Aftershocks of scrub typhus in Nepal
Authors: Hemant Ojha, Sampanna Jung Rayamajhi
Journal: The Lancet Global Health (2016)

Following the devastating earthquake in 2015, outbreaks of scrub typhus have been reported in Nepal, a country situated in the tsutsugamushi triangle. Buddha Basnyat1Basnyat B Typhoid versus typhus fever in post-earthquake Nepal.Lancet Glob Health. 2016; 4: e516-e517Summary Full Text Full Text PDF PubMed Scopus (24) Google Scholar (August, 2016) points out the diagnostic dilemma faced by resource-limited Nepal, and outlines a plan for empirical treatment for undifferentiated fever. In the present context of Nepal, Basnyat's view on the use of doxycycline as an empirical agent for undifferentiated febrile illness is justifiable.1Basnyat B Typhoid versus typhus fever in post-earthquake Nepal.Lancet Glob Health. 2016; 4: e516-e517Summary Full Text Full Text PDF PubMed Scopus (24) Google Scholar However, we would like to highlight that suspected and proven doxycycline-resistant scrub typhus2Watt G Chouriyagune C Ruangweerayud R et al.Scrub typhus infections poorly responsive to antibiotics in northern Thailand.Lancet. 1996; 348: 86-89Summary Full Text Full Text PDF PubMed Scopus (217) Google Scholar, 3Corwin A Soderquist R Suwanabun N et al.Scrub typhus and military operations in Indochina.Clin Infect Dis. 1999; 29: 940-941Crossref PubMed Scopus (39) Google Scholar, 4Kim YS Yun HJ Shim SK Koo SH Kim SY Kim S A comparative trial of a single dose of azithromycin versus doxycycline for the treatment of mild scrub typhus.Clin Infect Dis. 2004; 39: 1329-1335Crossref PubMed Scopus (102) Google Scholar and strains with reduced clinical susceptibility to doxycycline, as compared with other drugs such as rifampicin, have been well documented.5Watt G Kantipong P Jongsakul K Watcharapichat P Phulsuksombati D Strickman D Doxycycline and rifampicin for mild scrub-typhus infections in northern Thailand: a randomised trial.Lancet. 2000; 356: 1057-1061Summary Full Text Full Text PDF PubMed Scopus (125) Google Scholar Considering the large number of serotypes of Orientia tsutsugamushi, although this might not hold true in the context of Nepal, the possibility of resistant or less-susceptible serotypes cannot be ruled out. If such cases are prevalent, a single dose of azithromycin could be a good alternative to a week-long course of doxycycline.4Kim YS Yun HJ Shim SK Koo SH Kim SY Kim S A comparative trial of a single dose of azithromycin versus doxycycline for the treatment of mild scrub typhus.Clin Infect Dis. 2004; 39: 1329-1335Crossref PubMed Scopus (102) Google Scholar We therefore urge treating physicians to release pooled data regarding clinical response to different drugs on confirmed cases of scrub typhus in Nepal, so that in the future, patients can at least receive the optimum empirical therapy whenever scrub typhus is a factor. Finally, isolation and characterisation of the O tsutsugamushi endemic to Nepal is needed, since it might have its own antibiotic-susceptibility profile; the knowledge of which will benefit the patients with a more specific and targeted antimicrobial therapy, in case future outbreaks occur. We declare no competing interests. Aftershocks of scrub typhus in Nepal – Author's replyI agree with Hemant Ojha and Sampanna Jung Rayamajhi that, although the suggestion to use doxycycline for treatment of a presumptive diagnosis of scrub typhus is justified,1 we clearly have to be on the lookout for doxycycline-resistant scrub typhus. Indeed, the Comment was written in an attempt to serve as a wake-up call for more research on both typhus and typhoid, especially regarding reliable, rapid diagnostic tests to distinguish between these kinds of undifferentiated febrile illnesses in the tropics. Full-Text PDF Open Access