Objective: Serological tests are widely used for scrub typhus diagnosis; however, their limitations are evident. This study aims to assess their practical value in clinical settings. Methods: We analyzed the data of adult patients with suspected scrub typhus who visited a tertiary care hospital in the Republic of Korea from September to December from 2019 to 2021. The included patients had an acute fever and at least one of the followingten secondary findings: myalgia, skin rash, eschar, headache, thrombocytopenia, increased liver enzyme levels, lymphadenopathy, hepatomegaly, splenomegaly, and pleural effusion. The diagnoses were grouped as scrub typhus or other diseases by two infectious disease physicians. Results: Among 136 patients who met the eligibility criteria, 109had scrub typhus and 27 had different diseases. Single and paired total antibodies using immunofluorescence assay (IFA), and total antibodies using immunochromatography-based rapid diagnostic testing (ICT) were measured in 98%, 22%, and 75% of all patients, respectively. Confirmation using paired samples for scrub typhus was established at a median of 11 [interquartile range (IQR) 10-16] days following the first visit. Among the 82 admitted patients, the median admission time was 9 (IQR 7-13) days. According to IFA, 58 (55%) patients with scrub typhus had total immunoglobulin titers ≥1:320, while 23 (85%) patients with other disease had titers < 1:320. Positive ICT results were observed in 64 (74%) patients with scrub typhus and 10 (67%) patients with other diseases showed negative ICT results. Conclusions: Serological testing for scrub typhus is currently insufficient for decision-making in clinical practice.