ANTIMICROBIAL AGENTS AND CHEMOTHERAPY, Sept. 1995, p. 2061–2067 Vol. 39, No.

9
0066-4804/95/$04.0010
Copyright q 1995, American Society for Microbiology

Doxycycline-Rifampin versus Doxycycline-Streptomycin in

Treatment of Human Brucellosis Due to Brucella melitensis
JAVIER SOLERA,1* MANUEL RODRÍGUEZ-ZAPATA,2,3 PALOMA GEIJO,4 JOSÉ LARGO,5
JAVIER PAULINO,6 LOURDES SÁEZ,1 ELISA MARTÍNEZ-ALFARO,1
LORENZO SÁNCHEZ,2,3 MARÍA-ANTONIA SEPULVEDA,5
MARIA-DOLORES RUIZ-RIBÓ,4 AND THE GECMEI GROUP†
Unit of Infectious Diseases, Department of Medicine, Hospital of Albacete, Albacete,1 Department of Medicine,
Hospital of Guadalajara, Guadalajara,2 University of Alcala de Henares, Madrid,3 Department of Medicine,
Hospital of Cuenca, Cuenca,4 Department of Medicine, Hospital of Toledo, Toledo,5
and Service of Rheumatology, Hospital of Ciudad Real, Ciudad Real,6 Spain

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Received 3 March 1995/Returned for modification 28 April 1995/Accepted 30 June 1995

Brucellosis is a common zoonosis in many parts of the world; the best regimen for the treatment of
brucellosis has not been clearly determined. We have carried out a multicenter, open, controlled trial in five
general hospitals in Spain to compare the efficacy and safety of doxycycline and rifampin (DR) versus
doxycycline and streptomycin (DS) for the treatment of human brucellosis. The study included 194 ambulatory
or hospitalized patients with acute brucellosis, without endocarditis or neurobrucellosis. The diagnostic
criterion was isolation of Brucella species from blood or other tissues (n 5 120) or a standard tube aggluti-
nation titer of 1/160 or more for anti-Brucella antibodies with compatible clinical findings (n 5 74). Patients
were randomly assigned to receive either 100 mg of doxycycline twice daily plus rifampin, 900 mg/day, in a
single morning dose for 45 days (DR group) or the same dose of doxycycline for 45 days plus streptomycin, 1
g/day, intramuscularly for 14 days (DS group). A lack of therapeutic efficacy developed in 8 of the 100 patients
in the DR group (8%) and in 2 of the 94 patients in the DS group (2%) (P 5 0.10). Relapses occurred in 16 of
the 100 patients in the DR group (16%) but in only 5 of the 94 patients in the DS group (5.3%) (P 5 0.02). When
relapse was considered in combination with initial lack of efficacy, 26 patients in the DR group (24%) and 7
patients in the DS group (7.45%) failed to respond to therapy (P 5 0.0016). In general, therapy was well
tolerated, and only four patients (4%) in the DR group and two (2%) in the DS group had episodes of adverse
effects necessitating discontinuation of treatment (P > 0.2). We conclude that a doxycycline-and-rifampin
regimen is less effective than the doxycycline-and-streptomycin regimen in patients with acute brucellosis.

Brucellosis is a common zoonosis in many parts of the world.
A large number of cases due to Brucella melitensis are reported
every year in the Mediterranean littoral, the Middle East, and
parts of Latin America (36). In the United States and other
developed countries it is mainly an occupational disease; how-
ever, brucellosis can be acquired from ingestion of contami-
nated dairy products imported from other parts of the world
where the disease is endemic (6, 10, 51). The best regimen for
the treatment of brucellosis has not been clearly determined
(25, 38). Although tetracycline-streptomycin combinations had
been considered by the World Health Organization (WHO)
the standard therapy for years, in 1986 the Food and Agricul-
ture Organization-WHO Expert Committee on Brucellosis
changed their recommendations for treatment of adult acute
brucellosis to rifampin (600 to 900 mg/day orally) plus doxy-
cycline (200 mg/day orally) for 6 weeks as the regimen of
choice (22). However, the few studies that compared the ef-
fectiveness of the doxycycline-rifampin (DR) regimen with the
traditional doxycycline-streptomycin (DS) combination had in-
sufficient statistical power and no conclusive evidence (1, 5, 13,
39, 46). Moreover, administration of doxycycline and rifampin
for shorter periods of time has been associated with a relapse
* Corresponding author. Mailing address: Unidad de Enfermedades
Infecciosas, Hospital General, C/ Hermanos Falcó S/N, 02006 Al-
bacete, Spain. Phone: 34-67-597100. Fax: 34-67-597121.
† The members of the Grupo de Estudio de Castilla-la Mancha de
Enfermedades Infecciosas (GECMEI) who participated in this study
are listed in the Appendix.
rate of 30 to 40% in other studies (4, 50). Thus, we thought that
a further comparative study enrolling a larger number of pa-
tients was required in order to substantiate the WHO recom-
mendation. We conducted a multicenter trial to compare the
DR combination for 45 days with the combination of doxycy-
cline for 45 days and streptomycin for 14 days for patients with
brucellosis. The trial was designed and conducted similarly to
a previously reported multicenter trial comparing the classic
DS combination with the combination of doxycycline for 45
days and rifampin for the initial 21 days (50).
(This work was presented in part at the 33rd Interscience
Conference on Antimicrobial Agents and Chemotherapy, New
Orleans, La., October 18 to 20 1993 [50a].)
MATERIALS AND METHODS
Study design. This study was a prospective, multicenter, open, controlled trial
comparing the efficacy and safety of the DR combination with those of the DS
combination in the treatment of human brucellosis. The patients were recruited
from five general hospitals in Spain between June 1989 and October 1993. The
study was approved by the institutional review board at each center and done
with the informed consent of each patient. Treatment was given on an open-label
basis. The reason for this design was the intramuscular administration of strep-
tomycin for 14 days. Masking of this study would have required intramuscular
placebo injections for patients assigned to receive DR treatment, and this option
was rejected for ethical reasons. Patients received treatment with study drugs for
45 days unless treatment-limiting toxicity was encountered, and they were cate-
gorized according to end points defined as follows.
Definition of end points. The primary end point of the study was the absence
of relapses, as defined by the reappearance of symptoms or signs of the disease
or new positive blood cultures during 12 months after therapy. Secondary end
points included therapeutic failure due to lack of efficacy, defined as symptoms
or signs of the disease persisting after 4 weeks of treatment, and time to defer-

2061
2062 SOLERA ET AL.
vescence, defined as the number of days elapsed from the start of therapy until
the patient became afebrile (axillary temperature, ,37.18C). Safety was assessed
on the basis of all reported adverse events, laboratory tests, and other investi-
gations. Clinical adverse events were recorded and evaluated for severity, out-
come, and relation to the study drugs. The discontinuation of treatment resulting
from suspected toxicity of the study drugs and necessitating alternative therapy
was considered a treatment-limiting adverse effect (e.g., vomiting for more than
three consecutive days despite antiemetic therapy; hepatotoxicity, defined as a
.5-fold increase in the aspartate or alanine aminotransferase level over the
baseline value or more than 10 times the upper limit of the normal range or as
a .2-fold increase in the bilirubin level over the upper limit of the normal range;
nephrotoxicity, defined as more than twice the upper limit of the normal creat-
inine level range; ototoxicity; serious photosensitivity dermatitis manifested by an
exaggerated sunburn reaction, marked erythema with edema, or vesiculation; or
hypersensitivity reactions).
Selection of patients. Ambulatory and hospitalized patients of both sexes, 7
years of age or older, who had acute brucellosis, as defined below, were eligible
for the study. The diagnostic criterion was isolation of Brucella species from
blood or other tissues or fluids or a standard tube agglutination titer of 1/160 or
more for anti-Brucella antibodies with compatible clinical findings (fever, sweats,
arthralgias, hepatomegaly, splenomegaly, or signs of focal disease). Enrollment
was limited to patients without central nervous system involvement or endocar-
ditis. Patient exclusion criteria were pregnancy or nursing; known or suspected
hypersensitivity to or another contraindication for tetracyclines, rifamycins, or
aminoglycosides; severe concomitant disease; and effective antimicrobial therapy
within 7 days before entry into the study. Patients could enter the trial only once.
Treatment of subsequent episodes of brucellosis was left to the individual judg-
ments of the treating physicians.
Clinical and laboratory assessment. Patients were monitored for therapeutic
efficacy and signs of drug toxicity by clinical data; complete blood counts with a
differential count and a platelet count; erythrocyte sedimentation rate; urinalysis;
and measurements of the creatinine, aspartate aminotransferase, alanine ami-
notransferase, lactate dehydrogenase, g-glutamyl transpeptidase, alkaline phos-
phatase, albumin, total protein, bilirubin, and electrolyte levels; Brucella serol-
ogy; and blood culture. Radiological and other diagnostic imaging studies were
performed according to the symptoms of the patients. The patients were evalu-
ated initially, on days 7 to 14, and at the end of the course of therapy. After
ending the therapy, patients were reassessed as outpatients at months 1, 3, 6, and
12, as well as whenever clinical symptoms reappeared. Compliance was moni-
tored through clinic visits. Diagnosis of focal disease, such as epididymo-orchitis
and peripheral arthritis, was made on the basis of clinical evidence (inflammatory
local signs at a particular site, observed by a physician). Diagnoses of spondylitis,
sacroiliitis, and arthritis were made by appropriate findings in a physical exam-
ination and radiological, bone scintigraphy, or magnetic resonance studies.
Microbiological studies. Standard tube agglutination, the rose Bengal test, and
the anti-Brucella Coombs test were done by standard methods (2, 40) with
commercial reagents (Knickerbocker, Barcelona, Spain). Blood cultures were
performed as previously reported (50) and incubated for 6 weeks by using
BACTEC NR-730 (Becton Dickinson-Spain, Madrid, Spain). All isolates were
identified as recommended by Hausler et al. (28). Forty-one of the isolated
strains were sent to a reference center (Laboratorio Regional de Brucelosis,
Valladolid, Spain) for confirmation and biotyping. All microorganisms isolated
were B. melitensis.
Medication, dosage, and duration. All patients were randomized to receive
DR treatment or DS treatment. Patients with odd-numbered ages received the
DR regimen, and those with even-numbered ages received the DS regimen. This
method of assignment was chosen because it provided an easily available indi-
cator to the relatively large number of physicians who were involved in the trial.
The DR group received 100 mg of doxycycline (Vibracina, Pfizer, Madrid, Spain)
twice daily (5 mg/kg of body weight per day if the body weight was 40 kg or less)
and rifampin (Rifaldin, Merrell Down, Madrid, Spain), 900 mg/day in a single
morning dose for 45 days (15 mg/kg/day if the body weight was 50 kg or less). The
DS group received the same dose of doxycycline for 45 days plus streptomycin
(Estreptomicina Sulfato; Antibioticos, Madrid, Spain), 1 g/day intramuscularly
for 14 days (15 mg/kg/day if the body weight was 50 kg or less). Patients could not
receive any other antibiotics, but they could be given analgesics or anti-inflam-
matory agents, antacids, or histamine H2 receptor antagonists as required.
Statistical analysis. The end point chosen to determine the sample size was
the proportion of subjects with relapses. The sample size was calculated with the
objective of establishing that the DR regimen was not less successful therapeu-
tically than the DS regimen. A clinically important difference was defined as an
arithmetic difference of 0.15 in relapse rates. On the basis of our previous results
(50), we estimated a proportion of relapse of 0.05 in the most successfully treated
group. Thus, an appropriate statistical sample should include 88 patients per
group to ensure 80% power and an alpha level of 0.05 in a two-sided test (20).
The primary analysis of therapeutic-response end points and other measures
were performed with the intention-to-treat rule. Statistical calculations were
performed with Epi Info version 6 (17) and BMDP (18) software. The differences
in parametric and nonparametric values between the two treatment groups were
tested for significance by the two-tailed Student’s t test and the Mann-Whitney
test, respectively. Differences between proportions for both groups were ana-
lyzed with the two-tailed Fisher’s exact test. Time-to-event data were analyzed by
ANTIMICROB. AGENTS CHEMOTHER.
Kaplan-Meier survival analysis and the log-rank test (44). Cox proportional
hazards regression (16) was used to estimate the difference between the two
regimens after adjustment for the following baseline covariates: study center,
age, sex, occupational exposure, prior brucellosis, duration of symptoms before
therapy, focal disease, and isolation of brucella in blood cultures. Ninety-five
percent confidence intervals (CIs) were calculated when appropriate. A P value
of less than 0.05 was considered to indicate statistical significance.
RESULTS
Patient characteristics. Table 1 shows the similarity between
selected demographic and clinical variables at baseline in the
two groups. Potential factors that might be associated with an
altered risk of therapeutic failure, including age, sex, duration
of symptoms before therapy, focal disease, and positive blood
cultures were balanced between the two study groups. The
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median follow-up was 12 months and did not differ significantly
between the two groups. One hundred sixty-seven patients
(86%) completed at least 1 year of follow-up. Thirteen patients
in the DR group (13%) and 14 patients in the DS group (15%)
were lost to follow-up (before 12 months), and therefore data
on these patients were censored at the last visit. Six patients
discontinued the assigned treatment because of drug intoler-
ance (three in each group), and two patients were noncompli-
ers (one in each group), but they were monitored nonetheless.
The mean time to defervescence was 4.63 6 2.81 days (median,
4; range, 1 to 12) for patients in the DR group and 4.30 6 2.51
days (median, 4; range, 1 to 12) for patients in the DS group
(not significant). Ten episodes of initial therapeutic failure and
21 relapses occurred during the study.
Occurrence of therapeutic failure due to lack of efficacy. A
lack of therapeutic efficacy occurred in 8 of the 100 patients in
the DR group (8%) and in 2 of the 94 patients in the DS group
(2%) (difference, 5.87; 95% CI, 20.19 to 11.94; P 5 0.10). The
clinical characteristics of these patients are summarized in
Table 2. All patients with therapeutic failure had focal disease
at entry into the study. Among these, six had spondylitis (four
in the DR group and two in the DS group), two had peripheral
arthritis, one had sacroiliitis, and one had cervical lymphade-
nitis). Five of them had concomitant abscesses (Table 2).
Seven patients in the DR group and two patients in the DS
group who had osteoarticular focal disease continued to have
pain after 4 weeks of therapy. The risk of initial therapeutic
failure in the participants assigned to DR treatment was 3.76
times that in the participants assigned to DS treatment (95%
CI, 0.82 to 17.26). Of the 10 patients with therapeutic failure
due to lack of efficacy, 9 were maintained on treatment with
doxycycline and co-trimoxazole over longer periods (2 to 6
months). One patient with cervical lymphadenitis in the DR
group required surgery. The overall long-term clinical re-
sponse was favorable. None of these patients have had a re-
lapse after treatment.
Occurrence of relapses. Among the 194 patients included in
this study, 21 (10.8%) have had at least one relapse after
completion of therapy. Eighteen of these 21 patients (86%)
had clinical relapses, and 10 of these had associated Brucella
bacteremias. The remaining three patients (14%) had bacterial
relapses without clinical signs or symptoms. Eight patients had
focal disease at relapse, two in the same location (orchitis) and
six in another location (two with sacroiliitis, two with spondy-
litis, one with orchitis, and one with neurobrucellosis). Fifteen
of the 21 relapses (71%) occurred between the second week
and the third month after completion of therapy. The median
interval from the completion of therapy to onset of the relapse
was 3 months. The clinical characteristics of these patients are
summarized in Table 3. Relapses developed in 16 of the 100
patients in the DR group (16%; 95% CI, 9.43 to 24.67) com-
VOL. 39, 1995 DOXYCYCLINE-RIFAMPIN TREATMENT OF BRUCELLOSIS 2063

TABLE 1. Characteristics of patients at entry into the study

Value for groupa
Characteristic
DR (n 5 100) DS (n 5 94)

Median age [yr] (range) 33 (7–77) 34 (12–70)

Male (%) 80 79 (84)
Brucellosis risk factorb
Occupational exposure (%) 49 47 (50)
Ingestion of unpasteurized dairy products (%) 42 34 (36)
Previous brucellosis (%) 16 12 (13)
Duration of symptoms before therapy (days)
Mean 6 SD 27 6 34 25 6 29
Median (range) 15 (2–240) 15 (2–180)
Positive blood culture (%)c 63 57 (61)
Median agglutination titer (range)d 320 (20 [20]–480) 320 (40 [10]–240)
Focal disease (%) 36 42 (45)

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Peripheral arthritis 8 11
Sacroiliitis 13 17
Spondylitis 5 5
Orchitis 8 8
Othere 2 1
Follow-up
Median [mo] (range) 12 (1–24) 12 (1–24)
,6 mo (%) 5 6 (6)
,12 mo (%) 13 14 (15)
a
No statistically significant differences between the two groups were found for any variable.
b
Some patients had more than one risk factor.
c
In three patients brucella was isolated from cultures of other specimens.
d
Reciprocal of the standard tube agglutination titer.
e
Cervical granulomatous lymphadenitis, costochondritis, or Achilles tendinitis.

pared with 5 of the 94 patients in the DS group (5.3%; 95% CI,
1.74 to 11.97). The estimated absolute difference between the
percentages of relapses in the two study groups was 10.68 (95%
CI, 2.18 to 19.18%; P 5 0.02). The cumulative proportion of
patients with no relapse is shown in Fig. 1. In the Cox propor-
tional hazards regression model, the adjusted relapse risk in
patients assigned to DR treatment was 3.04 times that in pa-
tients assigned to DS treatment (95% CI, 1.05 to 8.70; P 5
0.04). There were no differences between patients who re-
lapsed and those who did not in age, sex, duration of the
symptoms before therapy, results of blood culture, focal dis-
ease, prior brucellosis, or occupational exposure. Five of the 21
patients with relapses were retreated with the same antibiotic
regimen (three with the DS combination), 14 were treated with
an alternative regimen (12 with the DS combination), and 2
were treated with monotherapy (one patient with doxycycline
and one pregnant patient with rifampin). In most cases the
treatment was given at the same doses and for similar periods.
Immediate clinical responses in all but three patients were
excellent. One patient required surgical drainage of a paraspi-
nal and epidural cervical abscesses, and another patient re-
quired orchiectomy. One (5%) of the patients suffered a re-
lapse after the second course of therapy, and none had a
relapse after the third course. When relapse is considered in
combination with initial lack of efficacy, 26 patients in the DR
group (24%) and 7 patients in the DS group (7.45%) failed to
respond to therapy (difference, 16.55%; 95% CI, 6.64 to 26.46;
P 5 0.0016).
Adverse effects. Therapy was generally well tolerated. The
numbers of adverse effects in the two study groups were similar

TABLE 2. Characteristics of patients with therapeutic failuresa

Duration of
Treatment Blood STA titer ESR Diagnostic
Patient Age (yr) Sex symptoms Focal disease
group culture reciprocal (mm) procedure(s)
(days)

1 33 M DR 21 1 640 24 Granulomatous lymphadenitis Surgery

2 59 F DR 30 1 320 54 Knee arthritis Clinical, Rx
3 63 M DR 90 1 640 80 Spondylitis L5-S1 Rx, 99mTc
4 41 M DR 180 2 160 5 Hip arthritis CT, MRI
5 51 F DR 15 2 1,280 22 Spondylitis D11-D12 CT, 67Ga, 99mTc
6 29 M DR 65 1 160 18 Spondylitis L5-S1, paraspinal and MRI
epidural abscess
7 69 M DR 20 1 2,560 67 Spondylitis L3-L4 MRI
8 23 M DR 21 1 160 9 Sacroiliitis, intra-articular abscess MRI
9 34 M DS 4 1 320 6 Spondylitis L5 MRI
10 52 M DS 20 1 2,560 53 Spondylitis L5 67Ga, 99mTc
a
ESR, erythrocyte sedimentation rate; M, male; F, female; 1, positive; 2, negative; MRI, magnetic resonance imaging; CT, computerized axial tomography; 99mTc,
technetium polyphosphate scan; 67Ga, gallium-67-citrate scan; Rx, radiographic studies; STA, standard tube agglutination. Brucella was isolated from the patient with
lymphadenitis. All other patients reported persistent pain in the back (patients 3, 5 to 7, 9, and 10), buttocks (patient 8), or elsewhere (patients 2 and 4).
2064 SOLERA ET AL. ANTIMICROB. AGENTS CHEMOTHER.

TABLE 3. Characteristics of patients with relapsesa

Before therapy After therapy
Treatment
Patientb Age (yr) Occupational Blood Time to Blood
group Focal disease Nature of relapse
risk culture relapse (mo) culture

1 21 DR 2 1 None 2 1 Bacterial relapse without clinical

signs or symptoms
2 17 DR 1 1 Orchitis 2.5 1 CNS involvement
3 17 DR 1 1 None 6 2 Positive blood culture
4 59 DR 2 1 None 3 2 Positive blood culture
5 41 DR 2 1 None 1 2 Positive blood culture
6 19 DR 1 1 None 9 1
7 47 DR 2 2 None 10 2
8 25 DR 1 2 Orchitis 2 1 Orchitis
9 25 DR 1 2 None 1 1 Bacterial relapse without clinical
signs or symptoms

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10 27 DR 1 1 None 1 1 Orchitis (orchiectomy)
11 31 DR 1 2 None 3 1
12 17 DR 1 1 None 3.5 1
13 19 DR 1 1 Pericarditis 2 2
14 25 DR 2 1 Granulomatous hepatitisc 0.5 2 Bilateral sacroiliitis (MRI)
15 59 DR 1 1 None 6 1 Sacroiliitis (99mTc)
16 65 DR 2 1 None 6 1 Cervical spondylitis with
paraspinal and epidural
abscesses (CT)d
17 22 DS 2 1 Sacroiliitis (MRI) 3 1 Relapse without sacroiliitis
18 12 DS 1 2 None 1.5 1
19 70 DS 2 1 None 3 2 Spondylitis (99mTc)
20 36 DS 2 1 Orchitis 0.5 2 Orchitis
21 54 DS 2 1 None 3 1 Bacterial relapse without clinical
signs or symptoms
a
M, male; F, female; 1, positive; 2, negative; MRI, magnetic resonance imaging; CT, computerized axial tomography; 99mTc, technetium polyphosphate scan; CNS,
central nervous system.
b
Patient 1 was pregnant. All other patients were male.
c
Percutaneous liver biopsy.
d
Surgical drainage; brucella resistant to rifampin.

(31% in the DR group and 23% in the DS group). Table 4
summarizes the data on adverse drug reactions. The majority
of these reactions were classified as mild, and only four pa-
tients (4%) in the DR group and two patients (2%) in the DS
group had episodes of treatment-limiting adverse effects (P .
0.2). The most commonly observed adverse effects were gas-
trointestinal complaints; 17 of the 100 patients (17%) who
received the DR combination, including two patients who dis-
continued treatment, had epigastric pain, heartburn, nausea or
vomiting, anorexia, or diarrhea. Sixteen of the 94 patients
(17%) treated with the DS combination, including one patient
who withdrew the treatment, had gastrointestinal complaints.
Although the majority of the adverse effects were judged to be
related to doxycycline, it is of interest that 19% of the patients
receiving DR therapy and 22% of those receiving DS therapy
were also taking analgesics or nonsteroidal anti-inflammatory
drugs. Only in two patients, who discontinued therapy because
of severe hypersensitivity reactions and because liver amino-
transferase levels increased more than five times the baseline
values, were the adverse effects considered to be related to
rifampin. Among six patients who had episodes of adverse
effects causing interruptions of treatment in the two study
groups, the median period before an alternative therapy began
was 30 days (range, 21 to 40 days). In these patients, the
discontinuation of doxycycline or rifampin was followed by
prompt resolution of adverse effects.
DISCUSSION
The primary objective of this multicenter, comparative trial
with patients with brucellosis was to determine the effect of
therapy with a DR regimen, as recommended by Food and
Agriculture Organization-WHO Expert Committee on Brucel-
losis, versus a DS regimen on the incidence of relapses. In 194
participants monitored for up to 2 years, 16 relapses (16%)
were diagnosed for the DR group, compared with 5 relapses
(5.3%) in the DS group (difference, 10.68%; 95% CI, 2.18 to
19.18%; P 5 0.02). The significant difference between the
groups when relapse is considered in combination with initial
therapeutic failure provides strong confirmation of the lower
therapeutic benefit of the DR regimen (difference, 16.55%;
95% CI, 6.64 to 26.46; P 5 0.0016). The less beneficial effect of
the DR regimen could not be attributed to any baseline dif-
ference between the two groups.
A full interpretation of the observed risk of a relapse re-
quires careful consideration of several issues. First, it is recog-
nized that certain clinical end points are difficult to define in
human brucellosis (21). Bacteriological confirmation of a re-
lapse is often impossible, for example (43). However, relapses,
defined as in previous studies (1, 4, 5, 13, 39, 46, 50), were
verified by monitors in the field and the principal investigator
without knowledge of the assigned treatment group. Also, the
majority of the relapses were bacteriologically documented,
and in these relapses the superior beneficial effects of the DS
combination were apparent (Table 3).
A second source of potential bias was the fact that most of
our patients continued to be exposed to risk factors; hence,
reinfection cannot be dismissed for those judged to have a
relapse. This exposure to risk factors alone, however, cannot
explain the observed difference between the proportions of
relapses for the two treatment groups, as both groups had
VOL. 39, 1995
FIG. 1. Cumulative proportion of patients with no relapse in each study group. P 5 0.02 by the log-rank test for the comparison between groups. After adjustment
for baseline characteristics in a Cox model, the risk of a relapse was 3.04 times higher in the DR group than in the DS group (P , 0.05).
similar numbers of patients exposed to risk factors before or
after therapy. Thus, if reinfection occurred, it should not have
benefited the DS group preferentially. Finally, compliance with
treatment may have been suboptimal in the DR group. How-
ever, the numbers of noncompliers and patients who discon-
tinued the assigned treatment because of drug intolerance
were similar in the two groups.
The history of therapy for brucellosis contains many reports
of enthusiastically endorsed treatments that have proved with
time to have limited value (26, 32). Definitive controlled trials,
common in evaluating the treatment of less heterogeneous
diseases, are particularly elusive in the literature on this dis-
ease (26). Organisms of the genus Brucella generally show in
vitro sensitivity to a wide range of antibiotics and chemother-
apeutic agents (15, 27, 41, 47, 48). Nevertheless, although many
of these have been used in the therapy of brucellosis, few have
been found to be clinically effective (26). A synergistic effect
between tetracycline and streptomycin was demonstrated in
Brucella-infected mice by Heilman (29), and this combination
was applied in the treatment of human infection in 1949 by
Herrell and Barber (30). This regimen has been used widely
since the 1950s and is associated with a low relapse rate (3, 9,
11, 14, 19, 34, 35, 37). In our study with the DS combination
only two initial therapeutic failures and five relapses occurred,
with 92.5% of the patients considered cured. These figures are
consistent with results from other studies showing relapse rates
ranging between 0 and 8% when tetracycline was given for 30
or more days and streptomycin was given for 14 or more days
(1, 3–5, 9, 11, 13, 14, 34, 35, 39, 46, 50).
DOXYCYCLINE-RIFAMPIN TREATMENT OF BRUCELLOSIS 2065
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Therapeutic use of rifampin in human brucellosis started in
the 1970s. In noncontrolled clinical trials, relapse rates with
rifampin ranged from 0 to 25%, depending on treatment du-
ration and characteristics of the patients included (7, 24, 31, 33,
42, 45). Results with monotherapy with rifampin were not
satisfactory, and it was taken into account that resistance could
develop, so rifampin is usually combined with tetracyclines,
particularly doxycycline (24). Currently, doxycycline at 200 mg/
day plus rifampin at 600 to 900 mg/day for 6 weeks is consid-
ered the treatment of choice by the Food and Agriculture
Organization-WHO Expert Committee on Brucellosis (22).
Nevertheless, there are very few comparative trials on this
subject, and none of them has demonstrated the advantages of
DR treatment over DS treatment given for a similar period
(49). Only three studies compared DR treatment for 45 days
with doxycycline (45 days) plus streptomycin (14 to 21 days) (1,
5, 39). Neither of these studies showed statistical differences
between the two treatments, although relapses in the DS group
were fewer than in the DR group (1, 5, 39). Since these studies
had relatively small sample sizes, the possibility of overlooking
an effect because of a type II error cannot be excluded. Ad-
ministration of DR treatment for shorter periods has been
associated with a relapse rate of 30 to 40% in other studies (4,
50). Interaction of rifampin with doxycycline has been reported
in recent studies (8, 12, 23). Rifampin is one of the most potent
inducing agents for hepatic mycrosomal enzymes and leads to
decreased levels of doxycycline in serum, in the same patients,
when administered in combination (23). These effects have
provided a probable explanation for the difference in efficacy
2066 SOLERA ET AL. ANTIMICROB. AGENTS CHEMOTHER.

TABLE 4. Patients discontinuing treatment because of APPENDIX

adverse reactions
The following persons participated in this trial, entered research
No. of patientsa subjects, or both: Francisco Medrano, Fernando Jiménez-Zorzo, An-
(no. discontinuing treatment) gel Puras, Eloy Camino, Pedro Ferreras, Antonio Alamillo, Miguel
Reaction
Angel Barba, Angel Férnandez, Angel Fernández-Fúnez, Fernando
DR DS Martı́nez-Salazar, José Antonio Sáez-Barcelona, Miguel Torralba, Di-
24 (4) 19 (2) ego Cebrian, Anunciación Pérez-Tello, and Marı́a Isabel Serrano (Al-
Epigastric painb 9 (1) 8 (1) bacete General Hospital); Manuel Morales (Guadalajara General
Heartburn 2 4 Hospital); Jaime Calderón, Marı́a Enriqueta Peiró, Juan Ruiz-Gonzá-
Abdominal discomfort 1 2 lez, and José Antonio Nieto (Cuenca General Hospital); Fernando
Nausea or vomitingb 9 (1) 5 Cuadra and Marı́a Antonia Sepúlveda (Toledo General Hospital); and
Anorexia 2 0 Luı́s de Juan (Ciudad Real General Hospital).
Diarrhea 1 0
REFERENCES
Photosensitivityb 2 2 (1)
1. Acocella, G., A. Bertrand, J. Beytout, J. B. Durrande, J. A. Garcı́a Rodrı́guez,
Hypersensitivityc 1 (1) 0
and J. Kosmidis. 1989. Comparison of three different regimens in the treat-
Oral candidiasis 1 0 ment of acute brucellosis: a multicenter multinational study. J. Antimicrob.

Downloaded from http://aac.asm.org/ on January 2, 2020 by guest

Genital candidiasis 1 0
Dizziness 1 0
Fatigue 0 1
,5-fold ALAT increasec,d 1 (1) 0 3. Ariza, J., F. Gudiol, R. Pallarés, G. Rufı́, and P. Fernández-Viladrich. 1985.
a
Of 100 patients in the DR group, 24 had adverse reactions, and 4 of the 24
were withdrawn from the study. Of 94 patients in the DS group, 19 had adverse
reactions, and 2 of the 19 were withdrawn from the study. Some patients had
more than 1 adverse effect. No statistically significant differences between the
two groups were found for any variable.
b
Considered related to doxycycline.
c
Considered related to rifampin.
d
Over the baseline. ALAT, alanine aminotransferase.
between the two therapeutic regimens (12). It should be em-
phasized, however, that this trial did not address the mecha-
nism of therapeutic efficacy directly and that our suggestions
regarding the mechanism are only speculative.
In previous trials (5, 50), most therapeutic failures in pa-
tients treated with the DR combination consisted of clinical
lesions in the spine. As in other studies (1, 4, 5, 13, 39, 46, 50),
in our trial severe toxic effects were uncommon in both treat-
ment groups and were not substantially more frequent in the
DR group than in the DS group.
What are the implications of these results for the clinician?
First, the clinical benefit of a lower proportion of relapses with
DS treatment suggests that this combination must be seriously
considered the treatment of choice for acute brucellosis. Sec-
ond, in view of the low frequency of relapses with the DS
regimen, clinical and laboratory monitoring for therapeutic
failure may be discontinued 6 months after the end of treat-
ment. The proportion of therapeutic failure (that is, initial lack
of efficacy combined with a relapse) with the DR regimen may,
however, dictate much more frequent and extensive monitor-
ing for some subjects. Third, the overall benefits of treatment
with the DS regimen must be weighed against potential toxicity
and the costs associated with intramuscular administration of
streptomycin.
ACKNOWLEDGMENTS
We are indebted to Francisco Medrano, Luis de Juan, and Javier del
Valle for assistance in the design of this study; to Fernando Rodrı́guez-
Artalejo and Raul Solera for editorial assistance; to Emilio Serna,
Marı́a Luisa Castillejos, and Dolores Cuenca, (Unit of Infectious Dis-
eases, Albacete General Hospital), Angel Gil and Juan del Rey-Calero
(Public Health Department, Universidad Autónoma, Madrid, Spain),
Salvador de Mateo (Consejerı́a de Sanidad de Castilla La Mancha,
Toledo, Spain), and the many members of the staff of the Clinical
Microbiology Laboratories and Division of Internal Medicine services
affiliated with GECMEI for collecting the study data; and to the
patients who volunteered to assist in this effort.
Chemother. 23:433–439.
2. Alton, G. G., L. M. Jones, and D. E. Pietz. 1975. Laboratory techniques in
brucellosis, 2nd ed. World Health Organization, Geneva.
Comparative trial of co-trimoxazole versus tetracycline-streptomycin in
treating human brucellosis. J. Infect. Dis. 152:1358–1359.
4. Ariza, J., F. Gudiol, R. Pallarés, G. Rufı́, and P. Fernández-Viladrich. 1985.
Comparative trial of rifampin-doxycycline versus tetracycline-streptomycin
in the therapy of human brucellosis. Antimicrob. Agents Chemother. 28:
548–551.
5. Ariza, J., F. Gudiol, R. Pallarés, P. F. Viladrich, G. Rufi, J. Corredoira, and
M. R. Miravitlles. 1992. Treatment of human brucellosis with doxycycline
plus rifampin or doxycycline plus streptomycin. A randomized, double-blind
study. Ann. Intern. Med. 117:25–30.
6. Arnow, P. M., M. Smaron, and V. Ormists. 1984. Brucellosis in a group of
travellers to Spain. JAMA 251:505–507.
7. Bertrand, A., J. Roux, F. Janbon, J. Jourdan, and O. Jonquet. 1979. Trait-
ement de la brucellose par la rifampicine. Résultats préliminaires. Nouv.
Presse Med. 8:3635–3639.
8. Bessard, G., J. P. Stahtl, F. Dubois, J. Gaillat, and M. Micoud. 1983.
Modification de la pharmacocinétique de la doxycycline par l’administration
de rifampicine chez l’homme. Med. Maladies Infect. 13:138–141.
9. Buchanan, M., L. C. Faber, and R. A. Fledman. 1974. Brucellosis in the
United States 1960–1972. An abattoir associated disease. Part I. Clinical
features and therapy. Medicine (Baltimore) 53:403–413.
10. Centers for Disease Control and Prevention. 1994. Brucellosis outbreak at a
pork processing plant in North Carolina, 1992. Morbid. Mortal. Weekly Rep.
43:113–116.
11. Cisneros, J. M., P. Viciana, J. D. Colmenero, J. Pachon, C. Martı́nez, and A.
Alarcón. 1990. Multicenter prospective study of treatment of Brucella
melitensis brucellosis with doxycycline for 6 weeks and streptomycin for 2
weeks. Antimicrob. Agents Chemother. 34:881–883.
12. Colmenero, J. D., L. C. Fernández-Gallardo, J. A. Agúndez, J. Sedeño, J.
Benı́tez, and E. Valverde. 1994. Possible implications of doxycycline-rifampin
interaction for treatment of brucellosis. Antimicrob. Agents Chemother.
38:2798–2802.
13. Colmenero, J. D., S. Hernández, J. M. Reguera, F. Cabrera, F. Rius, and A.
Alonso. 1989. Comparative trial of doxycycline plus streptomycin versus
doxycycline plus rifampin for the therapy of human brucellosis. Chemother-
apy (Basel) 35:146–152.
14. Colmenero, J. D., J. J. Porras, P. Valdivielso, J. A. Porras, E. de Ramón, M.
Cause, and C. Juárez. 1989. Brucelosis: estudio prospectivo de 100 casos.
Med. Clin. (Barcelona) 86:43–48.
15. Corbel, M. J. 1976. Determination of the in vitro sensitivity of brucella
strains to rifampicin. Br. Vet. J. 132:266–275.
16. Cox, D. R. 1972. Regression models and life-tables. J. R. Stat. Soc. B 34:
187–220.
17. Dean, A. G., J. A. Dean, D. Coulombier, K. A. Brendel, D. C. Smith, A. H.
Burton, R. C. Dicker, K. Sullivan, R. F. Fagan, and T. G. Arner. 1994. Epi
Info, version 6: a word processing, database, and statistics program for
epidemiology on microcomputers. Centers for Disease Control and Preven-
tion, Atlanta, Ga.
18. Dixon, W. J. (ed.). 1992. BMDP statistical software. University of California
Press, Berkeley.
19. Feiz, J. M., H. Sabbaghian, and F. Sohrabi. 1973. A comparative study of
therapeutic agents used for treatment of acute brucellosis. Br. J. Clin. Pract.
27:410–413.
20. Fleiss, J. L. 1981. Statistical methods for rates and proportions, 2nd ed., p.
260. John Wiley, & Sons, Inc., New York.
21. Food and Agriculture Organization-World Health Organization. 1971.
FAO-WHO Expert Committee on Brucellosis fifth report, p. 41–43. In
World Health Organization technical report series 464. World Health Or-
ganization, Geneva.
VOL. 39, 1995 DOXYCYCLINE-RIFAMPIN TREATMENT OF BRUCELLOSIS
22. Food and Agriculture Organization-World Health Organization. 1986.
FAO-WHO expert committee on brucellosis sixth report, p. 56–57. In World
Health Organization technical report series. 740. World Health Organiza-
tion, Geneva.
23. Garraffo, R., P. Dellamonica, J. P. Fournier, P. Lapalus, E. Bernard, H.
Beziau, and R. M. Chichmanian. 1987. Effet de la rifampicine sur la phar-
macocinetique de la doxycycline. Pathol. Biol. 35:746–749.
24. Godeau, P., G. Fuchs, L. Guillevin, A. Philippon, G. Tucat, J. Cabane, and
S. Herson. 1984. Traitement de la brucellose humaine par la rifampicine.
Sem. Hôp. Paris 60:5–9.
25. Gotuzzo, E., and C. Cellillo. 1992. Brucella, p. 1513–1521. In S. L. Gorbach,
J. H. Bartlett, and N. R. Blacklow (ed.), Infectious diseases. W. B. Saunders
Co., Philadelphia.
26. Hall, W. H. 1990. Modern chemotherapy for brucellosis in humans. Rev.
Infect. Dis. 12:1060–1099.
27. Hall, W. H., and R. E. Manion. 1970. In vitro susceptibility of brucella to
various antibiotics. Appl. Microbiol. 20:600–604.
28. Hausler, W. J., N. P. Moyer, and L. A. Holcomb. 1984. Brucella, p. 382–386.
In E. H. Lennette, A. Balows, W. J. Hausler, and H. J. Shadomy (ed.),
Manual of clinical microbiology, 4th ed. American Society for Microbiology,
Washington, D.C.
29. Heilman, F. R. 1949. The effect of combined treatment with aureomycin and
dihydrostreptomycin on brucella infection in mice. Mayo Clin. Proc. 24:133–
137.
30. Herrell, W. E., and T. E. Barber. 1949. The combined use of aureomycin and
dihydrostreptomycin in the treatment of brucellosis. Mayo Clin. Proc. 24:
138–145.
31. Lagomarsino, J. J., and J. E. Cacace. 1973. Evaluación clı́nica del trata-
miento de la brucelosis con rifampicina. Dı́a Méd. 45:446–451.
32. Lang, R., and E. Rubinstein. 1992. Quinolones for the treatment of brucel-
losis. J. Antimicrob. Chemother. 29:357–360.
33. Llorens-Terol, J., and R. M. Busquets. 1980. Brucellosis treated with ri-
fampin. Arch. Dis. Child. 55:486–488.
34. Lubani, M. M., K. I. Dubin, D. C. Sharda, D. S. Ndhar, G. F. Araj, H. A.
Hafez, Q. A. al-Saleh, I. Helin, and M. M. Salhi. 1989. A multicenter
therapeutic study of 1100 children with brucellosis. Pediatr. Infect. Dis. J.
8:75–78.
35. Lulu, A. R., G. F. Araj, and M. I. Khateeb. 1988. Human brucellosis in
Kuwait: a prospective study of 400 cases. Q. J. Med. 249:39–54.
36. Madkour, M. M., and G. Gargani. 1989. Epidemiological aspects, p. 11–28.
In M. M. Madkour (ed.), Brucellosis. Butterworths Co., London.
37. Magill, G. B., and J. H. Killough. 1953. Oxitetracycline-streptomycin therapy
in brucellosis due to Brucella melitensis. Arch. Intern. Med. 91:204–211.
38. Mikolich, D. J., and J. M. Boyce. 1990. Brucella species, p. 1735–1742. In
G. L. Mandell, R. G. Douglas, J. E. Bennett (ed.), Principles and practice of
infectious diseases, 3th ed. Churchill Livingstone Co., New York.
39. Montejo, J. M., I. Alberola, P. González-Zarate, A. Alvárez, J. Alonso, A.
2067
Cánovas, and C. Aguirre. 1993. Open, randomized therapeutic trial of six
antimicrobial regimens in the treatment of human brucellosis. Clin. Infect.
Dis. 16:671–676.
40. Morgan, W. J., D. J. Mackinnon, J. R. Lawson, and G. A. Cullen. 1969. The
rose bengal plate agglutination test in the diagnosis of brucellosis. Vet. Rec.
85:636–641.
41. Mortensen, J. E., D. G. Moore, J. E. Clarridge, and E. J. Young. 1986.
Antimicrobial susceptibility of clinical isolates of brucella. Diagn. Microbiol.
Infect. Dis. 5:163–169.
42. Pandolfo, G. P., and G. Villegas. 1970. Tratamiento de la brucelosis con
rifampicina. Estudio de 21 enfermos. Dı́a Méd. 42:215–220.
43. Pellicer, T., J. Ariza, A. Foz, R. Pallarès, and F. Gudiol. 1988. Specific
antibodies detected during relapse of human brucellosis. J. Infect. Dis. 157:
918–924.
44. Peto, R., M. C. Pike, P. Armitage, N. E. Breslow, D. R. Cox, and S. V.
Howard. 1977. Design and analysis of randomized clinical trials requiring
prolonged observation of each patient. II. Analysis and examples. Br. J.
Cancer 35:1–39.
Downloaded from http://aac.asm.org/ on January 2, 2020 by guest
45. Rodrı́guez-Creixens, M., L. Buzón, A. Meseguer, J. Martı́nez-Beltrán, and E.
Bouza. 1980. Rifampin as a single agent in the treatment of acute brucellosis
in humans, p. 1064–1066. In J. D. Nelson and C. Grassi (ed.), Current
chemotherapy and infectious diseases. American Society for Microbiology,
Washington, D.C.
46. Rodrı́guez-Zapata, M., A. Gamo, and J. de la Morena. 1987. Comparative
study of two regimens in the treatment of brucellosis. Chemioterapia
6(Suppl. 2):360–362.
47. Rubinstein, E., R. Lang, B. Shasha, B. Hagar, L. Diamanstein, G. Joseph, M.
Andersson, and K. Harrison. 1991. In vitro susceptibility of Brucella meliten-
sis to antibiotics. Antimicrob. Agents Chemother. 35:1925–1927.
48. Shir, Y., and J. Michel. 1984. Susceptibility of Brucella strains to antibiotics.
Pathol. Biol. 32:381–384.
49. Solera, J., E. Martı́nez-Alfaro, and L. Sáez. 1994. Meta-análisis sobre la
eficacia de rifampicina y doxiciclina en el tratamiento de la brucelosis hu-
mana. Med. Clin. (Barcelona) 102:731–738.
50. Solera, J., F. Medrano, M. Rodrı́guez, P. Geijo, and J. Paulino. 1991. Ensayo
terapéutico comparativo y multicéntrico de rifampicina y doxiciclina frente a
estreptomicina y doxiciclina en la brucelosis humana. Med. Clin. (Barcelona)
96:649–653.
50a.Solera, J., M. Rodriguez, P. Geijo, J. Paulino, J. Largo, L. Saez, E. Martinez,
and L. Sanchez. 1993. Treatment of human brucellosis with doxycycline plus
streptomycin. A randomized, multicenter study, abstr. 1228, p. 344. In Pro-
gram and abstracts of the 33rd Interscience Conference on Antimicrobial
Agents and Chemotherapy. American Society for Microbiology, Washing-
ton, D.C.
51. Young, E. J. 1975. Brucellosis outbreak attributed to ingestion of unpasteur-
ized goat cheese. Arch. Intern. Med. 135:240–243.