eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease
Brucellosis: Treatment & Medication
Updated: Jan 25, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
See Medication.
Surgical Care
Surgical intervention may be required to drain pyogenic joint effusions or rare paraspinal abscesses. Valve replacement surgery is often recommended in addition to a prolonged course of antibiotics.
Consultations
- Infectious disease specialist: Consult an infectious disease specialist regarding treatment in patients with brucellosis.
- Surgeon: Consult with a surgeon, if indicated.
Medication
Antibiotics
Despite extensive studies, optimal antibiotic therapy for brucellosis remains under dispute. For acute brucellosis in adults and children older than 8 years, World Health Organization (WHO) guidelines recommend rifampin (600-900 mg) and doxycycline (200 mg) daily for a minimum of 6 weeks. Treatment in children younger than 8 years requires rifampin and cotrimoxazole.9,10 Treatment of meningoencephalitis or endocarditis requires combination therapy with rifampin, a tetracycline, and an aminoglycoside.
Table 2. Age-related Dosing of Antimicrobial Agents in Brucellosis
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Table
| Age | Antimicrobial Agents | Dose |
| Patients >8 y | Doxycycline plus streptomycin or doxycycline plus gentamicin | Doxycycline: 2-4 mg/kg/d PO qd or divided bid for 6 wk; not to exceed 200 mg/d Streptomycin: 1 g/d IM for 2 wk Gentamicin: 3-5 mg/kg/d IM/IV divided q8h for 1 wk |
| Alternative in patients >8 y | Doxycycline plus rifampin | Doxycycline: 2-4 mg/kg/d PO qd or divided bid for 6 wk; not to exceed 200 mg/d Rifampin: 15-20 mg/kg/d PO for 6 wk; not to exceed 600-900 mg/d |
| Patients <8 y | Trimethoprim-sulfamethoxazole (TMP-SMZ) plus rifampin | TMP-SMZ: 8-10 mg (based on TMP component)/kg/d for 45 d; not to exceed 2 double-strength tab/d Rifampin: 15-20 mg/kg/d PO for 45 d; not to exceed 600-900 mg/d |
| Patients >8 y with meningitis,* endocarditis, or osteomyelitis | Doxycycline plus streptomycin or doxycycline plus gentamicin | Doxycycline: 2-4 mg/kg/d PO qd or divided bid for 4-6 mo; not to exceed 200 mg/d Streptomycin: 20 mg/kg/d IM for 1-2 wk; not to exceed 1 g/d Gentamicin: 3-5 mg/kg/d IM/IV divided q8h for 1-2 mo |
| Patients <8 y with meningitis,* endocarditis, or osteomyelitis | TMP-SMZ plus rifampin | TMP-SMZ: 8-10 mg (based on TMP component)/kg/d PO divided bid for 4-6 mo Rifampin: 15-20 mg/kg/d PO for 4-6 mo; not to exceed 600-900 mg/d |
| Age | Antimicrobial Agents | Dose |
| Patients >8 y | Doxycycline plus streptomycin or doxycycline plus gentamicin | Doxycycline: 2-4 mg/kg/d PO qd or divided bid for 6 wk; not to exceed 200 mg/d Streptomycin: 1 g/d IM for 2 wk Gentamicin: 3-5 mg/kg/d IM/IV divided q8h for 1 wk |
| Alternative in patients >8 y | Doxycycline plus rifampin | Doxycycline: 2-4 mg/kg/d PO qd or divided bid for 6 wk; not to exceed 200 mg/d Rifampin: 15-20 mg/kg/d PO for 6 wk; not to exceed 600-900 mg/d |
| Patients <8 y | Trimethoprim-sulfamethoxazole (TMP-SMZ) plus rifampin | TMP-SMZ: 8-10 mg (based on TMP component)/kg/d for 45 d; not to exceed 2 double-strength tab/d Rifampin: 15-20 mg/kg/d PO for 45 d; not to exceed 600-900 mg/d |
| Patients >8 y with meningitis,* endocarditis, or osteomyelitis | Doxycycline plus streptomycin or doxycycline plus gentamicin | Doxycycline: 2-4 mg/kg/d PO qd or divided bid for 4-6 mo; not to exceed 200 mg/d Streptomycin: 20 mg/kg/d IM for 1-2 wk; not to exceed 1 g/d Gentamicin: 3-5 mg/kg/d IM/IV divided q8h for 1-2 mo |
| Patients <8 y with meningitis,* endocarditis, or osteomyelitis | TMP-SMZ plus rifampin | TMP-SMZ: 8-10 mg (based on TMP component)/kg/d PO divided bid for 4-6 mo Rifampin: 15-20 mg/kg/d PO for 4-6 mo; not to exceed 600-900 mg/d |
*The use of corticosteroids as adjunctive therapy to antibiotics may be beneficial in culture-proven meningitis.
Doxycycline (Bio-Tab, Doxy, Vibramycin)
Bacteriostatic agent that reversibly binds to the 30S and 50S bacterial ribosomes.
Adult
200 mg/d PO qd or divided bid
Pediatric
<8 years: Not recommended
>8 years: 2-4 mg/kg/d PO qd or divided bid; not to exceed 200 mg/d
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of PO contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider testing drug serum levels in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Trimethoprim and sulfamethoxazole (Cotrim, Septra, Bactrim)
Commonly termed cotrimoxazole. Produces a sequential blockade in folic acid synthesis. This effect is frequently synergistic and bactericidal.
Adult
160 mg (based on TMP component)/800 mg (sulfamethoxazole component) PO q12h (ie, 1 double-strength tab PO bid)
Pediatric
8-10 mg (based on TMP component)/kg/d PO divided bid
May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly persons; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Documented hypersensitivity; megaloblastic anemia due to folate deficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use near term in pregnancy because of risk of kernicterus in newborns; discontinue at first appearance of rash or sign of adverse reaction; frequently obtain CBC counts; discontinue if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; caution in folate deficiency (eg, chronic alcoholism or patients who are elderly, are receiving anticonvulsant therapy, or have malabsorption syndrome); hemolysis may occur in G-6-PD deficiency; patients with AIDS may not tolerate or respond; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); administer fluids to prevent crystalluria and stone formation
Rifampin (Rifadin, Rimactane)
Bacteriostatic or bacteriocidal agent, depending on concentration of the drug at the site of infection. Suppresses initiation of chain formation for RNA synthesis.
Adult
600-900 mg/d PO/IV
Pediatric
15-20 mg/kg/d PO/IV qd or divided q12h; not to exceed 600-900 mg/d
Induces microsomal enzymes, which may decrease effects of acetaminophen, PO anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, PO contraceptives, corticosteroids, mexiletine, cyclosporine, digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin; blood pressure may increase with coadministration of enalapril; coadministration with isoniazid may result in higher rate of hepatotoxicity than with either agent alone (discontinue one or both agents if alterations occur in LFTs)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Obtain CBC counts and baseline clinical chemistry panels prior to and throughout therapy; weigh benefits against risk of further liver damage in patients with liver disease; interruption of therapy and high-dose intermittent therapy are associated with thrombocytopenia that is reversible if therapy is discontinued as soon as purpura occurs; if treatment is continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur
Streptomycin
Bacteriostatic by means of inhibiting protein synthesis by binding to 30S ribosomal subunit.
Adult
1 g/d IM
Pediatric
20 mg/kg/d IM; not to exceed 1 g/d
Nephrotoxicity may be increased with aminoglycosides, cephalosporins, penicillins, amphotericin B, vancomycin, and loop diuretics; increased potential for neuromuscular blockade with concomitant administration of magnesium, curarizing agents, colimycin, or chloramphenicol
Documented hypersensitivity; non–dialysis-dependent renal insufficiency
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Ototoxicity and nephrotoxicity may occur; risk factors for ototoxicity include excessive doses, preexisting renal disease, excessive serum peak concentration, and concurrent use of loop diuretics or vancomycin; can cause reversible neuromuscular blockade when administered with anesthetic agents or neuromuscular relaxants or in patients with myasthenia gravis or infant botulism
Gentamicin (Garamycin)
Bacteriostatic by means of inhibiting protein synthesis by binding to 30S ribosomal subunit.
Dosing regimens are numerous; adjust dose based on CrCl and changes in volume of distribution. May be administered IV/IM.
Adult
1-1.5 mg/kg IV q8h
Pediatric
3-5 mg/kg/d IV divided q8h
Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents, thus, prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)
Documented hypersensitivity; non–dialysis-dependent renal insufficiency
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment
More on Brucellosis |
| Overview: Brucellosis |
| Differential Diagnoses & Workup: Brucellosis |
 Treatment & Medication: Brucellosis |
| Follow-up: Brucellosis |
| References |
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References
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Further Reading
Keywords
brucellosis, Brucella abortus, Brucella melitensis, Brucella suis, Brucella canis, Brucella infection, zoonosis, Mediterranean fever, Malta fever, gastric remittent fever, undulant fever, sarcoidosis, endocarditis, sacroiliitis, epididymoorchitis, meningitis, papilledema, optic neuropathy, radiculopathy, stroke, intracranial hemorrhage, neurobrucellosis, hepatic abscess, splenic abscess, thyroid abscess, epidural abscess, pneumonitis, pleural empyema, uveitis, peritonitis, food-borne brucellosis, failure to thrive, chronic fatigue syndrome, hepatosplenomegaly, lymphadenopathy, arthritis, osteomyelitis
