What is the recommended treatment for neurobrucellosis?

Treatment of Neurobrucellosis

The optimal treatment for neurobrucellosis consists of a triple-drug regimen including doxycycline, rifampicin, and ceftriaxone for a minimum of six months. 1

First-Line Treatment Regimen

• Doxycycline (100 mg twice daily orally) plus rifampicin (600-900 mg daily as a single morning dose) plus ceftriaxone (parenteral) is the preferred regimen for neurobrucellosis 2, 1
• Treatment duration should be a minimum of six months, significantly longer than for uncomplicated brucellosis 2, 1
• Ceftriaxone is particularly valuable in the initial phase of treatment due to its excellent cerebrospinal fluid penetration 1

Alternative Treatment Options

• If ceftriaxone cannot be used, a combination of doxycycline and rifampicin with an aminoglycoside (preferably gentamicin over streptomycin) may be considered 3, 4
• Trimethoprim-sulfamethoxazole (TMP-SMX) can be added as a third or fourth agent in complicated cases 5, 6
• Streptomycin use is discouraged in neurobrucellosis due to its poor cerebrospinal fluid penetration and potential neurotoxicity that may complicate clinical assessment 1

Treatment Considerations

• MRI should be performed when spinal involvement is suspected in neurobrucellosis 7
• Aminoglycoside-containing regimens may be superior to rifampicin-containing ones for brucellar spondylitis, which may accompany neurobrucellosis 8
• Immobilization of the spine is crucial if there is cervical involvement to prevent devastating neurological complications 9

Monitoring and Outcomes

• Neurological sequelae may persist despite appropriate treatment, particularly hearing loss and walking difficulties 2
• Regular clinical and cerebrospinal fluid monitoring is essential to assess treatment response 5
• Treatment failure rates are higher in neurobrucellosis compared to uncomplicated brucellosis 4

Special Considerations

• In regions where brucellosis and tuberculosis coexist, consider the public health implications of using rifampicin, as this may contribute to mycobacterial resistance 3
• Corticosteroids have been used in specialized situations, particularly with significant inflammation or elevated intracranial pressure 1
• Imaging techniques often do not provide specific findings for neurobrucellosis, making clinical and laboratory diagnosis crucial 2, 6

Treatment Algorithm

1. Initiate triple therapy with doxycycline (100 mg twice daily), rifampicin (600-900 mg daily), and ceftriaxone (parenteral) 2, 1
2. Continue ceftriaxone for at least 4 weeks, then maintain doxycycline and rifampicin for a minimum total duration of 6 months 2, 1
3. Consider adding TMP-SMX if response is inadequate 5, 6
4. Monitor neurological status and cerebrospinal fluid parameters regularly 5
5. Extend treatment duration if clinical or laboratory parameters indicate ongoing infection 1