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Bartonella Infections

para>Advise lab if Bartonella infection is suspected so that cultures are prepared using appropriate media and laboratory conditions; prolonged incubation is required (up to 6 weeks).

Polymerase chain reaction (PCR; highly sensitive) of valve tissue can aid in diagnosis of endocarditis; otherwise, less helpful; not widely available (3)

Antibiotics may result in false-negative culture.

Lab and other workup not required for typical CSD in nontoxic immunocompetent patients

Diagnostic Procedures/Other

Biopsy of lymph nodes for histology and culture if needed; consider biopsy of involved organs.

Test Interpretation

  • CSD: granulomas, stellate necrosis, mixed inflammatory infiltrates; bacilli in tissue may be visible using silver impregnation stains (Warthin-Starry).
  • Verruga peruana: neovascular proliferation; bacteria is not usually identified.
  • Endocarditis: Warthin-Starry-stained bacilli may be seen in vegetations.
  • Bacillary angiomatosisLobular proliferations of small blood vessels with cuboidal endothelial cells interspersed with inflammatory cells, mostly neutrophils.Warthin-Starry stain or electron microscopy may show clusters of bacilli.
  • Bacillary peliosis: blood-filled cystic structures; Warthin-Starry stain may show surrounding clumps of bacilli.

TREATMENT

Many cases of CSD are self-limited. Base antibiotic treatment on clinical presentation and disease severity.

MEDICATION

  • Antipyretics and analgesics for symptom management
  • Antibiotic choice depends on clinical situation often based on case studies and expert opinion (2)[A].
  • Typical CSD: no clear benefit, azithromycin may speed resolution of extensive lymphadenopathy: adults and children >45.5 kg: 500 mg on day 1,250 mg daily on days 2 to 5; children <45.5 kg: 10 mg/kg on day 1, 5 mg/kg daily on days 2 to 5 (2)[A]
  • Bacteremia: gentamicin 3 mg/kg IV daily for 2 weeks and doxycycline 200 mg PO daily for 4 weeks (2)[B]
  • Oroya fever: chloramphenicol 500 mg (pediatric dose 50 mg/kg/day) PO/IV QID+/- β-lactam (IV: PCN G 3 million U q4h [40,000 units/kg q4h for pediatrics]/PO: PCN V 500 mg QID or 20 mg/kg QID for pediatrics) for 14 days or ciprofloxacin 500 mg BID for 10 days (2)[B]
  • Verruga peruana: rifampin 600 mg PO daily (10 mg/kg/day in children [not to exceed 600 mg/day]) for 2 to 3 weeks (2)[B]
  • Neuroretinitis: doxycycline 100 mg PO BID (in children <8 years old, consider erythromycin 20 mg/kg/day to maximum daily dose of 2 g/day) + rifampin 300 mg PO BID for 4 to 6 weeks (2)[B]. Usually self-limited, so some authors suggest no antibiotics are needed.
  • Trench fever or chronic B. quintana bacteremia without endocarditis: gentamicin 3 mg/kg IV daily for 2 weeks and doxycycline 200 mg PO daily for 4 weeks (2)[A]
  • Bacillary angiomatosis/peliosis: erythromycin 500 mg (pediatric dose 40 mg/kg/day to maximum daily dose of 2 g/day) PO QID or doxycycline 100 mg PO BID for 3 months (4 months for peliosis) (2,3)[B]
  • Endocarditis: gentamicin 1 mg/kg IV TID for 2 weeks + doxycycline 100 mg IV/PO BID for 6 weeks (2,3)[B]

ALERT

All HIV-infected patients should receive antibiotic treatment (3)[A].

ISSUES FOR REFERRAL

Cardiothoracic surgery if endocarditis

SURGERY/OTHER PROCEDURES

  • Drain lymph nodes with needle aspiration (usually not necessary).
  • Valve replacement if indicated in endocarditis

INPATIENT CONSIDERATIONS

Admission Criteria/Initial Stabilization

  • Consider admission for patients who are immunocompromised, hemodynamically unstable, or may not have access to appropriate antibiotics.
  • High degree of clinical suspicion and awareness of infection risk

Discharge Criteria

When hemodynamically stable on oral antibiotics or receiving IV antibiotics through a peripherally inserted central catheter line and fevers have resolved.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

Immunocompromised patients have increased risk for relapse. Extended periods of antibiotics are recommended.

DIET

No diet modifications needed

PATIENT EDUCATION

  • Educate patients about proper vector control.
  • Immunocompromised patients:Consider risk/benefit of cat ownership (3)[A].Only adopt cats >1 year old that are healthy and free of fleas (3)[B].No need to declaw cat, but avoid rough play (3)[A].Immediately wash cat-induced wounds (3)[B].Regular use of cat flea control (3)[B].No benefit in testing cats for Bartonella (3)[B]

PROGNOSIS

  • CSD: spontaneous resolution usually in 2 to 4 months without specific therapy
  • Other syndromes: with proper treatment, full resolution; if relapse, consider long-term suppressive antibiotics.
  • Oroya fever: if untreated, 40-85% mortality

COMPLICATIONS

Disseminated disease can present with specific organ-related findings such as focal seizures or renal microabscesses.

REFERENCES

11 Kaiser PO, Riess T, O'Rourke F, et al. Bartonella spp.: throwing light on uncommon human infections. Int J Med Microbiol. 2011;301(1):7-15.22 Angelakis E, Raoult D. Pathogenicity and treatment of Bartonella infections. Int J Antimicrob Agents. 2014;44(1):16-25.33 Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf. Accessed August 14, 2015; J1-J5.44 Vermeulen MJ, Verbakel H, Notermans DW, et al. Evaluation of sensitivity, specificity and cross-reactivity in Bartonella henselae serology. J Med Microbiol. 2010;59(Pt 6):743-745.

ADDITIONAL READING

Prutsky G, Domecq JP, Mori L, et al. Treatment outcomes of human bartonellosis: a systematic review and meta-analysis. Int J Infect Dis. 2013;17(10):e811-e819.

CODES

ICD10

  • A44.9 Bartonellosis, unspecified
  • A28.1 Cat-scratch disease
  • A79.0 Trench fever
  • A44.1 Cutaneous and mucocutaneous bartonellosis
  • A44.8 Other forms of bartonellosis
  • A44.0 Systemic bartonellosis

ICD9

  • 088.0 Bartonellosis
  • 078.3 Cat-scratch disease
  • 083.1 Trench fever

SNOMED

  • Bartonellosis (disorder)
  • Cat scratch disease (disorder)
  • Trench fever
  • Oroya fever

CLINICAL PEARLS

  • Diagnosing Bartonella infections requires a high degree of clinical suspicion.
  • CSD is self-limited in most immunocompetent patients.
  • Immunocompromised patients are at increased risk for occult infections.
  • CSD can be prevented by avoiding stray cats and ensuring proper flea and tick control in domestic pets.