Future trends in human brucellosis treatment.

The global burden of human brucellosis remains enormous. Existing treatment options, largely based on experience gained > 30 years ago, are adequate but not optimal. The evolving understanding of the pathophysiology of the disease may augment in designing and evaluating alternative approaches that may prove to be superior. Current alternative approaches such as co-trimoxazole-containing regimens, should be widely evaluated as being more cost-effective. New methods of delivery such as gentamicin-loaded microparticles, neutralisation of the environment where Brucella resides and use of novel antibiotics such as tigecycline may be of importance in the future. The role of immunomodulation, widely but inconsistently applied in 'chronic' brucellosis, should be further evaluated in all disease stages to define if it is of any use. The development of a subcellular vaccine would be an important step forward although one has to take into account the multiple interactions between Brucella and the immune system, various technical problems and the lack of funds. Reviewing existing attempts at the development of such a vaccine, the authors conclude that a trivalent subcellular vaccine may be needed for adequate efficacy.