From the Guidelines
For neurobrucellosis when doxycycline and rifampin cannot be used, the recommended treatment regimen is trimethoprim-sulfamethoxazole (TMP-SMX) combined with an aminoglycoside such as gentamicin or streptomycin, plus a third-generation cephalosporin like ceftriaxone. A common regimen would be TMP-SMX (5 mg/kg of trimethoprim component every 12 hours), gentamicin (5 mg/kg daily), and ceftriaxone (2 g daily) for at least 4-6 weeks, followed by oral TMP-SMX for a total treatment duration of 3-6 months 1. Other alternatives include fluoroquinolones such as ciprofloxacin (500-750 mg twice daily) combined with TMP-SMX.
Key Considerations
- Treatment should be individualized based on patient factors, with close monitoring for side effects and clinical response.
- Neurobrucellosis requires prolonged therapy because the blood-brain barrier limits antibiotic penetration, and the intracellular nature of Brucella makes eradication difficult.
- Treatment success should be monitored through clinical improvement, normalization of CSF parameters, and declining Brucella antibody titers.
- Adjunctive corticosteroids may be considered in cases with significant inflammation or neurological deficits.
Rationale
The choice of alternative regimens is based on the available evidence from studies on brucellosis treatment, which suggest that TMP-SMX combinations can be effective, although not as the first-line option 1. The use of fluoroquinolones, such as ciprofloxacin, in combination with TMP-SMX, is also considered an alternative, but with caution due to concerns about resistance and cost 1.
Monitoring and Adjustment
Close monitoring of the patient's response to treatment and adjustment of the regimen as necessary is crucial to ensure the best possible outcome. This includes monitoring for side effects, clinical improvement, and laboratory parameters such as CSF findings and Brucella antibody titers.
Special Considerations
In certain situations, such as pregnancy, the choice of antibiotics may need to be adjusted due to potential risks to the fetus 1. In such cases, rifampicin monotherapy until delivery may be considered for patients without risk factors for relapse or focal disease, balancing the risks of relapse against the potential for adverse fetal effects.
From the Research
Neurobrucellosis Treatment Alternatives
When doxycycline and rifampicin cannot be used for the treatment of neurobrucellosis, several alternative regimens can be considered:
- The use of ceftriaxone, as it achieves high concentrations in the cerebrospinal fluid, making it potentially effective against the pathogen 2, 3.
- Trimethoprim-sulfamethoxazole (TMP-SMZ) in combination with other antibiotics, as it is recommended for nervous system complications and has shown efficacy in treating neurobrucellosis 4, 3.
- Other antibiotics such as gentamicin, which can be used in combination with TMP-SMZ for the treatment of neurobrucellosis, especially in cases where other options are not feasible 4.
Treatment Duration and Considerations
The duration of treatment for neurobrucellosis should be individualized, with a minimum of six months of therapy with suitable antibiotics 2, 3.
- The treatment regimen should be tailored to the specific needs of the patient, taking into account the severity of the disease, the presence of any complications, and the patient's response to therapy.
- Corticosteroids may be used in specialized situations, but their use should be carefully considered and monitored 3.
Alternative Regimens
Other alternative regimens that can be considered for the treatment of neurobrucellosis include:
- Doxycycline plus streptomycin, although the use of streptomycin is discouraged due to its potential neurotoxicity and questionable ability to penetrate into the cerebrospinal fluid 5, 3.
- Quinolones, which have shown similar efficacy to doxycycline and rifampicin, but with higher relapse rates 6.
- Cotrimoxazole plus rifampin, which is recommended for the treatment of patients younger than 8 years old 6.