 10 days; Ciprofloxacin 15 mg/kg twice daily (up to 1 g daily) for at least 10 days

Typhoid fever

• Uncomplicated typhoid fever

• Fully sensitive

• Preferred regimen: Ofloxacin OR Ciprofloxacin 15 mg/kg daily dose for 5-7 days
• Alternative regimen (1): Chloramphenicol 50-75 mg/kg daily dose for 14-21 days
• Alternative regimen (2): Amoxicillin 75-100 mg/kg daily dose for 14 days
• Alternative regimen (3): TMP-SMX 8-40 mg/kg daily dose for 14 days

• Multidrug resistance

• Preferred regimen: Fluoroquinolone 15 mg/kg daily dose for 5-7 days OR Cefixime 15-20 mg/kg daily dose for 7-14 days
• Alternative regimen (1): Azithromycin 8-10 mg/kg daily dose for 7 days
• Alternative regimen (2): Cefixime 15-20 mg/kg daily dose for 7-14 days

• Quinolone resistance

• Preferred regimen: Azithromycin 8-10 mg/kg daily dose for 7 days OR Ceftriaxone 75 mg/kg daily dose for 10-14 days
• Alternative regimen: Cefixime 20 mg/kg daily dose for 7-14 days

• Severe typhoid fever

• Fully sensitive

• Preferred regimen: Ofloxacin 15 mg/kg daily dose for 10-14 days
• Alternative regimen (1): Chloramphenicol 100 mg/kg daily dose for 14-21 days
• Alternative regimen (2): Amoxicillin 100 mg/kg daily dose for 14 days
• Alternative regimen (3): TMP-SMX 8-40 mg/kg daily dose for 14 days

• Multidrug resistant

• Preferred regimen: Fluoroquinolone 15 mg/kg daily dose for 10-14 days
• Alternative regimen (1): Ceftriaxone 60 mg/kg daily dose for 10-14 days
• Alternative regimen (2): Cefotaxime 80 mg/kg daily dose for 10-14 days

• Quinolone resistant

• Preferred regimen: Ceftriaxone 60 mg/kg daily dose for 10-14 days OR Cefotaxime 80 mg/kg daily dose for 10-14 days
• Alternative regimen: Fluoroquinolone 20 mg/kg daily dose for 7-14 days

Kawasaki syndrome

• Initial treatment

• Preferred regimen: IVIG 2 g/kg in a single infusion within the first 7-10 days of illness AND Aspirin 80-100 mg/kg per day in 4 doses , reduce the aspirin dose after the child has been afebrile for 48 to 72 hours, then begin low-dose aspirin (3 to 5 mg/kg per day) and maintain it until the patient shows no evidence of coronary changes by 6 to 8 weeks after the onset of illness
• NOTE (1): Other clinicians continue highdose aspirin until day 14 of illness and 48 to 72 hours after fever cessation
• NOTE (2): For children who develop coronary abnormalities, aspirin may be continued indefinitely

• Treatment of Patients Who Failed to Respond to Initial Therapy (persistent or recrudescent fever ≥36 hours after completion of the initial IVIG infusion)

• Preferred regimen: IVIG 2 g/kg OR intravenous pulse Methylprednisolone 30 mg/kg for 2 to 3 hours, administered once daily for 1 to 3 days

Leptospirosis

• Severe

• Preferred regimen: High doses of intravenous Penicillin

• Less severe

• Preferred regimen: Amoxycillin OR Ampicillin OR Doxycycline OR Erythromycin orally
• Alternative regimen: Ceftriaxone OR Cefotaxime OR Quinolone orally
• NOTE (1): Treatment with effective antibiotics should be initiated as soon as the diagnosis of leptospirosis is suspected and preferably before the fifth day after the onset of illness
• NOTE (2): Clinicians should never wait for the results of laboratory tests before starting treatment with antibiotics because serological tests do not become positive until about a week after the onset of illness, and cultures may not become positive for several weeks.