What is the recommended treatment for brucellosis?

Treatment of Brucellosis

The recommended first-line treatment for brucellosis is a combination of doxycycline 100 mg twice daily orally for 6 weeks plus streptomycin 15 mg/kg daily intramuscularly for 2-3 weeks. 1

First-Line Treatment Options

Standard Regimen (Highest Evidence Level: AI)

• Doxycycline-Streptomycin (DOX-STR)
  • Doxycycline: 100 mg twice daily orally for 6 weeks
  • Streptomycin: 15 mg/kg daily intramuscularly for 2-3 weeks 1

Alternative First-Line Option

• Doxycycline-Gentamicin (DOX-GEN)
  • Doxycycline: 100 mg twice daily orally for 45 days
  • Gentamicin: 5 mg/kg/day intramuscularly for 7 days 2
  • This regimen has shown equal efficacy to the doxycycline-streptomycin combination with the advantage of shorter aminoglycoside duration

Second-Line Treatment Options

• Doxycycline-Rifampicin (DOX-RIF)
  • Doxycycline: 100 mg twice daily orally for 45 days
  • Rifampicin: 900 mg once daily orally for 45 days 1, 3
  • Note: This regimen has higher relapse rates (16%) compared to doxycycline-streptomycin (5.3%) 4

Special Populations

Pregnant Women

• Rifampicin Monotherapy
  • 900 mg once daily for 6 weeks 3, 5
  • Tetracyclines are contraindicated in pregnancy

Children <8 Years Old

• Rifampicin plus Cotrimoxazole
  • Duration: 45 days 3, 5
  • Alternative: Rifampicin for 45 days plus gentamicin 5-6 mg/kg/day for first 5 days 3

Treatment Duration by Complication Type

• Uncomplicated brucellosis: 6 weeks of combination therapy
• Neurobrucellosis: At least 3 months 1
• Complicated spinal brucellosis with abscesses: 6 months or longer 1

Surgical Intervention Indications

Surgical treatment should be considered in the following scenarios:

• Progressive neurologic deficits
• Spinal deformity or instability
• Spinal cord compression
• Presence of abscesses requiring drainage
• Persistent infection despite adequate medical therapy 1

Treatment Monitoring

• Regular clinical assessment
• Monitor inflammatory markers
• Follow-up imaging when indicated
• Continue monitoring for at least 12 months after treatment completion to detect relapses 1

Common Pitfalls and Caveats

1. Relapse risk: Treatment failure rates of approximately 20% have been reported in patients with brucellar vertebral osteomyelitis, regardless of regimen, highlighting the need for careful monitoring and adequate treatment duration 1

2. Imaging interpretation: Surgery should not be performed solely based on worsening imaging findings at 4-6 weeks if clinical symptoms, physical examination, and inflammatory markers are improving 1

3. Short-term treatment: Higher relapse rates (22% vs 4.8%) are associated with treatment durations less than 4 weeks 6

4. Monotherapy: Results in higher relapse rates (13% vs 4.8%) compared to combination therapy 6

5. Quinolone-containing regimens: Similar efficacy to doxycycline-rifampicin but with higher relapse rates 6