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Treatment of Brucellosis

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Increases ototoxicity of loop diuretics and noise; potentiates neuromuscular blocking agents ... Rest in bed as long as they are febrile ... – PowerPoint PPT presentation

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Title: Treatment of Brucellosis


1
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  • Treatment of Brucellosis
  • Shahid Beheshti University of medical sciences
  • April 2008
  • By Hatami H. MD. MPH

2
Antimicrobial therapy
  • Shortens the course of illness
  • Lessens morbidity
  • Reduce the incidence of complications

3
Antimicrobial therapy
  • Antimicrobial treatment must always be prescribed
  • Prolonged treatment is more likely to achieve
    permanent cure

4
Antimicrobial Regimens
  • Doxycycline Rifampin
  • Tetracycline Rifampin
  • Tetracycline Streptomycin
  • Co-trimoxazole Rifampin
  • 3.G. Cephalosporines Ritampin
  • Rifampin Doxycycline is the treatment of choice
    (WHO)

5
Doxycycline
  • Trials have established efficacy as treatment for
    brucellosis.
  • Because of concerns regarding treatment failures,
    combination therapy with rifampin or an
    aminoglycoside now is recommended

6
Doxycycline Adult dose
  • 200 mg/d,
  • usually divided into 100 mg PO bid
  • may be administered IV if needed
  • duration is 3-6 wk

7
Doxycycline Pediatric dose
  • 5 mg/kg/d PO for 3 wk

8
Doxycycline Pregnancy
  • D - Unsafe in pregnancy

9
Doxycycline Precautions
  • May cause photosensitivity
  • Can cause nausea and erosive esophagitis,
    especially if taken hs
  • May deposit in teeth, although less than with
    tetracycline
  • Safe to use in renal failure

10
Rifampin
  • Rifampin (Rifadin, Rimactane)
  • Used in combination therapy with Doxycycline,
    TMP-SMZ, or Gentamicin for treatment of
    brucellosis.

11
Rifampin Adult dose
  • 600-900 mg PO/IV qd

12
Rifampin Pediatric dose
  • 10-20 mg/kg PO/IV qd, not to exceed 600 mg

13
Rifampin / Interactions
  • Decreases serum levels of most antiretrovirals
  • Decreases effectiveness of beta-blockers
  • Decreases effectiveness of oral contraceptives
  • Decreases phenytoin levels
  • Decreases effectiveness of anticoagulants and
    sulfonylureas
  • Increases conversion of INH into its hepatotoxic
    metabolites levels
  • Increase with concurrent use of antiretrovirals
    and TMP-SMZ
  • Decreases levels of methadone, precipitating
    withdrawal

14
Rifampin Pregnancy
  • Safety for use during pregnancy has not been
    established.

15
Rifampin / Precautions
  • Monitor liver enzymes before starting therapy and
    repeat if symptoms of potential hepatotoxicity
    develop
  • Brownish discoloration of body fluids
  • Stains contact lenses
  • May cause drug-induced lupus
  • Flu syndrome if taken irregularly or restarted
    after an interval of no medication, (fever,
    chills, myalgias, and dyspnea)

16
Co-trimoxazole
  • (Bactrim, Septrin)
  • Used as adjunctive therapy with Gentamicin in
    treating infection in children lt8 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.

17
Co-trimoxazole
  • Results of Co-trimoxazole treatment in acute
    brucellosis have been very encouraging
  • Disappearance of symptoms within 48 hours and
    normal temperatures within first week have been
    found
  • Must be considered in treatment of
    neurobrucellosis, endocarditis, brucellosis in
    pregnancy and children . . .

18
Co-trimoxazole Adult dose
  • 2 tabs PO bid (160/800) 8-10 mg/kg IV divided q6,
    8, or 12h

19
Co-trimoxazole Pediatric dose
  • 5 mL/10 kg PO bid 5 mL 40/200

20
Co-trimoxazole Contraindications
  • Documented hypersensitivity
  • Relatively contraindicated in asthmatics, as
    sensitivity to the sulfa molecule may cause
    bronchospasm
  • Relatively contraindicated in thrombocytopenic
    patients, as thrombocytopenia may worsen

21
Co-trimoxazole Contraindications
  • Competes with creatinine for tubular reabsorption
    and thus may increase serum creatinine
  • Hyperkalemia observed in 20 of patients
  • May cause thrombocytopenia and aseptic
    meningitis Frequently causes GI disturbances
  • Occasionally may cause severe reactions in form
    of Stevens-Johnson syndrome or TEN

22
Co-trimoxazole Contraindications
  • Increases levels of phenytoin, rifampin, and
    loperamide
  • Increases activity of warfarin
  • Enhances bone marrow suppression when
    administered with methotrexate
  • Decreases effectiveness of oral contraceptives

23
Co-trimoxazole Pregnancy
  • C - Safety for use during pregnancy has not been
    established.

24
Co-trimoxazole Precautions
  • Avoid in sulfa-allergic patients or in concurrent
    use with rifampin

25
Gentamicin
  • Gentamicin (Garamycin, Gentacidin)
  • 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.

26
Gentamicin Adult dose
  • Once daily dose 5.1 mg/kg IV/IM qd
  • Multiple daily dose 2 mg/kg loading dose,
    followed by 1.7 mg/kg IV/IM q8h continue for 5 d

27
Gentamicin Pediatric dose
  • 5 mg/kg IM for 5 d, in combination with either
    doxycycline or TMP-SMZ

28
Gentamicin Contraindications
  • Documented hypersensitivity
  • Avoid if possible in patients with impaired renal
    function or sensorineural deafness because of
    known nephrotoxicity and ototoxicity
  • Once daily dosing is associated with decreased
    risk of nephrotoxicity

29
Gentamicin Interactions
  • Increases nephrotoxicity of contrast agents,
    cyclosporin, cis-platinum, NSAIDs, amphotericin
    B, and vancomycin
  • Increases ototoxicity of loop diuretics and
    noise potentiates neuromuscular blocking agents

30
Gentamicin Pregnancy
  • D - Unsafe in pregnancy

31
Gentamicin Precautions
  • Caution in patients with renal failure
  • or if IV contrast is planned
  • check levels at minimum q3d and adjust dose based
    on level and calculated creatinine clearance

32
Streptomycin
  • Used in combination with doxycycline, especially
    for spondylitis or sacroiliitis
  • Augments bacteriocidal action of other agents
    used to treat brucellosis.

33
Streptomycin Adult dose
  • 15 mg/kg, not to exceed 1 g/d IM qd for 3 wk

34
Streptomycin Pediatric dose
  • 20-40 mg/kg IM qd, not to exceed 1 g qd

35
Streptomycin Contraindications
  • Documented hypersensitivity
  • If possible avoid in patients with preexisting
    renal disease or vestibular disease because of
    ototoxicity and nephrotoxicity

36
Streptomycin Interactions
  • Increases nephrotoxicity of contrast agents,
    cyclosporin, cis-platinum, NSAIDs, amphotericin
    B, and vancomycin
  • Increases ototoxicity of loop diuretics and
    noise potentiates neuromuscular blocking agents

37
Streptomycin Pregnancy
  • D - Unsafe in pregnancy

38
Streptomycin Precautions
  • Caution in renal failure and preexisting
    vestibulocochlear disease
  • Adjust dose based on creatinine clearance ratio
  • Determine BUN and creatinine prior to starting
    therapy
  • Perform weekly audiograms for treatment duration

39
Brucellosis Exposure to Vaccines
  • These are live vaccines, and B-19 is known to
    cause disease in humans.
  • For the other vaccines the recommendations are
    the same
  • A baseline blood sample should be collected for
    testing for antibodies

40
Brucellosis Occupational exposure
  • Antibiotics (doxycycline and rifampin for B-19
    and REV-1, or doxycycline alone for RB-51) for 3
    weeks
  • At the end of that time you should be rechecked
    and a second blood sample should be collected.
  • The same recommendations hold true for spraying
    vaccine in the eyes (6 weeks of treatment in this
    case) or spraying onto open wounds on the skin
  • CDC, 2004

41
Brucellosis Antibiotics not recommended
  • Most penicillins
  • Most cephalosporins
  • Chloramphenicol
  • Erythromycin
  • Kanamycin
  • Sulfonamides

42
Chronic brucellosis
  • The patient with chronic brucellosis presents a
    difficult therapeutic problem
  • Long courses (2-6 months) of treatment may be
    required for patients with chronic brucellosis

43
Pregnant women
  • Toxicity of tetracycline is established
  • Streptomycin is contra-indicated
  • There is no evidence that Rifampin and
    Co-trimoxazole are harmful to developing human
    fetus

44
Indications for Corticosteroides
  • Prevention of Herxheimerlike reactions
  • Sever toxemia
  • Thrombocytopenia and related bleeding
  • Severe debility

45
Surgical treatment
  • Osteomyelitis
  • Paravertebral abscess
  • Suppurative lesions
  • Brucella endocarditis
  • Aneurysmal aortitis

46
Supportive treatment
  • Rest in bed as long as they are febrile
  • Glucose and electrolyte solutions in dehydrated
    patients
  • Diet should be liberal in calories and
    carbohydrates
  • Analgesics
  • Laxatives

47
Prognosis
  • Brucellosis appropriately treated within the
    first month of symptom onset is curable
  • Patients are frequently unable to work for up to
    2 month
  • Immunity to reinfection follows initial brucella
    infection
  • With early antimicrobial therapy cases of chronic
    brucellosis are rare

48
  • With Thanks
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