Treatment of Brucellosis in Children
Recommended First-Line Treatment by Age
For children under 8 years old, treat with rifampicin (15-20 mg/kg/day) combined with trimethoprim-sulfamethoxazole (10-12 mg/kg of trimethoprim component) given orally for 6 weeks. 1
For children 8 years and older, treat with doxycycline (100 mg twice daily) plus either streptomycin (15 mg/kg daily IM) for 2-3 weeks or gentamicin (5 mg/kg daily IV) for 7 days. 1
Treatment Algorithm by Age and Clinical Scenario
Children Under 8 Years Old
Primary regimen: Rifampicin (15-20 mg/kg/day) + TMP-SMX (10-12 mg/kg trimethoprim component) orally for 6 weeks 1, 2
This combination is cost-effective, avoids aminoglycoside toxicity, and has demonstrated low relapse rates (4-8%) in pediatric studies 1, 2
Critical caveat: TMP-SMX monotherapy has unacceptably high failure rates (30%) and should never be used alone 1, 3
Alternative if TMP-SMX allergy: Rifampicin + ciprofloxacin + gentamicin has been successfully used in case reports, though this is not a guideline-recommended first-line option 4
Children 8 Years and Older
Preferred regimen: Doxycycline (100 mg twice daily) + streptomycin (15 mg/kg daily IM) for 2-3 weeks, continue doxycycline to complete 6 weeks total 1
This aminoglycoside-containing regimen provides the lowest relapse rates in this age group 1
Alternative regimen: Doxycycline (100 mg twice daily) + gentamicin (5 mg/kg daily IV) for 7 days, continue doxycycline to complete 6 weeks total 1, 5
Gentamicin offers comparable efficacy to streptomycin with shorter parenteral therapy duration 5
When aminoglycosides are contraindicated: Doxycycline (100 mg twice daily) + rifampicin (600-900 mg daily) for 6 weeks 1
This all-oral regimen is convenient but has slightly higher relapse rates than aminoglycoside-containing regimens 1
Treatment Duration
- Standard duration is 6 weeks for uncomplicated brucellosis 1, 5
- Pediatric studies show no significant difference between 3,5, or 8 weeks when using combination therapy, though 6 weeks remains the standard recommendation 1, 3
Special Clinical Situations
Brucellar Spondylitis
- Aminoglycoside-containing regimens may be superior to rifampicin-containing regimens for spinal involvement 1, 6
- Always perform MRI when spinal involvement is suspected 1, 6
- Consider longer treatment duration and immobilization if cervical spine is involved 6
Neurobrucellosis
- Use triple therapy: doxycycline + rifampicin + aminoglycoside (preferably gentamicin) 1, 6
- Extend treatment duration to 3-6 months 1
- This applies to children 8 years and older; for younger children, expert consultation is needed 1
Important Clinical Pearls and Pitfalls
Expected Outcomes
- Relapse rates range from 5-15% even with appropriate treatment 1, 5
- Relapses are usually mild and respond well to retreatment with the same regimen 1, 5
- Defervescence and symptom resolution typically occur within 1-3 weeks of starting treatment 2
Common Pitfalls to Avoid
- Never use TMP-SMX as monotherapy - it has a 30% relapse rate and should only be used in combination with rifampicin 1, 3
- Do not use fixed-dose gentamicin (500 mg) - always calculate weight-based dosing at 5 mg/kg daily 5
- Avoid tetracyclines in children under 8 years old due to dental staining and bone growth effects 1, 7
Regional and Public Health 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, 6
- In resource-limited settings, the rifampicin-TMP-SMX combination offers significant cost advantages while maintaining efficacy 1, 2