What to do for a patient with brucellosis (brucella infection) on doxycycline (vibramycin) and rifamycin (rifampin) who experiences sweating and chills in the afternoon?

Management of Fever and Chills in a Patient with Brucellosis on Doxycycline and Rifampin

The afternoon sweating and chills experienced by your patient with brucellosis on doxycycline and rifampin therapy are most likely manifestations of the disease itself rather than medication side effects, and typically do not require a change in the antibiotic regimen.

Understanding the Symptoms

• Fever with temperature swings accompanied by profuse sweating, especially in the afternoon, is a hallmark symptom of brucellosis and may persist during early treatment 1
• Chills frequently accompany the fever pattern in brucellosis and are part of the natural disease course 1
• These symptoms typically represent the ongoing inflammatory response to the infection rather than adverse effects of the medications 2

Assessment of Current Treatment

• The doxycycline-rifampin combination (DOX-RIF) is a first-line regimen for brucellosis with Grade AI recommendation 2, 3
• Standard dosing is doxycycline 100 mg twice daily for 6 weeks plus rifampin 600-900 mg daily as a single morning dose for 6 weeks 3
• This regimen is appropriate but has a slightly higher relapse rate (16%) compared to doxycycline-streptomycin (5.3%) 4

Management Recommendations

Continue Current Treatment If:

• Symptoms are mild to moderate and improving since treatment initiation 3
• No evidence of focal disease complications (neurobrucellosis, endocarditis, spondylitis) 1
• No significant hepatic function abnormalities 5

Consider Treatment Modification If:

• Symptoms are severe or worsening despite 7-10 days of therapy 2, 3
• Patient has developed focal complications 1
• There are signs of hepatotoxicity (rifampin can cause hepatic reactions) 5

Supportive Measures for Symptom Relief

• Antipyretics such as acetaminophen can help manage fever and associated discomfort 3
• Adequate hydration is important, especially during episodes of sweating 2
• Rest during symptomatic periods and gradual return to activities as tolerated 3
• Monitor temperature patterns to track improvement 2

Monitoring Recommendations

• Regular clinical assessment of symptom progression - improvement should be noted within 7-14 days of treatment initiation 3
• Laboratory monitoring including complete blood count, liver enzymes, and renal function tests 5
• Serologic testing may not be helpful for early treatment response assessment as titers can remain elevated for months 3

When to Consider Alternative Regimens

• If symptoms persist or worsen after 2 weeks of therapy, consider switching to doxycycline-streptomycin or doxycycline-gentamicin regimen 2, 6
• Doxycycline-gentamicin (DOX-GENT) offers comparable efficacy to doxycycline-streptomycin with gentamicin given for 7 days 3
• In case of medication intolerance, trimethoprim-sulfamethoxazole containing regimens may be considered 3

Important Considerations

• Rifampin can cause orange-red discoloration of body fluids including sweat, which should not be confused with bleeding 5
• Paradoxical worsening of symptoms can occasionally occur during early treatment 5
• Full resolution of all symptoms may take several weeks even with appropriate therapy 3
• Relapse rates of 5-15% are reported even with appropriate treatment 3

When to Seek Immediate Medical Attention

• Development of new neurological symptoms suggesting neurobrucellosis 1
• Signs of hepatotoxicity: jaundice, right upper quadrant pain, significantly elevated liver enzymes 5
• High fever (>39°C) unresponsive to antipyretics 2
• Development of new focal symptoms suggesting disease progression 1