Meta-analysis of Drug Treatment for Scrub Typhus in Asia

Fang, Yirong; Huang, Zhaohui; Tu, Chunyu; Zhang, Lijie; Ye, Dong-Qing; Zhu, Bao–Ping

doi:10.2169/internalmedicine.51.7816

Cited by 39 publications

(38 citation statements)

References 25 publications

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“…Antibiotic treatment of severe scrub typhus is doxycycline 44 or chloramphenicol. 1,45 However, only the oral formulation of doxycycline is available in Thailand. The use of oral doxycycline may not allow the achievement of therapeutic levels due to hemodynamic instability 1 as seen in patient 6 (Table 5).…”

Section: Methodsmentioning

confidence: 99%

Scrub Typhus in Northeastern Thailand: Eschar Distribution, Abnormal Electrocardiographic Findings, and Predictors of Fatal Outcome

Thipmontree

Tantibhedhyangkul

Silpasakorn

et al. 2016

The American Society of Tropical Medicine and Hygiene

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Abstract. Scrub typhus is endemic in Thailand. Of the 495 patients with acute undifferentiated fever studied in Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima, Thailand, from June 1, 2011, to December 31, 2012, 146 patients (29.5%) had confirmed scrub typhus. The majority of cases were male, farmers, with the mean (±standard deviation) age of 54.1 ± 15.2 years. A total of 59 patients (40.4%) had eschar lesion. The commonest sites for an eschar in male patients were the perineum, inguinal, and buttock area; whereas in females, it was the head and neck area. Abnormal electrocardiogram was found in 39 of 79 patients (49.4%) with sinus tachycardia being the most frequent finding (17, 21.5%). A total of 73 patients (50%) had at least one complication. Myocarditis was the cause of complete heart block in a scrub typhus patient, and he fully recovered after receiving intravenous chloramphenicol treatment. The case fatality rate was 6.2% (nine deaths).The independent predictors for fatal outcome were age over 65 years (odds ratio [OR] = 14.49, 95% confidence interval [CI] = 1.26-166.44, P = 0.03), acute kidney injury (OR = 12.75, 95% CI = 1.77-92.07, P = 0.01), and hyperbilirubinemia (OR = 24.82, 95% CI = 2.12-286.61, P = 0.01). Early diagnosis and prompt appropriate treatment can improve the patient's outcome.

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Section: Methodsmentioning

confidence: 99%

Scrub Typhus in Northeastern Thailand: Eschar Distribution, Abnormal Electrocardiographic Findings, and Predictors of Fatal Outcome

Thipmontree

Tantibhedhyangkul

Silpasakorn

et al. 2016

The American Society of Tropical Medicine and Hygiene

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“…In the clinical setting, a diagnosis of scrub typhus is considered when a patient with an AFI has an eschar and a positive IgM ELISA for scrub typhus and other causes of fever excluded [74] . In the absence of an eschar, a positive IgM ELISA in the appropriate clinical setting with defervescence within 48-h of initiation of associated with significantly shorter median time to clearance of fever and lower adverse events when compared with azithromycin [75] . Six studies compared doxycycline with chloramphenicol; symptom clearance time was significantly shorter with doxycycline [75] .…”

Section: Diagnosismentioning

confidence: 98%

“…In the absence of an eschar, a positive IgM ELISA in the appropriate clinical setting with defervescence within 48-h of initiation of associated with significantly shorter median time to clearance of fever and lower adverse events when compared with azithromycin [75] . Six studies compared doxycycline with chloramphenicol; symptom clearance time was significantly shorter with doxycycline [75] . No significant differences were observed in symptom duration comparing azithromycin with doxycycline (3 studies), roxithromycin with doxycycline (3 studies) and doxycycline with either rifampicin or tetracycline (2 studies each) [75] .…”

Section: Diagnosismentioning

confidence: 98%

Severe scrub typhus infection: Clinical features, diagnostic challenges and management

Peter

Sudarsan

Prakash

et al. 2015

WJCCM

139

121

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Scrub typhus infection is an important cause of acute undifferentiated fever in South East Asia. The clinical picture is characterized by sudden onset fever with chills and non-specific symptoms that include headache, myalgia, sweating and vomiting. The presence of an eschar, in about half the patients with proven scrub typhus infection and usually seen in the axilla, groin or inguinal region, is characteristic of scrub typhus. Common laboratory findings are elevated liver transaminases, thrombocytopenia and leukocytosis. About a third of patients admitted to hospital with scrub typhus infection have evidence of organ dysfunction that may include respiratory failure, circulatory shock, mild renal or hepatic dysfunction, central nervous system involvement or hematological abnormalities. Since the symptoms and signs are non-specific and resemble other tropical infections like malaria, enteric fever, dengue or leptospirosis, appropriate laboratory tests are necessary to confirm diagnosis. Serological assays are the mainstay of diagnosis as they are easy to perform; the reference test is the indirect immunofluorescence assay (IFA) for the detection of IgM antibodies. However in clinical practice, the enzyme-linked immuno-sorbent assay is done due to the ease of performing this test and a good sensitivity and sensitivity when compared with the IFA. Paired samples, obtained at least two weeks apart, demonstrating a ≥ 4 fold rise in titre, is necessary for confirmation of serologic diagnosis. The mainstay of treatment is the tetracycline group of antibiotics or chloramphenicol although macrolides are used alternatively. In mild cases, recovery is complete. In severe cases with multi-organ failure, mortality may be as high as 24%.

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“…A previous study showed that fever decreased dra-matically after patients with scrub typhus were treated; the median time to defervescence, which was obtained by the Kaplan-Meier method, was 21 h for the azithromycin group and 29 h for the doxycycline group (11). In addition, a recently published meta-analysis on the outcomes of drug treatments in Asian patients with scrub typhus showed no significant differences between azithromycin and doxycycline treatments for the duration of fever, rapidness of symptom clearance, or rate of treatment failure (17). However, the above study failed to demonstrate the dynamics of scrub typhus clinical symptoms.…”

mentioning

confidence: 98%

Dynamics of Clinical Symptoms in Patients with Scrub Typhus

Lee

Chung

et al. 2013

Jpn J Infect Dis

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SUMMARY:The clinical manifestations and complications of scrub typhus are variable. Few studies have examined the timeline of clinical symptoms after the appropriate antimicrobial agents have been administered. The most prevalent clinical manifestations are fever and cough, followed by headache, myalgia, eschar, skin rash, and nausea. Systemic symptoms are most severe during the early stages of illness (i.e., the first 5 days), but resolve slowly within 2 weeks. The associated skin rash is most severe during the first 8 days of infection, but it resolves slowly within 21 days.Scrub typhus is a potentially fatal infectious disease caused by the organism Orientia tsutsugamushi (1). Typical signs include eschar formation and acute febrile illness with symptoms that include abrupt fever, chills, rash, lymphadenopathy, abdominal pain, and myalgia (2,3). The clinical manifestations and complications of scrub typhus vary; most symptoms are mild but severe complications have been reported, including acute respiratory distress syndrome, encephalitis, interstitial pneumonia, myocarditis and pericarditis, acute renal failure, and acute hepatic failure (4-10). Very few reports describe the clinical course beyond the occurrence of fever after the appropriate antimicrobial agents have been administered (11). An established timeline of the clinical symptoms may help physicians manage patients with scrub typhus more effectively.This study was conducted in 5 university medical centers in Korea between October and December 2010. In the current study, we used several diagnostic criteria for scrub typhus. First, a diagnosis of scrub typhus was made according to the World Health Organization criteria in 4 out of 5 hospitals when specific IgM antibody titers were equal to or greater than 1:10, or IgG titers were either equal to or greater than 1:256, or a 4-fold increase in titer was demonstrated using paired serum samples in an indirect immunofluorescence antibody (IFA) test (11,12). The O. tsutsugamushi strains used in the IFA test included Gilliam, Karp, Kato, and Boryong. Second, in the remaining hospital, O. tsutsugamushi was detected in passive hemagglutination assay (PHA) against O. tsutsugamushi with an antibody titer of 1:80 or greater in a single serum sample or 4-fold increase or greater during follow-up (13,14). The PHA was conducted using the Genedia Tsutsu PHA II test kit (Green Cross Corp., Yongin, Korea), which provides qualitative and quantitative detection of serum antibodies against O. tsutsugamushi. Sheep erythrocytes for the PHA were sensitized with the Karp and Gilliam strains, including the Boryong strain found in Korea (11,12).Respiratory symptoms included cough and dyspnea. Systemic symptoms included subjective fever, chills, headache, weight loss, and myalgia. Gastrointestinal symptoms included nausea, vomiting, diarrhea, and abdominal pain (15). Neurologic symptoms included mental confusion and delirium. Moreover, a skin rash was also observed. Symptom severity was scored using a 4-point scale: no symptoms...

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Meta-analysis of Drug Treatment for Scrub Typhus in Asia

Cited by 39 publications

References 25 publications

Scrub Typhus in Northeastern Thailand: Eschar Distribution, Abnormal Electrocardiographic Findings, and Predictors of Fatal Outcome

Scrub Typhus in Northeastern Thailand: Eschar Distribution, Abnormal Electrocardiographic Findings, and Predictors of Fatal Outcome

Severe scrub typhus infection: Clinical features, diagnostic challenges and management

Dynamics of Clinical Symptoms in Patients with Scrub Typhus

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