Treatment regimens for cat scratch disease^[1-5]

Manifestation	Regimens^*	Adult dosing	Pediatric dosing (<18 years of age)	Duration	Comments
Lymphadenitis	Preferred regimen:				Adjunctive therapies (needle aspiration, glucocorticoids) may be warranted in patients with severe or refractory disease.^¶
	Azithromycin	500 mg orally on day 1, followed by 250 mg orally daily for 4 days	≤45.5 kg: 10 mg/kg orally on day 1 (maximum 500 mg/dose), followed by 5 mg/kg orally for 4 days (maximum 250 mg/dose) >45.5 kg: 500 mg orally on day 1, followed by 250 mg for 4 days	5 days
	Alternative regimens:^Δ
	Clarithromycin	500 mg orally twice daily	≤45.5 kg: 15 to 20 mg/kg/day orally in 2 divided doses (maximum 500 mg/dose) >45.5 kg: 500 mg orally twice daily	7 to 10 days
	or
	Rifampin^◊	300 mg orally twice daily	10 mg/kg orally twice daily (maximum 300 mg/dose)	7 to 10 days
	or
	Trimethoprim-sulfamethoxazole^§	1 double-strength tablet orally twice daily	4 mg/kg orally (based on trimethoprim component) twice daily (maximum 160 mg [trimethoprim]/dose)	7 to 10 days
Hepatosplenic disease/fever of unknown origin	Preferred regimen:				Adjunctive glucocorticoids may be warranted in patients with severe or persistent disease.^¶
	Rifampin^◊	300 mg orally or IV twice daily	10 mg/kg orally or IV twice daily (maximum 300 mg/dose)	Give combination regimen for 10 to 14 days
	plus
	Azithromycin	500 mg orally or IV on day 1, followed by 250 mg orally or IV daily thereafter	≤45.5 kg: 10 mg/kg orally or IV on day 1 (maximum 500 mg/dose), followed by 5 mg/kg orally or IV daily thereafter (maximum 250 mg/dose) >45.5 kg: 500 mg orally or IV on day 1, followed by 250 mg orally or IV daily thereafter
	Alternative regimens:
	Rifampin^◊	300 mg orally or IV twice daily	10 mg/kg orally or IV every 12 hours (maximum 300 mg/dose)	Give combination regimen for 10 to 14 days
	plus
	Gentamicin^¥	3 mg/kg IV every 24 hours (if renal function normal)	3 mg/kg IV every 24 hours (if renal function normal)
	or
	Azithromycin	500 mg orally or IV once daily	Not recommended for use in children or adolescents	5 days
Neuroretinitis	Preferred regimen:				Patients with neuroretinitis should also receive adjunctive glucocorticoids. We suggest a 6-week course of prednisone: 1 mg/kg orally once daily (maximum 80 mg per dose) for the first 2 weeks, followed by a gradual taper over the following 4 weeks.
	Rifampin^◊	300 mg orally or IV twice daily	Children ≥8 years of age: 10 mg/kg orally or IV twice daily (maximum 300 mg/dose)	Give combination regimen for 4 to 6 weeks
	plus
	Doxycycline^‡	100 mg orally or IV twice daily	Children ≥8 years of age: ≤45 kg: 2.2 mg/kg orally or IV twice daily (maximum 100 mg/dose) >45 kg: 100 mg orally or IV twice daily
	Alternative regimens:
	Rifampin^◊	300 mg orally or IV twice daily	For children <8 years of age and those unable to take doxycycline:^‡ 10 mg/kg orally or IV twice daily (maximum 300 mg/dose)	Give combination regimen for 4 to 6 weeks
	plus either
	Azithromycin	500 mg orally or IV on day 1, followed by 250 mg orally or IV daily thereafter	For children <8 years of age and those unable to take doxycycline:^‡ ≤45.5 kg: 10 mg/kg orally or IV on day 1 (maximum 500 mg/dose), followed by 5 mg/kg orally or IV daily thereafter (maximum 250 mg/dose) >45.5 kg: 500 mg orally or IV on day 1, followed by 250 mg orally or IV daily thereafter
	or
	Trimethoprim-sulfamethoxazole^◊	1 double-strength tablet orally twice daily or 160 mg (trimethoprim component) IV twice daily	For children <8 years of age and those unable to take doxycycline:^‡ 4 mg/kg orally or IV (based on trimethoprim component) twice daily (maximum 160 mg [trimethoprim]/dose)
Other neurologic involvement (including encephalitis) and Parinaud oculoglandular disease	Same regimens as for neuroretinitis			10 to 14 days	Adjunctive glucocorticoids may be warranted in patients with severe or persistent disease.^¶

This table is for use in conjunction with UpToDate content on treatment of cat scratch disease. The doses recommended above are intended for patients with normal renal function; the doses of some of these agents must be adjusted in patients with reduced kidney function. Refer to the drug-specific monographs included within UpToDate for renal dose adjustments. Patients with advanced HIV (eg, CD4 count <100 cells/microL) may have additional clinical manifestations (eg, bacillary angiomatosis). Refer to the UpToDate topic on diagnosis, treatment, and prevention of Bartonella infections in patients with HIV for additional details.

IV: intravenous.

* The preferred and alternative regimens listed in this table are for nonpregnant patients.

¶ On rare occasion, adjunctive corticosteroids may be reasonable in those with severe or persistent disease other than neuroretinitis. In this setting, an initial dose of 1 mg/kg of prednisone (maximum daily dose 80 mg/day) can be administered for five to seven days, with a taper over the subsequent 10 to 14 days.

Δ Ciprofloxacin (500 mg orally twice daily for 7 to 10 days) may be considered as an alternative treatment option in immunocompetent adults who cannot receive other regimens.

◊ Patients should be carefully screened for drug-drug interactions prior to initiating rifampin.

§ Trimethoprim-sulfamethoxazole is dosed based upon the trimethoprim component. One double-strength tablet is equivalent to 160 mg of trimethoprim.

¥ In non-obese, average-weight adult patients, the gentamicin dose is based on ideal body weight. Renal function and gentamicin serum concentrations should be monitored at least once per week. The gentamicin dosing listed is recommended for patients with normal renal function; the initial gentamicin dose should be adjusted in patients with renal impairment and as needed based on serum concentration monitoring during treatment. Refer to the UpToDate topic on dosing and administration of parenteral aminoglycosides for further guidance.

‡ In general, we avoid prolonged doxycycline in children <8 years old because of concern of dental staining. However, doxycycline can be administered for ≤21 days without regard to the child's age. In patients with sight-threatening neuroretinitis or severe neurologic disease, the risks and benefits of doxycycline should be considered and discussed. Refer to the UpToDate topic that discusses treatment of cat scratch disease for further detail.

References:

Bass JW, Freitas BC, Freitas AD, et al. Prospective randomized double blind placebo-controlled evaluation of azithromycin for treatment of cat-scratch disease. Pediatr Infect Dis J 1998; 17:447.
Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis 2014; 59:147.
Rolain JM, Brouqui P, Koehler JE, et al. Recommendations for treatment of human infections caused by Bartonella species. Antimicrob Agents Chemother 2004; 48:1921.
Holley HP Jr. Successful treatment of cat-scratch disease with ciprofloxacin. JAMA 1991; 265:1563.
Arisoy ES, Correa AG, Wagner ML, et al. Hepatosplenic cat-scratch disease in children: selected clinical features and treatment. Clin Infect Dis 1999; 28:778.

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Treatment regimens for cat scratch disease[1-5]

Treatment regimens for cat scratch disease^[1-5]