Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

suspected Bartonella endocarditis

1st line – empiric antibiotic therapy plus supportive care

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INITIAL
|
suspected Bartonella endocarditis
1st line – 

empiric antibiotic therapy plus supportive care

Untreated cases of Bartonella endocarditis can lead to cardiac complications including valvular damage, abscesses, and heart failure.

When B henselae or B quintana is suspected as a cause of endocarditis and confirmatory tests are pending, ceftriaxone is given in addition to gentamicin plus doxycycline.[10][58] If there is a concern for kidney injury, rifampin may be used in place of gentamicin.[59]

Ceftriaxone does not provide antimicrobial coverage for Bartonella species; once the diagnosis of Bartonella endocarditis is confirmed, ceftriaxone should be discontinued.

Due to the lack of effective alternative antibiotics for Bartonella endocarditis and serious nature of the infection, doxycycline use is warranted in children of all ages. Consultation with a pediatric infectious disease specialist is recommended.[59]

Supportive care for Bartonella endocarditis is the same as for other types of endocarditis: careful attention to fluid and electrolytes balance, ECG monitoring, and management for heart failure. 

Primary options

gentamicin: children: consult specialist for guidance on dose; adults: 3 mg/kg intravenously every 24 hours, or 1 mg/kg intravenously every 8 hours

More

and

doxycycline: children <8 years of age: 2.2 mg/kg intravenously/orally every 12 hours, maximum 200 mg/day; children ≥8 years of age and adults: 100 mg intravenously/orally every 12 hours

and

ceftriaxone: children: 100 mg/kg/day intravenously/intramuscularly given in divided doses every 12 hours, maximum 4 g/day; adults: 2 g intravenously/intramuscularly every 12-24 hours

OR

rifampin: children: consult specialist for guidance on dose; adults: 300 mg intravenously/orally every 12 hours

and

doxycycline: children <8 years of age: 2.2 mg/kg intravenously/orally every 12 hours, maximum 200 mg/day; children ≥8 years of age and adults: 100 mg intravenously/orally every 12 hours

and

ceftriaxone: children: 100 mg/kg/day intravenously/intramuscularly given in divided doses every 12 hours, maximum 4 g/day; adults: 2 g intravenously/intramuscularly every 12-24 hours

ACUTE

cat-scratch disease: no endocarditis, hepatic involvement or bacillary angiomatosis

1st line – monitoring plus supportive care

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ACUTE
|
cat-scratch disease: no endocarditis, hepatic involvement or bacillary angiomatosis
1st line – 

monitoring plus supportive care

Immunocompetent patients tend to present with a mild to moderate infection - antibiotics are not necessary.[10][45]​ Symptoms generally subside within several weeks.

Patients with painful lymphadenopathy may require analgesics. Patients with fever should receive appropriate antipyretics.

Needle aspiration is indicated for suppurative lymph nodes; multiple aspirations may be necessary.

Untreated patients need close monitoring and follow-up; antibiotics should be initiated if signs and symptoms are worsening or persistent.

Primary options

acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: children: 10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; adults: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Plus – antibiotic therapy

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ACUTE
|
cat-scratch disease: no endocarditis, hepatic involvement or bacillary angiomatosis
|
immunocompromised or large nodes
Plus – 

antibiotic therapy

Treatment recommended for ALL patients in selected patient group

Immunocompromised patients with any severity of infection or immunocompetent patients with large nodes should be treated with azithromycin.[10][45][62]​ Alternatively, a combination of doxycycline with rifampin can be used.

In patients with HIV, doxycycline or erythromycin monotherapy has been recommended as preferred therapy.[54]

Although tooth discoloration is a general concern in children ages <8 years, the AAP recommends that doxycycline can be used irrespective of age for short durations (≤21 days).[59]

Treatment course: 5 days (azithromycin), 7-10 days (other antibiotics).

Prolonged treatment (at least 3 months) is recommended for patients with HIV.[54]

Primary options

azithromycin: children: 10 mg/kg orally on day 1, followed by 5 mg/kg once daily; adults: 500 mg orally on day 1, followed by 250 mg once daily

Secondary options

doxycycline: children <8 years of age: 2.2 mg/kg intravenously/orally every 12 hours, maximum 200 mg/day; children ≥8 years of age and adults: 100 mg intravenously/orally every 12 hours

and

rifampin: children: 20 mg/kg/day orally/intravenously given in 2 divided doses, maximum 600 mg/day; adults: 300 mg orally/intravenously twice daily

OR

doxycycline: children ≥8 years of age and adults: 100 mg orally/intravenously twice daily

OR

erythromycin base: children: 40 mg/kg/day orally given in 4 divided doses, maximum 2000 mg/day; adults: 500 mg orally four times daily

OR

erythromycin lactobionate: children: 20 mg/kg/day intravenously given in 4 divided doses, maximum 2000 mg/day; adults: 500 mg intravenously every 6 hours

trench fever: no endocarditis or bacillary angiomatosis

1st line – antibiotic therapy

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ACUTE
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trench fever: no endocarditis or bacillary angiomatosis
1st line – 

antibiotic therapy

Bartonella quintana infection generally causes trench fever at the acute stage. It may resolve spontaneously, but may progress to chronic bacteremia and endocarditis in untreated cases.

Patients in the acute and chronic stages should be treated with a combination of doxycycline and gentamicin.

Adult patients can be treated with oral doxycycline for 28 days and intravenous gentamicin for 14 days.[10][64][65]​

Erythromycin and gentamicin can be used in adults who have a contraindication to doxycycline.

Doxycycline is not recommended in children ages <8 years for longer than 21 days, as tooth discoloration is a concern.[59]​ Instead, gentamicin and erythromycin can be used as an alternative in this group.

Treatment course: 28 days (doxycycline, erythromycin); 14 days (gentamicin).

Primary options

doxycycline: children ≥8 years of age and adults: 100 mg orally/intravenously twice daily for 28 days

or

erythromycin base: children: 40 mg/kg/day orally given in 4 divided doses, maximum 2000 mg/day; adults: 500 mg orally four times daily

-- AND --

gentamicin: children and adults: 3 mg/kg intravenously every 24 hours

More

Consider – treatment of pediculosis

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ACUTE
|
trench fever: no endocarditis or bacillary angiomatosis
Consider – 

treatment of pediculosis

Treatment recommended for SOME patients in selected patient group

Body louse infestation (pediculosis) can usually be managed with improvements to personal hygiene, including changing into clean clothes at least once a week, and washing and machine drying clothing, bedding, and towels with hot water (at least 130°F [54°C]).[66]​ However, treatment with insecticides and/or a pediculicide may be advisable in the case of associated Bartonella infection to prevent reinfection or further transmission. Insecticides such as DDT, malathion, or permethrin may be used to treat clothing and bedding. Recommended pediculicides are the same as for head lice.[66] See Pediculosis capitis (Management approach).

bacillary angiomatosis

1st line – antibiotic therapy

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ACUTE
|
bacillary angiomatosis
1st line – 

antibiotic therapy

This is a vascular proliferative disease, which is caused by Bartonella henselae and B quintana in immunocompromised patients, especially those with HIV infection.[4][5]​ Bacillary angiomatosis occurs in late-stage HIV infection when CD4 counts are less than 50 cells/microliter.[54] Appropriate therapy is important to prevent infection from spreading, with possibly fatal results.

The antibiotics of choice for the treatment of bacillary angiomatosis are erythromycin or doxycycline for 3 months or longer.[54] Doxycycline is not recommended in children ages <8 years for longer than 21 days, as tooth discoloration is a concern.[59]

Although there are insufficient data published to support its use, azithromycin for 3 months has also been used successfully.[67] Given its good coverage for both B henselae and B quintana, azithromycin may be used as an alternative to erythromycin or doxycycline.[54] Clarithromycin may also be considered as an alternative, but there is limited evidence to support its use.[54]

Treatment course: 3 months.

Primary options

erythromycin base: children: 40 mg/kg/day orally given in 4 divided doses, maximum 2000 mg/day; adults: 500 mg orally four times daily

OR

doxycycline: children ≥8 years of age and adults: 100 mg orally twice daily

Secondary options

azithromycin: children: 10 mg/kg orally once daily; adults: 500 mg orally once daily

OR

clarithromycin: children: 7.5 mg/kg orally twice daily, maximum 1000 mg/day; adults: 500 mg orally twice daily

Consider – supportive care

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ACUTE
|
bacillary angiomatosis
Consider – 

supportive care

Treatment recommended for SOME patients in selected patient group

Supportive care includes appropriate antipyretics for fever, and measures to improve immunity in immunocompromised patients (e.g., antiretroviral therapy for HIV/AIDS, decreased use of immunosuppressive agents in transplant patients).

Primary options

acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: children: 10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; adults: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Consider – treatment of pediculosis

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ACUTE
|
bacillary angiomatosis
Consider – 

treatment of pediculosis

Treatment recommended for SOME patients in selected patient group

Body louse infestation (pediculosis) can usually be managed with improvements to personal hygiene, including changing into clean clothes at least once a week, and washing and machine drying clothing, bedding, and towels with hot water (at least 130°F [54°C]).[66]​ However, treatment with insecticides and/or a pediculicide may be advisable in the case of associated Bartonella infection to prevent reinfection or further transmission. Insecticides such as DDT, malathion, or permethrin may be used to treat clothing and bedding. Recommended pediculicides are the same as for head lice.[66] See Pediculosis capitis (Management approach).

peliosis hepatis or hepatosplenic microabscesses

1st line – antibiotic therapy

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ACUTE
|
peliosis hepatis or hepatosplenic microabscesses
1st line – 

antibiotic therapy

Immunocompromised adults and children may present with peliosis hepatis, characterized by dilated capillaries and blood-filled cavernous spaces in the liver. Patients manifest with fever, chills, gastrointestinal symptoms, and hepatosplenomegaly.

Peliosis hepatis should be treated with erythromycin or doxycycline for ≥3 months.[54] Doxycycline is not recommended in children ages <8 years for longer than 21 days, as tooth discoloration is a concern.[59]​

Immunocompetent children may also present with hepatosplenic microabscesses secondary to B henselae infection. These respond well to a 2-week course of treatment with rifampin alone or in combination with gentamicin or trimethoprim/sulfamethoxazole.[68]

Treatment course: ≥3 months for peliosis hepatis. 10-14 days for hepatosplenic microabscesses

Primary options

Peliosis hepatis

erythromycin base: children: 40 mg/kg/day orally given in 4 divided doses, maximum 2000 mg/day; adults: 500 mg orally four times daily

OR

Peliosis hepatis

doxycycline: children ≥8 years of age and adults: 100 mg orally twice daily

OR

Hepatosplenic microabscesses

rifampin: children: 20 mg/kg/day orally/intravenously given in 2 divided doses, maximum 600 mg/day

OR

Hepatosplenic microabscesses

rifampin: children: 20 mg/kg/day orally/intravenously given in 2 divided doses, maximum 600 mg/day

-- AND --

gentamicin: children: 3 mg/kg intravenously every 24 hours

More

or

sulfamethoxazole/trimethoprim: children >2 months of age: 8-10 mg/kg/day intravenously/orally given in divided doses every 6-12 hours

More

Consider – supportive care

Back
ACUTE
|
peliosis hepatis or hepatosplenic microabscesses
Consider – 

supportive care

Treatment recommended for SOME patients in selected patient group

Supportive care includes appropriate antipyretics for fever, and measures to improve immunity in immunocompromised patients (e.g., antiretroviral therapy for HIV/AIDS, decreased use of immunosuppressive agents in transplant patients).

Primary options

acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: children: 10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; adults: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

confirmed Bartonella endocarditis

1st line – antibiotic therapy plus supportive care

Back
ACUTE
|
confirmed Bartonella endocarditis
|
immunocompetent
1st line – 

antibiotic therapy plus supportive care

When Bartonella is confirmed as the pathogen for endocarditis, the patient is preferably treated with gentamicin (14 days) in combination with doxycycline (6 weeks).[10][58]​​​​ If there is a concern for kidney injury, rifampin plus doxycycline should be used (6 weeks).[54][59]​​​

Due to the lack of effective alternative antibiotics for Bartonella endocarditis and serious nature of the infection, doxycycline use is warranted in children of all ages despite the longer treatment course (>21 days). Consultation with a pediatric infectious disease specialist is recommended.[59]

Seek advice from an infectious disease specialist if the patient has confirmed endocarditis due to an unusual Bartonella species (e.g., B bacilliformis).[10]​​[17][47]

A follow-up echocardiogram may be helpful in visualizing resolution of valvular vegetations, where applicable.

Supportive care for Bartonella endocarditis is the same as for other types of endocarditis: careful attention to fluid and electrolytes balance, ECG monitoring, and management for heart failure.

Treatment course: 14 days (gentamicin); 6 weeks (doxycycline).

Primary options

gentamicin: children: consult specialist for guidance on dose; adults: 3 mg/kg intravenously every 24 hours, or 1 mg/kg intravenously every 8 hours

More

and

doxycycline: children <8 years of age: 2.2 mg/kg intravenously/orally every 12 hours, maximum 200 mg/day; children ≥8 years of age and adults: 100 mg intravenously/orally every 12 hours

OR

rifampin: children: consult specialist for guidance on dose; adults: 300 mg intravenously/orally every 12 hours

and

doxycycline: children <8 years of age: 2.2 mg/kg intravenously/orally every 12 hours, maximum 200 mg/day; children ≥8 years of age and adults: 100 mg intravenously/orally every 12 hours

Consider – valve replacement

Back
ACUTE
|
confirmed Bartonella endocarditis
|
immunocompetent
Consider – 

valve replacement

Treatment recommended for SOME patients in selected patient group

If the patient has extensive valve damage and leakage leading to congestive heart failure or embolic lesions, they may require valve replacement. All patients should be followed clinically and monitored closely for any complications, such as embolic events and congestive heart failure. A follow-up echocardiogram may be helpful in visualizing resolution of valvular vegetations, where applicable.

1st line – antibiotic therapy plus supportive care

Back
ACUTE
|
confirmed Bartonella endocarditis
|
immunocompromised
1st line – 

antibiotic therapy plus supportive care

The treatment of Bartonella endocarditis should be individualized in immunocompromised patients, as a prolonged course of therapy may be necessary.

The recommended treatment for confirmed Bartonella endocarditis in adults with HIV is intravenous doxycycline plus intravenous or oral rifampin for 6 weeks, followed by intravenous or oral doxycycline monotherapy for ≥3 months. Doxycycline plus gentamicin, both administered intravenously, for 14 days followed by intravenous or oral doxycycline monotherapy for ≥3 months is an alternative option, but is less preferred because of the potential nephrotoxicity of gentamicin.[54] Children with HIV infection should be managed under specialist guidance.

Seek advice from an infectious disease specialist if the patient has confirmed endocarditis due to an unusual Bartonella species (e.g., B bacilliformis).[10]​​[17][47]

A follow-up echocardiogram may be helpful in visualizing resolution of valvular vegetations, where applicable.

Supportive care for Bartonella endocarditis is the same as for other types of endocarditis: careful attention to fluid and electrolytes balance, ECG monitoring, and management for heart failure.

Primary options

doxycycline: adults: 100 mg intravenously every 12 hours for 6 weeks, followed by 100 mg intravenously/orally every 12 hours for ≥3 months

and

rifampin: adults: 300 mg intravenously/orally every 12 hours for 6 weeks

Secondary options

doxycycline: adults: 100 mg intravenously every 12 hours for 2 weeks, followed by 100 mg intravenously/orally every 12 hours for ≥3 months

and

gentamicin: adults: 1 mg/kg intravenously every 8 hours for 2 weeks

More

Consider – valve replacement

Back
ACUTE
|
confirmed Bartonella endocarditis
|
immunocompromised
Consider – 

valve replacement

Treatment recommended for SOME patients in selected patient group

If the patient has extensive valve damage and leakage leading to congestive heart failure or embolic lesions, they may require valve replacement. All patients should be followed clinically and monitored closely for any complications, such as embolic events and congestive heart failure. A follow-up echocardiogram may be helpful in visualizing resolution of valvular vegetations, where applicable.

Carrion disease: Oroya fever

1st line – antibiotic therapy

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ACUTE
|
Carrion disease: Oroya fever
1st line – 

antibiotic therapy

Treatment should be initiated immediately upon diagnosis.

The following examples of treatment regimens have been recommended by the national guidelines of the Peruvian government:[20]

In adults and adolescents (i.e., ≥14 years and ≥45 kg), uncomplicated cases are treated with oral ciprofloxacin for 14 days. Alternatives include amoxicillin/clavulanate, trimethoprim/sulfamethoxazole, or chloramphenicol. Severe cases are treated with ciprofloxacin plus ceftriaxone for 7-14 days. Alternative regimens for severe cases include ciprofloxacin plus either ceftazidime or amikacin.[20]

In pregnant or breast-feeding women, amoxicillin/clavulanate is recommended for uncomplicated cases, and ceftriaxone plus chloramphenicol for severe cases.[20]

In children ages <14 years, amoxicillin/clavulanate is recommended as the first-line treatment of uncomplicated cases, and ciprofloxacin plus ceftriaxone for severe cases.[20]

Primary options

Adolescents and adults: uncomplicated

ciprofloxacin: adolescents and adults: 500 mg orally twice daily for 14 days

OR

Children, adolescents, and adults (including pregnant or breast-feeding): uncomplicated

amoxicillin/clavulanate: children: 20 mg/kg orally twice daily for 14 days, maximum 1000 mg/dose; adolescents and adults: 1000 mg orally twice daily for 14 days

More

Secondary options

Adolescents and adults: uncomplicated

sulfamethoxazole/trimethoprim: adolescents and adults: 160 mg orally twice daily for 14 days

More

OR

Adolescents and adults: uncomplicated

chloramphenicol: adolescents and adults: consult specialist for guidance on dose

Tertiary options

Children, adolescents, and adults: severe

ciprofloxacin: children: 10-15 mg/kg intravenously every 12 hours for 14 days, maximum 400 mg/dose; adolescents and adults: 400 mg intravenously every 12 hours for 3 days, followed by 200 mg every 12 hours for 11 days

and

ceftriaxone: children: 70 mg/kg intravenously every 24 hours for 7-10 days, maximum 2 g/dose; adolescents and adults: 2 g intravenously every 24 hours for 7-10 days

OR

Adolescents and adults: severe

ciprofloxacin: adolescents and adults: 400 mg intravenously every 12 hours for 3 days, followed by 200 mg every 12 hours for 11 days

-- AND --

ceftazidime sodium: adolescents and adults: 1 g intravenously every 8 hours for 7 days

or

amikacin: adolescents and adults: 7.5 mg/kg intravenously/intramuscularly every 12 hours for 7-10 days

More

OR

Pregnant or breast-feeding: severe

ceftriaxone: adults: 1 g intravenously every 24 hours for 10 days

and

chloramphenicol: adults: consult specialist for guidance on dose

Plus – dexamethasone

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ACUTE
|
Carrion disease: Oroya fever
|
with neurologic manifestations
Plus – 

dexamethasone

Treatment recommended for ALL patients in selected patient group

Patients with neurologic manifestations should also receive intravenous dexamethasone.

Treatment course: 3 to 4 days.

Primary options

dexamethasone sodium phosphate: children: 1-2 mg/kg/day intravenously given in divided doses every 4-6 hours, maximum 16 mg/day; adults: 4 mg intravenously every 6-8 hours

Plus – blood transfusion

Back
ACUTE
|
Carrion disease: Oroya fever
|
with severe anemia
Plus – 

blood transfusion

Treatment recommended for ALL patients in selected patient group

Supportive measures include blood transfusion for severely anemic patients.

Plus – pericardiocentesis

Back
ACUTE
|
Carrion disease: Oroya fever
|
with pericardial effusion
Plus – 

pericardiocentesis

Treatment recommended for ALL patients in selected patient group

Supportive measures include pericardiocentesis for patients who have pericarditis with effusion.

Carrion disease: verruga peruana

1st line – antibiotic therapy

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ACUTE
|
Carrion disease: verruga peruana
1st line – 

antibiotic therapy

Azithromycin is the recommended drug of choice for the treatment of verruga peruana in both adults and children. It is given orally for 7 days.[20]​ Azithromycin is also recommended for pregnant and breast-feeding women, but the dose and treatment course may differ.[20] Alternatives include rifampin, ciprofloxacin, or erythromycin.[5][20]​​[48][70]​​​ Ciprofloxacin is not recommended during pregnancy.

Primary options

azithromycin: children: 10 mg/kg orally once daily for 7 days, maximum 500 mg/dose; adults: 500 mg orally once daily for 7 days

More

Secondary options

rifampin: children: 10 mg/kg orally once daily for 21-28 days, maximum 600 mg/dose; adults: 600 mg orally once daily for 21-28 days

OR

ciprofloxacin: children: 10-20 mg/kg orally twice daily for 14 days, maximum 500 mg/dose; adults: 500 mg orally twice daily for 14 days

OR

erythromycin base: children: 7.5 to 12.5 mg/kg orally four times daily for 14 days, maximum 500 mg/dose; adults: 500 mg orally four times daily for 14 days

Bartonella vinsonii infection

1st line – antibiotic therapy

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ACUTE
|
Bartonella vinsonii infection
1st line – 

antibiotic therapy

There are case reports of the successful use of prolonged courses of doxycycline plus rifampin with resolution of symptoms without relapse in patients infected with B vinsonii.[12] In one pediatric case, despite initial clinical improvement with azithromycin, the patient relapsed and was subsequently treated successfully with doxycycline. Consult a pediatric infectious disease expert for guidance on treatment of young children. Doxycycline is not recommended in children ages <8 years for longer than 21 days as tooth discoloration is a concern, except in severe infections where there is no effective alternative.[59]

As demonstrated in the case reports, therapeutic progress can be monitored with follow-up serologic testing.[71]

Primary options

doxycycline: children ≥8 years of age and adults: 100 mg orally/intravenously twice daily

and

rifampin: children: 20 mg/kg/day orally/intravenously given in 2 divided doses, maximum 600 mg/day; adults: 300 mg orally/intravenously twice daily

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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