Treatment of Brucellosis in Pediatric Patients
For children under 8 years old with brucellosis, the preferred first-line regimen is rifampicin (15-20 mg/kg/day) combined with trimethoprim-sulfamethoxazole (TMP-SMX: 10-12 mg/kg trimethoprim component) given orally for 6 weeks. 1, 2
First-Line Treatment for Pediatric Brucellosis
Children Under 8 Years Old
Since tetracyclines are contraindicated in this age group due to effects on developing teeth and bones, the treatment approach differs from adults:
- Rifampicin + TMP-SMX is the regimen of choice: rifampicin 15-20 mg/kg/day plus TMP-SMX (10-12 mg/kg trimethoprim, 50-60 mg/kg sulfamethoxazole) in two divided doses for 6 weeks 2, 3, 4
- This combination has demonstrated excellent efficacy with relapse rates of only 3.5% in prospective pediatric studies 3
- An alternative regimen is rifampicin for 45 days combined with gentamicin 5-6 mg/kg/day for the first 5 days 2
Children 8 Years and Older
Once tetracyclines can be safely used, treatment options expand:
- Doxycycline + Streptomycin: doxycycline 100 mg twice daily for 6 weeks plus streptomycin 15 mg/kg daily IM for 2-3 weeks (lowest relapse rate) 1, 5
- Doxycycline + Gentamicin: doxycycline 100 mg twice daily for 6 weeks plus gentamicin 5 mg/kg daily IV for 7 days (WHO-recommended with comparable efficacy) 1, 5
- Doxycycline + Rifampicin: doxycycline 100 mg twice daily for 6 weeks plus rifampicin 600-900 mg daily for 6 weeks (when aminoglycosides are contraindicated) 1, 5
Evidence Supporting Pediatric Regimens
The rifampicin-TMP-SMX combination has strong pediatric-specific evidence:
- A large multicenter study of 1,100 children demonstrated that TMP-SMX monotherapy had unacceptably high relapse rates (30%), but when combined with rifampicin, relapse rates dropped to 4-8% for 3-5 week courses and 0% for 8-week courses 6
- A prospective trial of 113 children treated with rifampicin plus TMP-SMX for 6 weeks showed excellent tolerance with only 4 relapses (3.5%), all of which responded to repeat therapy 3
- This regimen is both cost-effective and avoids the toxicity and expense of aminoglycosides 7, 3
Important Caveats and Clinical Pearls
Duration Matters More Than Specific Agents
- Standard treatment duration is 6 weeks for uncomplicated disease 1, 5
- Pediatric studies showed no significant difference between 3,5, or 8 weeks when using combination therapy (not monotherapy), though 6 weeks is the accepted standard 6
TMP-SMX Should Never Be Used Alone
- TMP-SMX monotherapy has unacceptably high failure rates (30%) and should only be used in combination with rifampicin or as a third agent 7, 6
- The absence of doxycycline from regimens containing TMP-SMX was associated with high treatment failure rates 7
Aminoglycoside-Containing Regimens
- When aminoglycosides are used in children ≥8 years, streptomycin for 2 weeks or gentamicin for 5-7 days combined with doxycycline provides the lowest relapse rates 1, 6
- Gentamicin offers the advantage of shorter duration (7 days vs 2-3 weeks) and wider availability compared to streptomycin 1, 5
Special Situations in Pediatrics
Brucellar Spondylitis:
- Aminoglycoside-containing regimens may be superior to rifampicin-containing ones 7, 8, 5
- MRI should always be performed when spinal involvement is suspected 7, 8, 5
- Treatment duration should be extended based on clinical response 7
- Immobilization is crucial for cervical involvement to prevent devastating neurological complications 8
Neurobrucellosis:
- Aminoglycoside-containing regimens (preferably gentamicin) combined with doxycycline and rifampicin should be considered 8
- Treatment duration typically extends to 3-6 months 4
Regional Considerations
- In areas where tuberculosis and brucellosis coexist, consider the public health implications of rifampicin use, as widespread use may contribute to mycobacterial resistance 1, 5
- In resource-limited settings, the rifampicin-TMP-SMX combination offers significant cost advantages while maintaining efficacy 7, 3