Ofloxacin plus rifampicin versus doxycycline plus rifampicin in the treatment of brucellosis: a randomized clinical trial [ISRCTN11871179]

Treatment of Childhood Brucellosis: A Systematic Review

BACKGROUND

Proper treatment for brucellosis is crucial to eradicate the infection and prevent complications, but there is a notable gap in evidence for pediatric treatment. This study aims to address this gap by reviewing current literature, analyzing the efficacy and safety of brucellosis treatment in children, and identifying areas that require further investigation.

METHODS

A systematic review, following preferred reporting items for systematic reviews and meta-analyses and Cochrane Handbook guidelines, assessed antimicrobial regimens' efficacy and safety for treating human brucellosis in children. Original human studies with clinical outcomes after drug therapy intervention for children up to 10 years were included. Searches were conducted in Medline, Embase, Cochrane Library and LILACS databases for studies indexed until March 6, 2023. Study selection, data extraction, and bias risk assessment were performed by pairs of reviewers. The quality assessment used Joanna Briggs Institute tools and grading of recommendations assessment, development and evaluation system. Data were analyzed using R software.

RESULTS

A total of 1773 records were reviewed, yielding 11 eligible studies encompassing 1156 children. All included studies presented an observational design. The most reported treatment approaches included sulfamethoxazole-trimethoprim with rifampicin or aminoglycosides, with summarized failure rates of 2% (95% confidence interval: 0.0-0.49) and 13% (95% confidence interval: 0.06-0.29), respectively (very low certainty of evidence). Adverse events and time to defervescence were not reported.

CONCLUSIONS

Sulfamethoxazole-trimethoprim + rifampicin were the most prescribed antibiotics for brucellosis for pediatrics. The study highlights the need for more research with robust designs, and emphasizes uncertainty regarding the efficacy of antimicrobial regimens, emphasizing the importance of further investigations to guide specific treatment protocols for this population.

Efficacy and safety of therapeutic strategies for human brucellosis: A systematic review and network meta-analysis

BACKGROUND

Human brucellosis is a neglected, re-emerging, and endemic zoonosis in many countries. The debilitating and disabling potential of the disease is a warning about its morbidity, generating socioeconomic impact. This review aims to update the current evidence on the efficacy and safety of therapeutic options for human brucellosis using the network meta-analysis (NMA).

METHODOLOGY

A systematic search was conducted in four different databases by independent reviewers to assess overall therapy failure, adverse events, and time to defervescence associated with different therapies. Randomized clinical trials (RCTs) evaluating any therapeutic drug intervention were selected, excluding non-original studies or studies related to localized forms of the disease or with less than 10 participants. Data were analyzed by frequentist statistics through NMA by random effects model. The risk of bias and certainty of evidence was assessed, this review was registered at PROSPERO.

RESULTS

Thirty-one (31) RCTs involving 4167 patients were included. Three networks of evidence were identified to evaluate the outcomes of interest. Triple therapy with doxycycline + streptomycin + hydroxychloroquine for 42 days (RR: 0.08; CI 95% 0.01-0.76) had a lower failure risk than the doxycycline + streptomycin regimen. Doxycycline + rifampicin had a higher risk of failure than doxycycline + streptomycin (RR: 1.96; CI 95% 1.27-3.01). No significant difference was observed between the regimens when analyzing the incidence of adverse events and time to defervescence. In general, most studies had a high risk of bias, and the results had a very low certainty of evidence.

CONCLUSIONS

This review confirmed the superiority of drugs already indicated for treating human brucellosis, such as the combination of doxycycline and aminoglycosides. The association of hydroxychloroquine to the dual regimen was identified as a potential strategy to prevent overall therapy failure, which is subject to confirmation in future studies.

Identifying potential natural inhibitors of Brucella melitensis Methionyl-tRNA synthetase through an in-silico approach

Background

Brucellosis is an infectious disease caused by bacteria of the genus Brucella. Although it is the most common zoonosis worldwide, there are increasing reports of drug resistance and cases of relapse after long term treatment with the existing drugs of choice. This study therefore aims at identifying possible natural inhibitors of Brucella melitensis Methionyl-tRNA synthetase through an in-silico approach.

Methods

Using PyRx 0.8 virtual screening software, the target was docked against a library of natural compounds obtained from edible African plants. The compound, 2-({3-[(3,5-dichlorobenzyl) amino] propyl} amino) quinolin-4(1H)-one (OOU) which is a co-crystallized ligand with the target was used as the reference compound. Screening of the molecular descriptors of the compounds for bioavailability, pharmacokinetic properties, and bioactivity was performed using the SWISSADME, pkCSM, and Molinspiration web servers respectively. The Fpocket and PLIP webservers were used to perform the analyses of the binding pockets and the protein ligand interactions. Analysis of the time-resolved trajectories of the Apo and Holo forms of the target was performed using the Galaxy and MDWeb servers.

Results

The lead compounds, Strophanthidin and Isopteropodin are present in Corchorus olitorius and Uncaria tomentosa (Cat’s-claw) plants respectively. Isopteropodin had a binding affinity score of -8.9 kcal / ml with the target and had 17 anti-correlating residues in Pocket 1 after molecular dynamics simulation. The complex formed by Isopteropodin and the target had a total RMSD of 4.408 and a total RMSF of 9.8067. However, Strophanthidin formed 3 hydrogen bonds with the target at ILE21, GLY262 and LEU294, and induced a total RMSF of 5.4541 at Pocket 1.

Conclusion

Overall, Isopteropodin and Strophanthidin were found to be better drug candidates than OOU and they showed potentials to inhibit the Brucella melitensis Methionyl-tRNA synthetase at Pocket 1, hence abilities to treat brucellosis. In-vivo and in-vitro investigations are needed to further evaluate the efficacy and toxicity of the lead compounds.

The cure for brucellosis involves a long course of treatment with a combination of antibiotics. However, some of the drugs are not recommended for very young children and pregnant women. Moreover, cases of relapse and resistance to these drugs are reported. With the Brucella Methionyl-tRNA synthetase as a target, molecular docking and virtual screening was used to identify possible drug candidates from a library of 1524 compounds obtained from edible African plants. Two lead compounds, Strophanthidin and Isopteropodin usually present in Corchorus olitorius and Uncaria tomentosa (Cat’s claw) plants showed potentials to inhibit the Brucella melitensis Methionyl-tRNA synthetase. Their bioactivities were also confirmed in their molecular dynamic simulation with the target protein. Consequently, both compounds have potentials for safety and efficacy in the treatment of brucellosis.

Relapsed Brucellosis Manifested as Endocarditis with Vegetation on the Implantable Cardioverter Defibrillator Lead

Implantable cardioverter defibrillator lead endocarditis due to Brucella melitensis is a rare and life-threatening complication of brucellosis. Successful management requires a combination of medical treatment and device extraction. We present a case of relapsing brucellosis manifested as infective endocarditis colonizing the lead of the implantable cardioverter defibrillator with formation of vegetation on the lead. A 63-year-old male presented to the rehabilitation unit with hypotension. No other signs of infection were noted. The patient had a history of drinking unpasteurized milk since childhood and a previous episode of Brucella infective endocarditis. A transthoracic echocardiography showed an oscillating vegetation on the lead of the tip of the right atrial ICD, and the blood cultures were positive for Brucella melitensis. Surgical removal of the device was infeasible, and medical management was the only feasible option in this case.

Enhanced Antibacterial Activity Of Doxycycline And Rifampicin Combination Loaded In Nanoparticles Against Intracellular Brucella Abortus

BACKGROUND

Brucellosis is a zoonotic disease and prevalent in livestock animals. The bacteria reside inside the macrophage cells of host. The WHO endorsed the combination treatment therapy for brucellosis as compared to monotherapy to avoid relapse and resistance. Therefore, we developed nanoparticles incorporating doxycycline and rifampicin in combination.

OBJECTIVE

The aim of the study is to develop polymeric nanoparticles incorporating doxycycline as well as rifampicin and investigate the antibacterial activity of nanoparticles in U937 human macrophage cells infected with B. abortus.

METHODS

Polymeric nanoparticles were developed by emulsion-solvent diffusion method and characterization was done.

RESULTS

The nanoparticles with high entrapment efficiency of both drugs were developed successfully. Scanning electron microscopy revealed spherical morphology with a size ranging ~450nm, which can be easily engulfed by macrophages. Zeta potential confirmed colloidal stability. Differential scanning calorimetry and X-ray diffraction suggested amorphization of doxycycline and rifampicin in nanoparticles. Fourier transfer infrared spectroscopy could not confirm interaction of drugs with AOT. In vitro haemolysis study confirmed safety of nanoparticles (<10%) for IV administration. Further, nanoparticles revealed the sustained release of both drugs, which followed diffusion kinetics. Nanoparticles were found stable for 6 months as per WHO guidelines. The internalization study revealed nanoparticles can be easily uptake by U-937 human macrophage cells. The efficacy study demonstrated significantly high antibacterial activity of nanoparticles as compared to free drug solution in U937 human macrophage cells infected with Brucella abortus.

CONCLUSION

It can be concluded that developed nanoparticles entrapping doxycycline and rifampicin combination could be considered as a promising delivery system for enhancing the antibacterial activity against Brucella abortus.

Use of Rifabutin as an Alternative Agent for Human Brucellosis: A Case Report

Drugs that have a good intracellular passage are used in the treatment of brucellosis. According to our knowledge, there is no report in English about rifabutin usage in brucellosis. We present a case that developed intolerance to many anti-brucella drugs, who was then successfully treated with a combination of rifabutin, ofloxacin, and ceftriaxone.

An Overview of Brucellosis in Cattle and Humans, and its Serological and Molecular Diagnosis in Control Strategies

Brucellosis is one of the most common contagious and communicable zoonotic diseases with high rates of morbidity and lifetime sterility. There has been a momentous increase over the recent years in intra/interspecific infection rates, due to poor management and limited resources, especially in developing countries. Abortion in the last trimester is a predominant sign, followed by reduced milk yield and high temperature in cattle, while in humans it is characterized by undulant fever, general malaise, and arthritis. While the clinical picture of brucellosis in humans and cattle is not clear and often misleading with the classical serological diagnosis, efforts have been made to overcome the limitations of current serological assays through the development of PCR-based diagnosis. Due to its complex nature, brucellosis remains a serious threat to public health and livestock in developing countries. In this review, we summarized the recent literature, significant advancements, and challenges in the treatment and vaccination against brucellosis, with a special focus on developing countries.

Review of brucellosis in Nepal

Brucellosis is an abortifacient zoonotic disease that remains prominent in third world countries like Nepal. Brucellosis poses a public health concern, because its incidence in livestock can present substantial economic and health burdens for herders and health professionals. Several cases of bovine and human brucellosis have been reported and the prevalence is higher among livestock than among humans in Nepal. Lack of awareness, unhealthy food habit, traditional husbandry practices, and a lack of surveillance and immunization have been the major factors in maintaining a vicious cycle of propagation of the disease in human and animals. The aim of this paper is to evaluate the current status of the disease, the mechanism of infection, and pathogenesis, its zoonotic potential, diagnostic advances, treatment regimens, and the preventive measures that can be adopted in managing human brucellosis in under-developed countries such as Nepal.

Review of Brucellosis in Nepal

OBJECTIVES

The aim of this paper is to evaluate the current status of the disease, the mechanism of infection, and pathogenesis, its zoonotic potential, diagnostic advances, treatment regimens, and the preventive measures that can be adopted in managing human brucellosis in under-developed countries such as Nepal.

METHODS

We performed a systematic review of all the available literture through Google Scholar, PubMed, Gideon Informatics, World Health Organization and other legitimate sources. Other secondary informations were collected from the government agencies such as department of livestock services and Ministry of Health. The obtained information was then re-analysed and summarized.

RESULTS

Few publications have addressed brucellosis in Nepal and most of those publications have focused on bovine brucellosis with sparse information available on brucellosis in humans and small ruminants. Brucella abortus is the most predominant causative agent followed by B. suis. B. abortus is predominant in cattle accounting for a substantial portion of bovine abortion in the country. Lack of awareness, unhealthy food habit, traditional husbandry practices, and a lack of surveillance and immunization have been the major factors in maintaining a vicious cycle of propagation of the disease in human and animals. Unfortunately, nothing has been done to identify the species of Brucella at the biovar level.

CONCLUSIONS

Although brucellosis has been reported to be endemic in Nepal, neither the distribution nor the economic and public health impact of this disease is well characterized. Robust and well-designed nationwide survey is warranted to assess the prevalence and distribution of disease in livestock and humans. Such data would facilitate the design of appropriate control programmes.

Brucellosis in Nepal - A Potential Threat to Public Health Professionals

Brucellosis is a prominent zoonotic disease affecting humans and animals which with the lack of proper diagnosis and treatment remains dangerous in third world countries like Nepal. Currently, Brucellosis poses a public health concern, whose incidences among entire herds of animals can present substantial economic and health burdens for herders and health professionals. Additionally, factors such as close contact with animals, poor animal husbandry, and unhygienic feeding habits can exacerbate the spread of Brucella and related zoonotic agents. In Nepal, serious cases of bovine and even human brucellosis have been reported, although the topic is yet to be extensively reviewed. This paper evaluates the literatures on human and animal brucellosis in Nepal and other countries, with an emphasis on the impact of Brucella outbreaks on public health professionals. Herein, we summarize the current status of the disease, the mechanism of infection, pathogenesis, zoonotic potential, diagnostic advances, treatment regimens, and the preventive measures that can be adopted in managing human brucellosis in under-developed countries such as Nepal.

Brucella melitensis Methionyl-tRNA-Synthetase (MetRS), a Potential Drug Target for Brucellosis

We investigated Brucella melitensis methionyl-tRNA-synthetase (BmMetRS) with molecular, structural and phenotypic methods to learn if BmMetRS is a promising target for brucellosis drug development. Recombinant BmMetRS was expressed, purified from wild type Brucella melitensis biovar Abortus 2308 strain ATCC/CRP #DD-156 and screened by a thermal melt assay against a focused library of one hundred previously classified methionyl-tRNA-synthetase inhibitors of the blood stage form of Trypanosoma brucei. Three compounds showed appreciable shift of denaturation temperature and were selected for further studies on inhibition of the recombinant enzyme activity and cell viability against wild type B. melitensis strain 16M. BmMetRS protein complexed with these three inhibitors resolved into three-dimensional crystal structures and was analyzed. All three selected methionyl-tRNA-synthetase compounds inhibit recombinant BmMetRS enzymatic functions in an aminoacylation assay at varying concentrations. Furthermore, growth inhibition of B. melitensis strain 16M by the compounds was shown. Inhibitor-BmMetRS crystal structure models were used to illustrate the molecular basis of the enzyme inhibition. Our current data suggests that BmMetRS is a promising target for brucellosis drug development. However, further studies are needed to optimize lead compound potency, efficacy and safety as well as determine the pharmacokinetics, optimal dosage, and duration for effective treatment.

A randomized, comparative study of dual therapy (doxycycline-rifampin) versus triple therapy (doxycycline-rifampin-levofloxacin) for treating acute/subacute brucellosis

Aim

The aim of this study was to compare both the efficacy and safety profile of the WHO-recommended, dual therapy (doxycycline–rifampin) to a quinolone-based, triple therapy (doxycycline–rifampin–levofloxacin) for treating acute/subacute brucellosis.

Patients and methods

We studied 107 consecutive, naïve patients with acute/subacute brucellosis admitted to Assiut University Hospital. Patients were randomly allocated to receive the dual therapy of doxycycline–rifampin (group-A) or to receive the triple therapy of doxycycline–rifampin–levofloxacin (group-B). Acute/subacute brucellosis was diagnosed based on the presence of: (1) contact with animals or fresh animal products, (2) suggestive clinical manifestations of less than one-year duration, and (3) positive antibody titer (1:160) by standard tube agglutination test.

Results

There was no significant difference between the two groups regarding their demographic data. Fever was the most frequent manifestation (96.3%). Epigastric pain was the most frequent adverse effect of treatment (12.1%). Group-A patients had a significantly higher relapse rate compared to group-B patients (22.6% versus 9.3%, p-value = 0.01). The rate of treatment adverse effects was higher among group-B patients, although not reaching statistical significance (20.4% versus 11.3%, p-value = 0.059).

Conclusions

Adding levofloxacin to the dual therapy for acute/subacute brucellosis (doxycycline–rifampin) may increase its efficacy in terms of lowering the relapse rate of the disease. Further, larger scale studies are needed before considering modifying the standard, dual therapy for brucellosis.

Efficacy evaluation of some antibiotics against syrian brucella spp isolates, in vitro

Brucellosis is an endemic zoonosis in Syria, affecting large numbers of animals and there are an increasing number of cases in humans. The aim of this study is to investigate the in vitro efficacy of various traditional and new antibiotics against 89 Brucella isolates (isolated from domestic animals) collected from different Syrian regions. Minimum inhibitory concentrations (MICs) of seventeen antibiotics were determined. Ciprofloxacin and ofloxacin were the most effective antibiotics, whereas sparfloxacin, levofloxacin, doxycycline and tetracycline had a moderate activity. In contrast, moxifloxacin and rifampicin had a low activity, while streptomycin, spiramycin and cephalosporines were ineffective. As a result, we come to the conclusion that a combination between one effective quinolone and doxycycline has a good efficacy against Brucella. Further in vivo studies are necessary to support this suggestion.

Effect of Medium pH on Antibiotic Activity against Syrian Brucella spp. Isolates

BACKGROUND

Brucellosis is an endemic zoonosis in Syria, affecting large numbers of animals. There are an increasing number of cases in humans. Brucella is a facultative intracellular pathogen, a small, non-motile, Gram-negative coccobacillus, which causes abortion in domestic animals and a febrile illness in humans.

METHODS

One hundred isolates collected from different Syrian regions were confirmed to be Brucella melitensis by biochemical tests. The minimum inhibitory concentration (MIC) of 6 antibiotics, alone and in combination, was determined at pH 7.0 and pH 5.0.

RESULTS

Ciprofloxacin and sparfloxacin were the most effective antibiotics tested at either pH value. In contrast, rifampicin had low activity and streptomycin was ineffective at either pH value. A combination of rifampicin-doxycycline revealed the highest synergistic activity at both test pH values (against 19/24 and 17/24 isolates, respectively) in vitro. Antagonistic activities were observed using a ciprofloxacin-streptomycin combination (against 9/24 and 13/24 isolates, respectively) as well as a ciprofloxacin-tetracycline combination (against 6/24 and 9/24 isolates, respectively). No differences were observed at both test pH values, when combining a Quinolone with rifampicin or doxycycline.

CONCLUSION

Combination of a Quinolone with doxycycline demonstrated good in vitro activity against B. melitensis. Further in vivo studies are necessary to support this suggestion.

The Antibacterial Activity of Selected Labiatae (Lamiaceae) Essential Oils against Brucella melitensis

BACKGROUND

Brucellosis, a zoonosis caused by four species of brucella, has a high morbidity. The major cause of brucellosis worldwide is brucella melitensis. Medicinal plants are considered as new antibacterial sources that could replace conventional antibiotics in the treatment of antibiotic-resistant bacteria. The aim of this study was to evaluate the efficacy of some native plants, alone and in combination with some antibiotics, in the treatment of brucellosis.

METHODS

The present experimental in vitro study was carried out to evaluate the anti-brucella activities of essential oils of Rosmarinus officinalis L., Origanum syriacum, Thymus syriacus, Salvia palaestina Benth, Mentha piperia, and Lavandula stoechas L., alone and in combination with some antibiotics. The activity against 16 tetracycline-resistant B. melitensis isolates was determined by disc diffusion method incorporating a concentration of 5%. Antibiotic discs were also used as a control. Microdilution brucella broth susceptibility assay was used in order to determine the MICs of essential oils and five antibiotics.

RESULTS

Among all the herbs evaluated, only the essential oils of O. syriacum and T. syriacus plants demonstrated most effective anti-brucella activity, and were then chosen for MIC study. The minimal inhibitory concentrations (MIC50) of essential oils of O. syriacum and T. syriacus against tetracycline-resistant B. melitensis were 3.125 µl/ml and 6.25 µl/ml, respectively.

CONCLUSION

Among the essential oils studied, those of O. syriacum and T. syriacus were most effective. Since a combination of levofloxacin and Thymus syriacus essential oil increased the efficacy of this antibiotic, O. syriacum and T. syriacus are recommended to be used as bactericidal agents against B. melitensis.

Prevalencia de brucelosis en columna: Evolución clínica y manejo quirúrgico

OBJETIVO: Conocer la prevalencia, características clínicas y de tratamiento de la espondilodiscitis por Brucella. MÉTODOS: Un total de 104 pacientes con diagnóstico de espondilitis espinal de los cuales 20 correspondieron a espondilitis por Brucella, tratados de forma conservadora con antibióticos o quirúrgicamente, mediante descompresión y estabilización de la columna en cualquier segmento, en el periodo comprendido entre Enero 2006 a Junio 2011. Se elaboró una hoja de captura para recolección de la información, la cual contenía la identificación del paciente, síntomas referidos, signos físicos, parámetros laboratoriales y tratamiento médico y quirúrgico. RESULTADOS: Trece pacientes del sexo masculino y 7 del sexo femenino, con edad promedio de 59,2 años y desviación estándar de 13,6 años. Tres pacientes tenían afectación del segmento torácico, 13 del segmento lumbar y 4 del segmento lumbo-sacro. Trece pacientes presentaron fiebre, el dolor lumbar se presentó en los 20 pacientes, parestesias en 12, debilidad en 9, artralgias, mialgias y anorexia en 5, radiculopatía en 13, cefalea en 1 y pérdida de peso en 5 pacientes. Veinte casos recibieron tratamiento médico con doxiciclina combinada con rifampicina. En 8 casos se realizó instrumentación posterior combinada con laminectomía y fusión póstero-lateral, en 2 se realizó instrumentación posterior combinada con discectomía del nivel afectado y fusión póstero-lateral y en 1 caso se realizó laminectomía combinada con discectomía y fusión. CONCLUSIÓN: La prevalencia de espondilodiscitis fue del 19,2%, siendo el dolor lumbar y la fiebre síntomas con alto índice de sospecha de espondilitis espinal. La descompresión combinada con estabilización y fusión es el tratamiento quirúrgico de elección.

Treatment of brucellosis: a systematic review of studies in recent twenty years

BACKGROUND

The treatment of human brucellosis is controversial. The purpose of this study was to search published clinical trial papers to provide a simple and effective treatment in brucellosis.

METHODS

Many studies on brucellosis treatment in a twenty- year span from 1993 to 2012 were searched in PubMed, Web of Science (ISI), Scopus, Google Scholar, Magiran, Iranmedex and SID. The studies that were searched and classified in groups according to combination therapy and monotherapy and their results in treatment outcome were compared. Regimens with lower treatment failure or relapse were considered as more suitable for brucellosis treatment.

RESULTS

The comparison of combined doxycycline and rifampicin (DR) with a doxycycline plus streptomycin (DS) favors the latter regimen. The combined doxycycline/cotrimoxazole (DCTM) showed similar effect with DR. The treatment with the combined regimen including quinolones was similar to DR but with higher relapse rates. Higher relapse rate was searched in monotherapy (13% vs. 4.8%) and in short-term (less than 4 weeks) treatment regimen (22% vs. 4.8%), respectively. Although in children, clinical trials were limited but showed cotrimoxazole plus rifampin for six weeks was the best treatment regimen.

CONCLUSION

In uncomplicated brucellosis in adult patients, doxycycline-aminoglycoside combination is the first choice with doxycycline- rifampin and doxycycline-cotrimoxazole should be the alternative regimens. The other oral regimens including quinolones may be considered as alternatives. Cotrimoxazole plus rifampin for six weeks may be the regimen of choice for the treatment of patients younger than 8 years old. Gentamicin for 5 days plus cotrimoxazole for six weeks may be a suitable alternative regimen.

Antibiotics for treating human brucellosis

BACKGROUND

Brucellosis is the most common zoonotic infection in the world. Several antibiotics, separately or in combination, have been tried for treatment of human brucellosis. The inconsistencies between different treatment regimens warrants the need for a systematic review to inform clinical practice and future research.

OBJECTIVES

To evaluate the effects of various antibiotic regimens, monotherapy or in combination with other antibiotics, for treating human brucellosis.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and LILACS until May 2012. We browsed the abstract books of several international infectious diseases conferences. We also checked the reference lists of all studies identified

SELECTION CRITERIA

We included the randomized controlled trials on the pharmaceutical interventions in treatment of acute, chronic, non-complicated, and complicated human brucellosis. The outcomes of interest were relapse, persistence of symptoms at the end of treatment, and adverse drug effects.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the studies for inclusion, risk of bias, and extracted relevant data using pre-designed extraction forms. The findings of homogenous studies were pooled using fixed-effect meta-analysis.

MAIN RESULTS

In total we included 25 studies comparing various antibiotic regimens. Methods of allocation and concealment were inadequately described in half the studies, and only three were blinded. In comparisons of doxycycline plus rifampicin versus doxycycline plus streptomycin we found eight studies with 694 participants. For treatment failure, the doxycycline plus rifampicin regimen was less effective (risk ratio (RR) 1.91, 95% confidence interval (CI) 1.07 to 3.42, seven studies, 567 participants), relapse (RR 2.39, 95% CI 1.17 to 4.86), and minor adverse drug reactions (RR 1.38, 95% CI 0.99 to 1.92). In comparisons of doxycycline plus rifampicin against quinolone (ciprofloxacin or ofloxacin) plus rifampicin we found five studies of 336 participants. The pooled analysis did not demonstrate any significant difference between two regimens in terms of relapse and symptom persistence, but showed a non-significant higher risk of minor adverse reactions in doxycycline plus rifampicin (RR 1.80, 95% CI 0.78 to 4.18). Other comparisons were reported in a few heterogenous studies, and the pooled analyses, where applied, did not show any significant difference.

AUTHORS' CONCLUSIONS

Doxycycline (six weeks) plus streptomycin (two or three weeks) regimen is more effective regimen than doxycycline plus rifampicin (six weeks) regimen. Since it needs daily intramuscular (IM) injection, access to care and cost are important factors in deciding between two choices. Quinolone plus rifampicin (six weeks) regimen is slightly better tolerated than doxycycline plus rifampicin, and low quality evidence did not show any difference in overall effectiveness.

A rare case of seronegative culture--proven infection with Brucella suis

Brucellosis is a chronic infection produced by members of the Brucella family. Diagnosis of this condition requires either isolation of the organism in culture or positive serological tests.We describe a 27-year-old male admitted as a case of pyrexia of unknown origin (PUO), who tested negative for Brucella IgM ELISA test on preliminary evaluation but was subsequently diagnosed on the strength of positive blood and bone marrow cultures to be a case of brucellosis secondary to Brucella suis infection. In addition to highlighting the pathogenic potential of an unusual organism, this case demonstrates the unreliability of standard serological tests based on the Brucella melitensis antigen for infection with other species of Brucella.

Systematic review and meta-analysis of randomized clinical trials in the treatment of human brucellosis

Background

Brucellosis is a persistent health problem in many developing countries throughout the world, and the search for simple and effective treatment continues to be of great importance.

Methods and Findings

A search was conducted in MEDLINE and in the Cochrane Central Register of Controlled Trials (CENTRAL). Clinical trials published from 1985 to present that assess different antimicrobial regimens in cases of documented acute uncomplicated human brucellosis were included. The primary outcomes were relapse, therapeutic failure, combined variable of relapse and therapeutic failure, and adverse effect rates. A meta-analysis with a fixed effect model was performed and odds ratio with 95% confidence intervals were calculated. A random effect model was used when significant heterogeneity between studies was verified.

Comparison of combined doxycycline and rifampicin with a combination of doxycycline and streptomycin favors the latter regimen (OR = 3.17; CI95% = 2.05–4.91). There were no significant differences between combined doxycycline-streptomycin and combined doxycycline-gentamicin (OR = 1.89; CI95% = 0.81–4.39). Treatment with rifampicin and quinolones was similar to combined doxycycline-rifampicin (OR = 1.23; CI95% = 0.63–2.40). Only one study assessed triple therapy with aminoglycoside-doxycycline-rifampicin and only included patients with uncomplicated brucellosis. Thus this approach cannot be considered the therapy of choice until further studies have been performed. Combined doxycycline/co-trimoxazole or doxycycline monotherapy could represent a cost-effective alternative in certain patient groups, and further studies are needed in the future.

Conclusions

Although the preferred treatment in uncomplicated human brucellosis is doxycycline-aminoglycoside combination, other treatments based on oral regimens or monotherapy should not be rejected until they are better studied. Triple therapy should not be considered the current treatment of choice.

Comparison of doxycycline-streptomycin, doxycycline-rifampin, and ofloxacin-rifampin in the treatment of brucellosis: a randomized clinical trial

BACKGROUND

Traditional regimens for the treatment of brucellosis are associated with significant relapse rates. The aim of this study was to compare the efficacy of ofloxacin plus rifampin (OFX-RIF) versus doxycycline plus streptomycin (DOX-STR) and doxycycline plus rifampin (DOX-RIF) regimens in the treatment of brucellosis.

METHODS

Two hundred and nineteen patients with brucellosis were enrolled in a randomized clinical trial; 28 cases were withdrawn because they did not attend the follow-up. Out of 191 patients with brucellosis, 64 received OFX-RIF, 62 received DOX-RIF, and 65 patients received DOX-STR regimens. All patients were assessed during the period of therapy in the second, fourth, and sixth weeks by clinical course and were also followed up clinically and serologically for 6 months after the cessation of therapy.

RESULTS

The highest clinical response (95.4%) was observed in the DOX-STR group (p=0.009). The results of multivariate analysis indicate that treatment with DOX-STR had the least therapeutic failures among the three groups (p=0.033). Adverse reactions were seen in 16.8% of patients, but there was no significant difference among the three groups (p=0.613). The lowest relapse rate (4.6%) was observed in the DOX-STR group (p=0.109).

CONCLUSIONS

We conclude that the DOX-STR combination should remain the first-line regimen for the treatment of brucellosis in our region; we recommend DOX-RIF and OFX-RIF combinations as the second-line regimens.

A comparison of Brucella IgG and IgM ELISA assays with agglutination methodology

Despite brucellosis having a low incidence rate in developed nations, it still remains the leading zoonotic disease in the world. Culturing of Brucella spp. provides good specificity but in cases where the fever is intermittent, sensitivity is problematic. This has led to the development of serological methods of detection. Brucella agglutination methods have been considered the serological gold-standard since their inception, although commercial Brucella IgG and IgM enzyme-linked immunosorbent assays are available to potentially aid in the diagnosis of the disease. In our study, anti-Brucella IgG and IgM assays were compared with agglutination. Individually the IgG assay tested had an accuracy of 56% and the IgM assay had an accuracy of 77%. These poor accuracies reinforce Centers for Disease Control's conclusion that nonagglutination tests should not be used to confirm brucellosis.

Human brucellosis in Macedonia - 10 years of clinical experience in endemic region

AIM

To present our 10-year clinical experience with brucellosis patients at the University Clinic for Infectious Diseases and Febrile Conditions in Skopje, Republic of Macedonia.

METHODS

A total of 550 patients with brucellosis treated between 1998 and 2007 were retrospectively assessed for their demographic, epidemiological, and clinical characteristics and outcomes.

RESULTS

Of the 550 patients, 395 (72%) were male. The median age was 34.5 years (range, 1-82). Direct contact with infected animals was recorded in 333 (61%) patients and positive family history in 310 (56%). The most frequently seen symptoms were arthralgia (438, 80%), fever (419, 76%), and sweating (394, 72%). The most common signs were fever and hepatomegaly, which were verified in 357 (65%) and 273 (50%) patients, respectively. Focal brucellosis was found in 362 patients (66%) and osteoarticular in 299 (54%). Therapeutic failures were registered in 37 (6.7%) patients. Of the 453 (82%) patients who completed a follow-up period of at least 6 months, relapses occurred in 60 (13%).

CONCLUSION

Due to non-specific clinical manifestation and laboratory parameters, brucellosis should be considered one of the differential diagnoses of any patient suffering from obscure involvement of various organs in a brucellosis-endemic region. High percentage of relapses and therapeutic failures in spite of the use of currently recommended therapeutic regimens indicates the seriousness of this zoonosis and the need to control it.

A comparative trial of three therapeutic regimens: ciprofloxacin-rifampin, ciprofloxacin-doxycycline and doxycycline-rifampin in the treatment of brucellosis

This study was designed to compare the efficacy of ciprofloxacin plus rifampin (CR) and ciprofloxacin plus doxycycline (CD) versus doxycycline plus rifampin (DR) in the treatment of brucellosis. A total of 178 patients with brucellosis who were referred to the Sina Hospital, Hamedan, Iran, were included. The responses to therapy were observed in 166 cases (93.7%) - 59 were in the DR group, 59 in the CR group and 48 in the CD group. No significant differences in the therapeutic responses were observed (P = 0.09). Relapse was observed in 11.7% (DR 7.7%, CR 8.3% and CD 17.5%) after a six-month follow-up. No significant differences were also observed in relapse rates among the three groups (P = 0.35). We concluded that DR is still the first choice regimen and CR or CD may be used as alternatives for treatment of brucellosis in adults.

Brucellosis in India - a review

Brucellosis is an important re-emerging zoonosis with a worldwide distribution. It is still an uncontrolled serious public health problem in many developing countries including India. Brucellosis in India is yet a very common but often neglected disease. Currently, Brucella melitensis accounts for most recorded cases globally with cattle emerging as a important reservoir with the few cases of B. suis. Isolated cases of non-terrestrial brucellosis and continuing transmission from wild animals have raised important epidemiological issues. Routine serological surveillance along with high clinical suspicion and screening of family members of index cases would be essential in delineating the real magnitude of human brucellosis in endemic countries. Increased business and leisure travel to endemic countries have led to diagnostic challenge in non-endemic areas. Laboratory testing is indispensable for diagnosis. Advances in newer rapid, sensitive, and specific testing methodologies and alternate treatment strategies are urgently needed. A safe and effective vaccine in human is not yet available. Prevention is dependent upon increasing public awareness through health education programmes and safe livestock practices. Active co-operation between health and veterinary services should be promoted. This review collates world literature and its impact to the discovery, isolation and diagnosis and epidemiology along with the control measures adapted in the Indian scenario.

Presentation, complications, and treatment outcome of brucellosis in Turkish children

BACKGROUND

Brucellosis constitutes a public health problem in Turkey. In endemic Brucella melitensis areas such as Turkey, children represent 20-25% of cases.

METHODS

Hospital records of 90 children with brucellosis admitted during a 9 year period, 1997-2006, were evaluated retrospectively.

RESULTS

Of 90 patients, 27 (30%) were female and 63 (70%) were male (P < 0.05). Patients were aged between 1 and 16 years of age. The mean age was 9.02 +/- 3.59 years. Fifty-two patients (57.8%) were from rural areas of Turkey. The mode of transmission was consumption of unpasteurized milk and milk products in 64 patients (71.1%). Parents of 41 patients (45.6%) worked in animal breeding. A positive family history for brucellosis was noted in 14 patients (15.6%). The most frequently involved joint with arthralgia was the knee joint. Arthritis was found in six patients (6.7%), and five of the six had monoarthritis. Serum agglutination test was >or=1/160 in 82 patients (91.1%). The joint symptoms rapidly responded to the treatment and the majority of the patients had significant improvement. The duration of treatment was 6 weeks in 81 patients (90%). Six patients experienced relapse. Four patients presented with complications that included neurobrucellosis, discitis and sclerosis of the hip joint.

CONCLUSIONS

Treatment of childhood brucellosis with co-trimoxazole + rifampicin or doxycycline + rifampicin, according to patient age, is effective and has low relapse rates. Complications and relapse were successfully treated with triple-drug regimens with a low sequelae rate.

Current therapeutic strategy in spinal brucellosis

Brucellosis is a systemic disease and may affect many organ systems. However, musculoskeletal involvement represents 10-85% of the focal complications. Involvement of the spine is one of the most common localized forms of human brucellosis, especially in elderly patients. It is a destructive disease that requires a correct and early diagnosis, and immediate treatment. However, controversy remains over the optimal duration and antimicrobial regimen required for the treatment of spinal brucellosis. Relapses and sequelae are still reported. In recent years, in order to improve outcomes, alternative regimens have been investigated. However, the classical regimen (doxycycline, 100mg twice daily, for at least 12 weeks combined with streptomycin, 1g daily, for the first 2 or 3 weeks) remains the first choice of antibiotic therapy. Alternative therapies (rifampin, fluoroquinolones, co-trimoxazole) should be considered when adverse reactions or contraindications to the above drugs (ototoxicity, nephrotoxicity, pregnancy, etc.) are reported.

Brucellosis: a retrospective evaluation of 99 cases and review of brucellosis treatment

This retrospective study was performed in two university hospitals between January 2002 and 2006. Ninety-nine brucellosis patients were included in the study. These patients were classified as acute (91), chronic (4) and relapse (4) according to their clinical presentations and serological tests. Brucella bacteria were isolated in the blood of 17 (17.2%) cases. The most frequent symptom and clinical sign was fever. The osteoarticular complications were found in 17 patients (17.2%). Four of them were complicated with epidural abscess the same time. Two (2.2%) had meningitis, two (2.2%) had epididymoorchitis, three (3.3%) had skin rashes and one (1.1%) had hepatitis. Three of the acute brucellosis patients were pregnant. Rifampin and doxycycline combination therapy had been administered to most of the patients with acute and relapse brucellosis. However, complicated and chronic brucellosis cases were given different treatment combinations. This study reviews brucellosis therapy choices.

Therapeutic options for human brucellosis

Worldwide, human brucellosis is the most common zoonotic disease and it has gained increasing interest because of the potential use of Brucella as a biological weapon. Monotherapy for brucellosis is associated with a high relapse rate and dual therapy in different combinations is more efficacious. The combination regimen of intramuscular streptomycin with an oral tetracycline resulted in fewer relapses than the doxycycline-rifampin combination in meta-analysis and prospective studies, although the use of doxycycline and rifampin is a reasonable choice in certain conditions. Longer duration and triple antimicrobial therapy appear to improve outcome and prevent relapses, especially in patients with focal disease. Recently, the use of gentamicin-loaded microparticles and the use of new antibiotics, such as tigecycline, may hold future promise. In addition, there are a few studies of the enhanced effect of immune response stimulators, such as levimasole and IFN-2, in the treatment of brucellosis. The development of an effective subcellular Brucella vaccine would be an important step forward to curtail the disease. However, currently and for the near future, only the control of animal disease is possible using vaccine strategies.

Gluteal abscesses caused by Brucella species

Soft tissue involvement is an uncommon complication of brucellosis. We report a rare case of gluteal abscesses caused by brucellosis. The patient was a housewife living in a city. There was no history of systemic complaints or other organ involvement. Diagnosis was made by positive pus culture and serological tests. Histopathological examination of the abscess wall revealed granulomatous inflammatory reaction. The patient was treated successfully with abscess drainage and a 6-week course of oral doxycycline and rifampicin. Brucellosis should be kept in mind in the diagnosis of gluteal abscess, especially in endemic areas.

Chronic Brucella infection of the humerus diagnosed after a spontaneous fracture

Brucellosis is uncommon in humans and only rarely manifests as osteomyelitis. We report the case of a 57-year-old patient with chronic Brucella osteomyelitis of both humeri. The diagnosis was established upon evaluation of a spontaneous fracture of the right humerus. The organism was recovered in fluid draining to the skin from an abscess located in the bone and soft tissues.

Prosthetic hip infection due to Brucella melitensis: case report and literature review

Prosthetic joint infection (PJI) due to Brucella spp. is extremely rare. We report the case of a prosthetic hip infection due to Brucella melitensis in a 51-year-old male patient. The initial presentation was a gluteal abscess. There was radiographic evidence of implant loosening. The patient was cured after prolonged treatment with streptomycin, rifampicin, and doxycycline, followed by 2-stage exchange of the prosthesis. Brucella spp. should be considered in the differential diagnosis of PJI in countries where brucellosis is endemic. The review of all cases previously reported shows that a conservative approach using antibiotics alone can be followed in patients without signs of implant loosening. In contrast, prolonged antibiotic treatment and prosthetic joint revision should be considered in patients with evidence of implant loosening.

Treatment of Brucella endocarditis: our surgical experience with 6 patients

BACKGROUND

Endocarditis is a rare but life-threatening complication of brucellosis. Its mortality rate has recently been reduced with the use of combined medical and surgical treatment.

METHODS

Between March 2002 and April 2004, 6 patients with Brucella endocarditis underwent surgery at the Siyami Ersek Cardiovascular Center in Istanbul, Turkey. The diagnosis of Brucellosis was based on the presence of clinical signs and symptoms compatible with brucellosis, serology and/or a positive blood culture. All patients with suspected Brucella endocarditis were studied by echocardiography. The diagnosis of Brucella endocarditis was made in accordance with Duke's criteria.

RESULTS

The most commonly affected valve was the aortic valve (4 patients). Four patients had prosthetic valves because of a previous history of rheumatic fever. In 5 patients, elective surgery was performed. Five patients underwent valve replacement with prosthetic valves, but 1 patient underwent excision of the abscess cavity without valve replacement. There was no operative mortality. All patients continued antibiotic treatment for at least 3 months postoperatively. The median duration of follow-up after surgery was 12 months. During the follow-up period, 1 patient died, while the others remained alive with no recurrences.

CONCLUSION

Prosthetic valve replacement is a safe procedure in patients with Brucella endocarditis. Surgical interventions combined with triple antibiotic therapy yield good results with no recurrence in the long-term follow-up.

Quinolones for brucellosis: treating old diseases with new drugs

Although quinolones are theoretically interesting candidates for the treatment of brucellosis, the existing data concerning their efficacy are limited and conflicting. A number of small clinical studies with combination regimens that include quinolones have shown adequacy, but not superiority, although cost-effectiveness, excluding certain disease complications, is an important issue. The emergence of quinolone resistance and its implications is another drawback. Experimental data have yielded contradictory results, although most studies do not indicate a bactericidal effect for quinolones. However, in-vitro studies contrast repeatedly with the clinical response, both in terms of clinical failure, despite in-vitro success, and vice versa.

Doxycycline plus streptomycin versus ciprofloxacin plus rifampicin in spinal brucellosis [ISRCTN31053647]

Background

The optimal treatment regimen and duration of the therapy is still controversial in spinal brucellosis. The aim of this study is to compare the efficacy, adverse drug reactions, complications and cost of ciprofloxacin plus rifampicin versus doxycycline plus streptomycin in the treatment of spinal brucellosis.

Methods

The patients diagnosed as spinal brucellosis between January 2002 to December 2004 were enrolled into the study. Patients were enrolled into the two antimicrobial therapy groups (doxycycline plus streptomycin vs. ciprofloxacin plus rifampicin) consecutively. For the cost analysis of the two regimens, only the cost of antibiotic therapy was analysed for each patient.

Results

During the study period, 31 patients with spinal brucellosis were enrolled into the two antimicrobial therapy groups. Fifteen patients were included in doxycycline plus streptomycin group and 16 patients were included in ciprofloxacin plus rifampicin group. Forty-two levels of spinal column were involved in 31 patients. The most common affected site was lumbar spine (n = 32, 76%) and involvement level was not different in two groups. Despite the disadvantages (older age, more prevalent operation and abscess formation before the therapy) of the patients in the ciprofloxacin plus rifampicin group, the duration of the therapy (median 12 weeks in both groups) and clinical response were not different from the doxycycline plus streptomycin. The cost of ciprofloxacin plus rifampicin therapy was 1.2 fold higher than the cost of doxycycline plus streptomycin therapy.

Conclusion

Classical regimen (doxycycline plus streptomycin), with the appropriate duration (at least 12 weeks), is still the first line antibiotics and alternative therapies should be considered when adverse drug reactions were observed.

Effective treatments in the management of brucellosis

Treatment of uncomplicated brucellosis in humans utilises a variety of anti-biotic combinations, applied to a series of important pathogenetic and clinical parameters. The currently recommended treatment regimens have not been surpassed by newer compounds, and various therapeutic strategies utilising these compounds cannot be adequately evaluated due to the absence of large, multi-centre, multinational trials. The review focuses on the basic principles of brucellosis treatment, the properties of the various regimens used, the results of trials involving them, and the questions raised about the efficacy of these regimens in certain clinical situations.