Antibiotics Effective Against Bartonella Infections
Doxycycline and erythromycin are the first-line antibiotics for treating Bartonella infections, with gentamicin added for severe infections such as endocarditis. 1
First-Line Treatment Options
General Bartonella Infections
- Doxycycline is considered a first-line treatment for bartonellosis based on case series evidence (AII) 1
- Erythromycin is equally effective as a first-line agent for most Bartonella infections (AII) 1
- Treatment should be administered for at least 3 months for standard infections (AII) 1
Severe Infections
- For central nervous system involvement or severe infections, doxycycline with or without rifampin is the treatment of choice (AIII) 1
- For Bartonella endocarditis, the combination of doxycycline plus gentamicin is recommended for optimal outcomes (IIa/B) 1, 2
- Patients receiving aminoglycosides are more likely to fully recover from Bartonella endocarditis, with at least 14 days of aminoglycoside therapy associated with better survival (P=0.02) 2
Alternative Options
- Clarithromycin or azithromycin are effective alternatives with good clinical response (BIII) 1
- Azithromycin is particularly recommended for patients who may have difficulty with the more frequent dosing schedule of doxycycline or erythromycin 1
- For Bartonella henselae specifically, doxycycline or azithromycin, with or without rifampin, can be considered (C-III) 1
Species-Specific Recommendations
Bartonella bacilliformis
- Chloramphenicol, ciprofloxacin, doxycycline, ampicillin, or trimethoprim-sulfamethoxazole are recommended (B-III) 1
Bartonella henselae
- Doxycycline or azithromycin, with or without rifampin, are the preferred options (C-III) 1
- For suspected Bartonella endocarditis, ceftriaxone (2g/day) plus gentamicin for 2 weeks, with or without doxycycline for 6 weeks total is recommended (IIa/B) 1
Ineffective Antibiotics
- Penicillins and first-generation cephalosporins have no in vivo activity and should not be used for bartonellosis (DII) 1
- Quinolones and trimethoprim-sulfamethoxazole have variable in vitro activity and inconsistent clinical response and are not recommended (DIII) 1
Recent Research Findings
- Recent studies have identified several promising agents against stationary phase Bartonella:
- Pyrvinium pamoate, daptomycin, methylene blue, azole drugs, and aminoglycosides (gentamicin, streptomycin) showed complete eradication of stationary phase B. henselae in laboratory studies 3
- Combination therapy with azithromycin/ciprofloxacin, azithromycin/methylene blue, rifampin/ciprofloxacin, or rifampin/methylene blue demonstrated superior activity against both stationary phase and biofilm forms of B. henselae 4
Special Considerations
Pregnancy
- Erythromycin should be used for Bartonella infections during pregnancy 1
- Tetracyclines (including doxycycline) should be avoided during pregnancy due to risk of hepatotoxicity and fetal teeth/bone staining (EII) 1
Prevention of Recurrence
- For immunocompromised patients (CD4+ count <200 cells/μL), long-term suppression with doxycycline or a macrolide is recommended after initial treatment (AIII) 1
- Suppression can be discontinued after 3-4 months of therapy when CD4+ count remains >200 cells/μL for >6 months (CIII) 1
- Some specialists recommend continuing therapy until Bartonella titers have decreased by fourfold (CIII) 1
Clinical Pitfalls and Caveats
- Standard antibiotics that are effective against growing B. henselae (rifampin, erythromycin, azithromycin, doxycycline, ciprofloxacin) have relatively poor activity against stationary phase B. henselae, which may explain treatment failures in persistent infections 3
- Patients treated with oral doxycycline should be cautioned about pill-associated ulcerative esophagitis, which occurs most often when a dose is taken with only a small amount of liquid or at night just before retiring (AIII) 1
- For Bartonella endocarditis, treatment duration is critical - aminoglycosides should be administered for at least 14 days for optimal outcomes 2