Brucellosis Treatment
For uncomplicated brucellosis, treat with doxycycline 100 mg twice daily for 6 weeks combined with streptomycin 15 mg/kg daily intramuscularly for 2-3 weeks, as this regimen has the lowest relapse rates. 1, 2
First-Line Treatment Regimens
Preferred Option
- Doxycycline-Streptomycin combination is the gold standard with the lowest relapse rates (5-15%) 1, 2
Alternative First-Line Options
Doxycycline-Gentamicin offers comparable efficacy with the advantage of wider availability and shorter parenteral therapy duration 1, 2
Doxycycline-Rifampicin is considered second-choice due to higher relapse rates but avoids injectable therapy 1, 2
Special Populations
Pregnancy
Rifampicin 900 mg once daily for 6 weeks combined with trimethoprim-sulfamethoxazole (800+160 mg twice daily) for 6 weeks is the recommended regimen, as tetracyclines are contraindicated. 3, 4, 5
- Treatment should be initiated immediately upon diagnosis to prevent obstetric complications including abortion (2.5-54.5%), intrauterine fetal death (0-20.6%), and preterm delivery (1.2-28.6%) 5
- Early adequate therapy significantly reduces adverse outcomes 5
- Monotherapy with rifampicin alone is also widely used while awaiting prospective trial data 5
- Breastfeeding should be avoided during treatment 6
Children Under 8 Years
- Rifampicin 900 mg once daily for 6 weeks combined with trimethoprim-sulfamethoxazole for 45 days is the preferred regimen, as tetracyclines cause tooth discoloration 3
- Alternative: Rifampicin for 45 days with gentamicin 5-6 mg/kg/day for the first 5 days 3
Liver Disease Considerations
- Rifampicin should be used cautiously or avoided in patients with significant hepatic impairment 2
- Consider doxycycline-streptomycin or doxycycline-gentamicin regimens instead 1, 2
Complicated Brucellosis
Brucellar Spondylitis (Spinal Involvement)
- Extend treatment duration to 12 weeks (3 months) when MRI demonstrates spinal involvement 2
- Aminoglycoside-containing regimens (doxycycline-streptomycin or doxycycline-gentamicin) may be superior to rifampicin-containing regimens 2
- Carefully assess for back pain in all brucellosis patients, as it may indicate spondylitis requiring extended therapy 2
Brucellar Endocarditis
- This is a high-mortality complication requiring aggressive antimicrobial management 2
- Surgical intervention is necessary in most cases 2
- Extended treatment duration beyond standard 6 weeks is required 2
Neurobrucellosis
- Requires extended treatment duration of 12-24 weeks 2
- Consider triple-drug regimens for severe cases 7
Treatment Duration and Monitoring
- Standard duration is 6 weeks for uncomplicated cases 1, 2
- Shorter durations (3 weeks) are inadequate and associated with unacceptably high relapse rates 2
- Fever and sweating typically improve within 7-14 days of treatment initiation 8
- Full symptom resolution may take several weeks even with appropriate therapy 8
Important Caveats
Relapse Management
- Relapse rates of 5-15% occur even with appropriate treatment 1, 2, 8
- Relapses are usually mild and respond to the same treatment regimens 1, 2
- Serologic testing is not helpful for early treatment response assessment 8
Public Health Considerations
- In regions where tuberculosis coexists with brucellosis, carefully consider the implications of using rifampicin, as this may contribute to mycobacterial resistance 1, 2
When to Modify Treatment
- If symptoms persist or worsen after 2 weeks of therapy, switch to doxycycline-streptomycin or doxycycline-gentamicin 8
- Development of new neurological symptoms requires immediate evaluation for neurobrucellosis 8
- High fever unresponsive to antipyretics warrants reassessment 8