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Thursday, February 07, 2013

Rocky Mountain Spotted Fever: Knowledge Gaps in Health Care Providers

Rocky Mountain spotted fever (RMSF) is the most deadly and most common illness caused by Rickettsia, a group of bacterial parasites. A parasite is an organism that lives in or on another organism to obtain nourishment. The specific type of Rickettsia that causes RMSF is known as Rickettsia rickettsi, which is spread by a group of ticks known as Dermacentor ticks (American dog ticks).

Signs and symptoms of Rocky Mountain spotted fever include an acute (sudden) onset of fever, muscle pain, and headache one to two weeks after a tick bite. This makes RMSF initially appear flu-like, which can delay accurate diagnosis and treatment. This is followed by a rash in about 80-90% of cases. The initial rash begins about 2 to 5 days after fever onset and is initially small, pink, flat, and not itchy. The rash begins on the arms and legs and moves towards the trunk. The spotted rash for which the disease is named after is red but only develops in 35 to 60% of cases. The disease can affect the brain, kidneys, intestines, and lungs.

RMSF can cause severe long-term health problems, which is why knowledge of proper treatment is essential. Delays in treatment can cause severe problems including paralysis, loss of hearing, amputation, loss of bladder control, loss of bowel control, disorders of speech and movement, and death. Standard of care treatment for adults and children of all ages is antibiotics, specifically doxycycline. Doctors recommended beginning this treatment even before laboratory confirmation of the disease. The treatment continues for at least three days after the fever stops and until there is clear improvement of the patient. Treatment usually lasts for a total of 5 to 10 days, but can last longer in more severe cases.

RMSF gets part of its name from the Rocky Mountain Laboratories, which is where much of the early research in this condition began. The disease can and does present throughout most of the U.S. and some other countries. Thus, it is not isolated to the Rocky Mountain region. One state outside of the Rocky Mountain region where RMSF is very common is Tennessee. This is because the tick that causes the disease is common in the southeastern U.S.

In the most recent issue of the American Journal of Tropical Medicine and Hygiene, researchers presented the results of a survey of 1,139 Tennessee healthcare workers (physicians, nurse practitioners, physician assistants) on their knowledge, perceptions, and attitudes on RMSF diagnosis and treatment. About 90% of those surveyed were current practicing and most surveyed were physicians. The response rate in the study was low (14%) which limits the generalizability of the results.

While 93% of respondents correctly identified that doxycycline was a treatment they would use in RMSF, only 39% correctly identified that doxycycline was the treatment of choice for RMSF in children younger than age 8. This was particularly a problem among family medicine and emergency room physicians, which can lead to unnecessary deaths among children. Twenty percent of providers preferred to wait for a rash to develop to initiate treatment, which is a problem because by the time a rash develops (if it develops) it may be too late to begin effective treatment.

Only 42% of providers correctly identified the fatality rate of untreated RMSF. Although correct diagnosis of RMSF requires laboratory testing, 26% of providers stated that they always or almost always treat RMSF without laboratory testing. Fortunately, most providers were aware that RMSF is common in their region and that the condition should still be considered if the patient does not recall a tick bite.

Doctors practicing emergency medicine, internal medicine, and family medicine; and nurse practitioners, physician assistants, and providers practicing for less than 20 years demonstrated less knowledge regarding RMSF. Thus, providers with more education and experience were more knowledgeable of RMSF. The authors suggested targeted educational campaigns about RMSF, particularly focused on the need to treat patients less than age 8 with doxycycline.

Suggested reading: Rocky Mountain Spotted Fever: History of a Twentieth-Century Disease

Reference: Mosites E, Carpenter LR, McElroy K, Lancaster MJ, Ngo TH, McQuiston J, Wiedeman C, Dunn JR. (2013). Knowledge, Attitudes, and Practices Regarding Rocky Mountain Spotted Fever among Healthcare Providers, Tennessee, 2009.Am J Trop Med Hyg. 88(1):162-6.

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