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

Treatment Regimens

First-Line Treatment

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

Alternative Regimens

• Doxycycline-Rifampicin

  • Doxycycline: 100 mg twice daily orally for 6 weeks
  • Rifampicin: 900 mg daily orally for 6 weeks
  • Note: This regimen is less effective than doxycycline-streptomycin, with higher relapse rates (16% vs 5.3%) 2

• Doxycycline-Gentamicin

  • Can substitute gentamicin for streptomycin in the first-line regimen
  • No significant differences in efficacy between doxycycline-streptomycin and doxycycline-gentamicin 3

• Quinolone-Rifampicin

  • Similar efficacy to doxycycline-rifampicin but better tolerated 4
  • However, one study found higher relapse rates compared to doxycycline-rifampicin 5

Treatment Duration

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

Special Populations

Pregnant Women

• Rifampicin 900 mg once daily for 6 weeks is considered the drug of choice 6
• Tetracyclines (including doxycycline) are contraindicated 6

Children <8 Years Old

• Preferred regimen: Rifampicin with co-trimoxazole for 45 days 6
• Alternative: Rifampicin for 45 days with gentamicin 5-6 mg/kg/day for the first 5 days 6
• Tetracyclines are contraindicated 6

Complicated Brucellosis

Spinal Involvement

• Combination of doxycycline plus rifampicin for 3-6 months, with the addition of an aminoglycoside (preferably streptomycin) for the first 2-3 weeks 1
• Surgical intervention should be considered for:
  • Progressive neurologic deficits
  • Spinal deformity or instability
  • Persistent infection
  • Spinal cord compression
  • Presence of abscesses requiring drainage
  • Failure of medical treatment 1

Neurobrucellosis

• Same regimen as spinal involvement, with treatment duration of at least 3 months 1

Monitoring and Follow-up

• Regular clinical assessment
• Monitor inflammatory markers
• Follow-up imaging as needed
• Monitor for at least 12 months after treatment completion to detect relapses 1
• Treatment failure rates of approximately 20% have been reported in patients with brucellar vertebral osteomyelitis 1

Important Considerations

• Meta-analyses consistently show that doxycycline-streptomycin is superior to doxycycline-rifampicin, with lower relapse rates 3, 4, 2
• The need for daily intramuscular injections with streptomycin may impact treatment choice based on access to care and cost 4
• 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

Prevention

• Pasteurization of dairy products
• Vaccination of livestock
• Use of personal protective equipment when handling potentially infected animals
• Public education about risks of consuming unpasteurized dairy products 1