Sandbox ID Systemic

Babesiosis

• Pathogen-directed antimicrobial therapy
• Preferred regimen (1): Combined therapy with Clindamycin and Quinine
• Preferred regimen (2): Both Atovaquone (a hydroxy-1,4-naphthoquinone) alone and Azithromycin (an azalide macrolide) alone appeared to be effective.

Note : Neither the regimen of Atovaquone and Azithromycin nor the regimen of Clindamycin and Quinine clears Babesiosis microti merozoites from the human blood as rapidly as might be desired.

Bartonella

• Bartonellosis or Carrion's disease

• The acute phase, or hematic phase, known as Oroya Fever

• Preferred regimen: Ciprofloxacin for 10 days- for patients younger than 7 years old, the scheme is 10 mg/kg divided into two doses, for patients between 7 and 14 years old the dose is 250 mg BID, and for patients older than 14 years old the dose is 500 mg BID
• Alternative regimen: Chloramphenicol 50mg/kg/day, divided into four doses during the first three days, and then 25 mg/kg/day until completing 14 days of treatment

Note (1): If a complication occurs during the acute phase, and the patient is not pregnant, then the treatment would be Ciprofloxacin AND (Ceftriaxone or Ceftazidime) during 10 days.

Note (2): If a pregnant patient has complicated acute Bartonellosis, the treatment is Chloramphenicol 50-100 mg/kg/day, divided into four doses, AND Penicillin G 50,000-100,000 IU/kg/day divided into 4 or 6 doses, for 14 days. (A complication should be suspected if there is no improvement within the first 72 hours of treatment.)

Note (3): The treatment schemes based on ciprofloxacin and chloramphenicol have the advantage of also covering the possibility of Salmonella species and Haemophilus influenzae in the pediatric population

Note (4): Patients with neurobartonellosis, respiratory distress syndrome, coagulopathy, and/or moderate to severe pericarditis may benefit from corticosteroids, such as Dexamethasone (0.5-1 mg/kg/day for three days).

Note (5): Red blood cell transfusions in the amount of 10-20mL/kg are given when the hematocrit is less than 20%.

Note (6): In case of severe pericardial tamponade, a pericardiectomy is done.

• The eruptive phase or tissue phase, known as Peruvian Wart

• Preferred regimen: Rifampin 10 mg/kg/day QID during 14 to 21 days.
• Alternative regimen: Azithromycin OR Erythromycin, OR Ciprofloxacin can be given for 7 to 14 days.

Note (1): In this phase, Chloramphenicol and Penicillin are not useful.

Note (2): In vitro analysis, Bacillus bacilliformis showed susceptibility to most beta-lactams, Rifampin, Erythromycin, Macrolides, Tetracycline, Quinolones, and Chloramphenicol.

Note (2): The bacterium is resistant to Vancomycin, Clindamycin, and Aminoglycosides.

Fever of unknown origin

• Fever of unknown origin (FUO)

• Management should generally be withheld until the etiology of the fever has been ascertained, so that treatment can be directed against a specific pathology.
• Specific clinical considerations

• Neutropenic fever

• Exception may be made for neutropenic patients in which delayed treatment could lead to serious complications.
• After samples for cultures are obtained, patients with febrile neutropenia should be aggressively treated with broad-spectrum antibiotics covering Pseudomonas.

• HIV/AIDS individuals

• HIV/AIDS individuals with pyrexia and hypoxia should be placed on empiric therapy for Pneumocystis jirovecii.

• Giant cell arteritis

• Empiric corticosteroids may be considered in patients with suspected giant cell arteritis to prevent vascular complications.
• Giant cell arteritis should be suspected in a patient over the age of 50 with the following symptoms:

• Newly onset headaches
• Abrupt onset of blurry vision
• Symptoms of polymyalgia rheumatica
• Jaw claudication
• Unexplained anemia
• Elevated ESR and/or CRP