Early treatment is critical to the outcome in Rocky Mountain spotted fever (RMSF) and must be started on the basis of clinical diagnosis.  Consider the possibility of RMSF and promptly begin antibiotic treatment in any patient with potential tick exposure who develops fever, myalgia, or headache, even if they do not have a rash.
Never delay treatment while awaiting a confirmatory laboratory diagnosis or the development of a rash. The best outcomes are achieved when treatment is started within 4 days of symptom onset, and the classic petechial rash may not appear until day 6.
Doxycycline is considered to be first line treatment for both adults and children and should be started as soon as RMSF is suspected.  The use of any other antibiotics has been associated with a higher risk of death (see Table 2, below).
Doxycycline treatment is most effective at preventing death if it is begun within the first 5 days after symptoms begin. As a result doxycycline treatment should be started before the return of lab results and before manifestation of severe symptoms, such as petechiae. If the patient is treated within the first 5 days of disease, fever generally subsides within 24-72 hours. 
The recommended dosage of doxycycline is 2.2 mg/kg body weight twice daily for children less than 45 kg (100 lb). For adults, the dosage is 100 mg every 12 hours. Patients should be treated for at least 3 days after the fever subsides and until there is evidence of clinical improvement. Standard duration of treatment is 7-14 days.
The recommended dosage of doxycycline for RMSF has not been shown to cause staining of permanent teeth. 
Chloramphenicol was previously recommended for the treatment of children younger than 9 years. In national surveillance data, however, patients treated with chloramphenicol were more likely to die than those treated with a tetracycline. Staining of teeth caused by one or more courses of tetracyclines (particularly doxycycline) is negligible.
Some authors have advocated the use of adjunctive corticosteroids, but the specific therapeutic benefits of these drugs are not known. Physicians should be aware that sulfonamide treatment given empirically in a febrile child can worsen Rocky Mountain spotted fever.
Other supportive measures (eg, intravenous administration of fluids, oxygenation, correction of electrolyte impairments, management of disseminated intravascular coagulation) should be provided according to the patient's clinical situation.
Patients with Rocky Mountain spotted fever should be treated in consultation with an infectious disease specialist.
Deterrence and Prevention
Avoidance of tick-infested areas is the first line of defense against Rocky Mountain spotted fever. If tick-infested areas cannot be avoided, wearing light-colored shirts and trousers that fit tightly around the waist and ankles can minimize the risk of being bitten.
Exposed areas of the skin should be covered with insect repellents containing N -N -diethyl-M -toluamide (DEET). In children, insect repellents should be used carefully on exposed skin. Application to the face and hands should be avoided.
After people leave an endemic area, they should inspect their bodies for attached ticks, with particular attention on areas containing hair.
If ticks are found, any of several commercial removal devices should be used if possible. Otherwise, ticks should be removed by grasping them with fine tweezers at the point of attachment and by pulling them out slowly and steadily. The aim is to remove the tick's mouthparts from the site of insertion without damaging the body of the tick.
After the tick is removed, the skin should be disinfected. Check to make sure that the head of the tick is not still embedded.
Some have recommended keeping the removed tick in a jar along with a dampened paper towel in the refrigerator for a month. This way, if the person later develops symptoms, the tick may be used to help identify what (if any) infection it may have transmitted.
Burning the tick, smothering it in alcohol or petroleum jelly (or another substance), or twisting or rubbing it off is not recommended. These methods have not been shown to decrease the time the tick remains embedded. In addition, they may pose of risk breaking the body of the tick open and releasing bacteria that were otherwise contained within it.
After a tick bite occurs, use of antimicrobial prophylaxis has no role in the prevention of Rocky Mountain spotted fever.
Table: Specific Recommended Treatment
Table 2. Doxycycline Treatment for RMSF (Open Table in a new window)
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