What is the recommended treatment for brucellosis?

Brucellosis Treatment Recommendations

The optimal treatment for uncomplicated brucellosis is a combination of doxycycline (100 mg twice daily orally for 6 weeks) with streptomycin (15 mg/kg daily intramuscularly for 2-3 weeks), which has the lowest relapse rate among available regimens. 1, 2, 3

First-Line Treatment Options

• Doxycycline-Streptomycin (DOX-STR): Doxycycline 100 mg twice daily orally for 6 weeks plus streptomycin 15 mg/kg daily intramuscularly for 2-3 weeks - considered the gold standard with the highest clinical response rate (95.4%) and lowest relapse rate (4.6%) 1, 3

• Doxycycline-Rifampicin (DOX-RIF): Doxycycline 100 mg twice daily orally for 6 weeks plus rifampicin 600-900 mg daily as a single morning dose for 6 weeks - an effective alternative but with higher relapse rates (16%) compared to DOX-STR (5.3%) 1, 2

• Doxycycline-Gentamicin (DOX-GENT): Doxycycline 100 mg twice daily orally for 6 weeks plus gentamicin 5 mg/kg daily parenterally for 7 days - comparable efficacy to DOX-STR with the advantage of wider availability of gentamicin and shorter duration of parenteral therapy 1, 4

Second-Line Treatment Options

• Trimethoprim-Sulfamethoxazole (TMP-SMX) containing regimens: TMP-SMX 800+160 mg twice daily for 6 weeks - may be used as a cost-effective alternative in resource-limited settings or as a third agent in combination therapy for complicated cases 1, 4

• Quinolone-containing regimens: Ofloxacin 400 mg twice daily or ciprofloxacin 500 mg twice daily for 6 weeks - should be reserved as second or third agents in combination regimens due to higher cost and risk of promoting antimicrobial resistance 1, 4

Special Populations

• Pregnant women: Rifampicin 900 mg once daily for 6 weeks is considered the drug of choice due to contraindication of tetracyclines 5

• Children <8 years old: Rifampicin with cotrimoxazole for 45 days is the preferred regimen, or alternatively rifampicin for 45 days with gentamicin 5-6 mg/kg/day for the first 5 days 5, 6

Treatment Duration and Monitoring

• Standard treatment duration is 6 weeks for most regimens 1
• Shorter treatment durations (<4 weeks) are associated with significantly higher relapse rates (22% vs. 4.8%) 6
• Monotherapy has higher relapse rates (13%) compared to combination therapy (4.8%) and should be avoided 6

Pitfalls and Caveats

• Relapse rates range from 5-15% even with appropriate treatment; relapses are usually milder and can be treated with the same regimens 1
• In regions where brucellosis and tuberculosis coexist, consider the public health implications of using rifampicin, as this may contribute to mycobacterial resistance 1
• Triple therapy with aminoglycoside-doxycycline-rifampicin should not be considered the treatment of choice until further studies have been performed 7
• TMP-SMX has been extensively used in triple combinations with reported response rates above 90%, but routine use of triple regimens containing TMP-SMX cannot be advocated based on current evidence 4

Treatment Algorithm

1. First assess: Patient age, pregnancy status, and presence of complications
2. For uncomplicated brucellosis in adults:
   • First choice: Doxycycline-Streptomycin
   • If streptomycin unavailable: Doxycycline-Gentamicin
   • If parenteral therapy not feasible: Doxycycline-Rifampicin
3. For pregnant women: Rifampicin monotherapy
4. For children <8 years: Rifampicin-Cotrimoxazole
5. For complicated brucellosis: Consider longer treatment duration and possible surgical intervention for endocarditis, cerebral/epidural abscess, or spleen abscess 5