What is the treatment for brucellosis?

Brucellosis Treatment

The optimal treatment for brucellosis is a six-week regimen of doxycycline (100 mg twice daily) combined with either streptomycin (1 g daily) for 2-3 weeks or rifampicin (600-900 mg daily) for six weeks, with the doxycycline-streptomycin combination showing superior efficacy. 1

First-Line Treatment Options

• Doxycycline-Streptomycin combination is the preferred regimen with the lowest relapse rates:

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

• Doxycycline-Gentamicin is an effective alternative to doxycycline-streptomycin:

  • Doxycycline: 100 mg twice daily orally for 6 weeks
  • Gentamicin: 5 mg/kg daily parenterally for 7 days 1, 3

• Doxycycline-Rifampicin is considered a second-choice regimen due to higher relapse rates:

  • Doxycycline: 100 mg twice daily orally for 6 weeks
  • Rifampicin: 600-900 mg daily as a single morning dose for 6 weeks 1, 2

Special Populations

• Pregnant women:

  • Rifampicin 900 mg once daily for 6 weeks is the drug of choice 4, 5
  • Tetracyclines are contraindicated due to fetal risks 4

• Children under 8 years:

  • Preferred regimen: Rifampicin with trimethoprim-sulfamethoxazole for 45 days 4, 5
  • Alternative: Rifampicin for 45 days with gentamicin 5-6 mg/kg/day for the first 5 days 4
  • Tetracyclines are contraindicated due to dental staining 5

Complicated Brucellosis

• Brucellar spondylitis (spinal involvement):

  • Aminoglycoside-containing regimens may be superior to rifampicin-containing ones 6
  • MRI of the spine should be performed when clinical suspicion exists 6
  • Immobilization of the spine (especially cervical) is crucial to prevent neurological complications 6
  • Treatment duration may need to be extended beyond the standard 6 weeks 6

• Brucellar endocarditis:

  • High mortality complication requiring aggressive management 6
  • Empirical antimicrobial selection with surgical intervention in most cases 6
  • Extended antibiotic therapy is typically required 5

• Other focal disease (cerebral/epidural/splenic abscesses):

  • Surgical intervention should be considered for antibiotic-resistant cases 4, 5
  • Extended duration of antibiotic therapy based on clinical response 7

Treatment Monitoring and Outcomes

• Relapse rates range from 5-15% even with appropriate treatment 1
• Relapses are usually mild and can be treated with the same regimens 1
• Monitor for adverse effects, particularly with aminoglycosides (ototoxicity, nephrotoxicity) 8
• Total treatment duration is typically 6 weeks for uncomplicated cases 1

Public Health Considerations

• In regions where brucellosis and tuberculosis coexist, consider the implications of using rifampicin, as this may contribute to mycobacterial resistance 1
• Tetracycline monotherapy (especially doxycycline) may be considered for patients with non-focal disease and low risk of relapse to reduce costs and toxicity 7

Treatment Algorithm

1. Assess for complications/focal disease (spondylitis, endocarditis, neurobrucellosis)

   • If present: Extended therapy and possible surgical intervention 6, 5
   • If absent: Standard regimen 1

2. Evaluate patient characteristics:

   • Pregnant: Rifampicin monotherapy 4, 5
   • Children <8 years: Rifampicin + TMP-SMX 4, 5
   • Adults/children >8 years: Doxycycline + streptomycin (first choice) or doxycycline + gentamicin (alternative) 1, 2

3. Monitor for treatment response and adverse effects:

   • If adverse effects occur with aminoglycosides, consider switching to doxycycline + rifampicin 1
   • If relapse occurs, retreat with the same regimen or consider alternative combinations 1