BRUCELLOSIS-TREATMENT

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BRUCELLOSIS-TREATMENT Powered By Docstoc
					  ‫بسم اهلل الرحمن الرحيم‬
     Treatment of
      Brucellosis
 Shahid Beheshti University of
       medical sciences
         April 2008
By: Hatami H. MD. MPH            1
Antimicrobial therapy:
 • Shortens the course of illness
 • Lessens morbidity
 • Reduce the incidence of
   complications




                                    2
Antimicrobial therapy:
 • Antimicrobial treatment must
   always be prescribed
 • Prolonged treatment is more
   likely to achieve permanent cure




                                  3
Antimicrobial Regimens
•   Doxycycline + Rifampin
•   Tetracycline + Rifampin
•   Tetracycline + Streptomycin
•   Co-trimoxazole + Rifampin
•   3.G. Cephalosporines + Ritampin

• Rifampin + Doxycycline is the
                                  4
  treatment of choice (WHO)
      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
                                   5
     Doxycycline
     Adult dose
• 200 mg/d,
• usually divided into 100 mg
  PO bid;
• may be administered IV if
  needed;
• duration is 3-6 wk            6
     Doxycycline
    Pediatric dose
• 5 mg/kg/d PO for 3 wk




                          7
     Doxycycline
     Pregnancy
• D - Unsafe in pregnancy




                            8
        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       9
       Rifampin
• Rifampin (Rifadin, Rimactane)
• Used in combination therapy
  with Doxycycline, TMP-SMZ,
  or Gentamicin for treatment
  of brucellosis.



                             10
      Rifampin
      Adult dose
• 600-900 mg PO/IV qd




                        11
      Rifampin
    Pediatric dose
• 10-20 mg/kg PO/IV qd, not to
  exceed 600 mg




                                 12
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                                            13
       Rifampin
       Pregnancy
• Safety for use during pregnancy
  has not been established.




                                14
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)                                  15
    Co-trimoxazole
• (Bactrim, Septrin)
• 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.
                                         16
    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      17
  children . . .
    Co-trimoxazole
      Adult dose
• 2 tabs PO bid (160/800)
  8-10 mg/kg IV divided q6, 8, or 12h




                                        18
    Co-trimoxazole
    Pediatric dose
• 5 mL/10 kg PO bid; 5 mL: 40/200




                                    19
   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           20
   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;
                                              21
   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
                                             22
    Co-trimoxazole
      Pregnancy
• C - Safety for use during pregnancy has
  not been established.




                                            23
     Co-trimoxazole
      Precautions
• Avoid in sulfa-allergic patients or in
  concurrent use with rifampin




                                           24
        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.



                                           25
        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




                                           26
       Gentamicin
      Pediatric dose
• 5 mg/kg IM for 5 d, in combination with
  either doxycycline or TMP-SMZ




                                        27
    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
                                         28
       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
                                     29
       Gentamicin
       Pregnancy
• D - Unsafe in pregnancy




                            30
       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

                                      31
     Streptomycin
• Used in combination with
  doxycycline, especially for
  spondylitis or sacroiliitis;
• Augments bacteriocidal action of
  other agents used to treat
  brucellosis.


                                     32
      Streptomycin
       Adult dose
• 15 mg/kg, not to exceed 1 g/d IM qd
  for 3 wk




                                        33
     Streptomycin
     Pediatric dose
• 20-40 mg/kg IM qd, not to exceed 1 g
  qd




                                    34
   Streptomycin
 Contraindications
• Documented hypersensitivity;
• If possible avoid in patients with
  preexisting renal disease or
  vestibular disease because of
  ototoxicity and nephrotoxicity


                                       35
      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
                                         36
     Streptomycin
      Pregnancy
• D - Unsafe in pregnancy




                            37
      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                         38
    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

                                         39
     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 40
            Brucellosis
Antibiotics not recommended
•   Most penicillins
•   Most cephalosporins
•   Chloramphenicol
•   Erythromycin
•   Kanamycin
•   Sulfonamides



                          41
  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

                                     42
    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



                                        43
Indications for Corticosteroides

  • Prevention of Herxheimerlike
    reactions
  • Sever toxemia
  • Thrombocytopenia and related
    bleeding
  • Severe debility

                                   44
        Surgical treatment

•   Osteomyelitis
•   Paravertebral abscess
•   Suppurative lesions
•   Brucella endocarditis
•   Aneurysmal aortitis


                             45
    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                            46
            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   47
With Thanks


              48

				
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