CBRNE - Brucellosis Medication
- Author: Gerald E Maloney Jr, DO, FAAEM; Chief Editor: Robert G Darling, MD, FACEP more...
Medication Summary
The appropriate antibiotic therapy for brucellosis has been studied to some degree. Doxycycline (100 mg PO bid for 6 wk) is the most appropriate monotherapy in simple infection; however, relapse rates approach 40% for monotherapy treatment. Rifampin (600-900 mg/d) usually is added to doxycycline for a full 6-week course. In patients with spondylitis or sacroiliitis, doxycycline plus streptomycin (1 g/d IM for 3 wk) was found to be more effective than the doxycycline/rifampin combination. Streptomycin currently is favored over rifampin for combination therapy of any significant infection. In pediatric patients older than 8 years, doxycycline (5 mg/kg/d for 3 wk) plus gentamicin (5 mg/kg/d IM for the first 5 d) was the recommended therapy. For children younger than 8 years, trimethoprim/sulfamethoxazole (TMP-SMZ) for 3 weeks and a 5-day course of gentamicin were most effective. TMP-SMZ also was effective in treating pregnant women, either as a single agent or in combination with rifampin or gentamicin.
Fluoroquinolones have a high relapse rate when used as monotherapy. Fluoroquinolones added to doxycycline have no advantage over the other regimens described, but may be preferred in an area where resistance to rifampin is high. No uniform recommendation exists for treatment of meningitis or endocarditis; however, TMP-SMZ plus rifampin remains the preferred combination. In endocarditis, early replacement of the infected valve is recommended, along with medical therapy. Corticosteroids are recommended in CNS infection, but data supporting their utility are lacking. Also prescribe symptomatic treatment for pain and fever.
A meta-analysis comparing rates of resistance among several potential biological weapons found that doxycycline was the most effective antibiotic, with lower rates of resistance than seen with fluoroquinolones. In brucellosis, doxycycline for 45 days with either streptomycin or gentamicin seems to be the best regimen based on recent data.
Antibiotics
Class Summary
Indicated to abolish infection. Therapy must cover all likely pathogens in the context of the clinical setting.
Doxycycline (Doryx, Vibramycin, Bio-Tab)
Several different controlled and retrospective trials have established efficacy as treatment for brucellosis. Because of concerns regarding treatment failures, combination therapy with rifampin or an aminoglycoside now is recommended, although it remains approved for use as monotherapy.
Rifampin (Rifadin, Rimactane)
Used in combination therapy with doxycycline, TMP-SMZ, or gentamicin for treatment of brucellosis.
Sulfamethoxazole and trimethoprim (Bactrim, Septra)
Used as adjunctive therapy with gentamicin in treating infection in children < 8 y; used as monotherapy or combined with rifampin or gentamicin to treat infection in pregnant females. Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.
Gentamicin (Garamycin, Gentacidin)
Aminoglycosides have been used for several years to treat brucellosis; studies to date have shown gentamicin to be the preferred aminoglycoside to treat infection as combined therapy with either TMP-SMZ or doxycycline in children. Adult dose is either once-daily dosing or a multiple-daily dose.
Streptomycin
Has been used for several years to treat brucellosis; used in combination with doxycycline, especially for spondylitis or sacroiliitis; augments bacteriocidal action of other agents used to treat brucellosis.
Corticosteroids
Class Summary
Indicated to reduce inflammation and improve neurologic outcome in patients with neurobrucellosis.
Dexamethasone (Decadron, AK-Dex)
Use of corticosteroids is reserved for symptomatic brucella meningitis. Although generally recommended, scientific evidence supporting their use is lacking. No consensus exists on optimal dosing, frequency, or duration of therapy.
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