Bertrand A
Clinique des Maladies infectieuses A, Hôpital Gui de Chauliac, Montpellier.
Presse Med. 1994 Jun 25;23(24):1128-31.
Forty years after active drug therapy was defined, the treatment of brucellosis still raises the problem of selecting the correct antibiotic and the duration of treatment. Indeed, requirements may be complex since one must select antibiotics which are active in vitro and which diffuse readily into the tissues and into the cells without developing bacterial resistance. Prescriptions must also be long enough, not only to achieve cure, but also to eliminate the Brucella strain. Antibiotics must be found which meet this last criteria yet do not lead to toxic effects or impair the patient's own immune response. Acute septicemic brucellosis in adult men and non-pregnant women has been effectively treated with the following three regimens: 1) doxycycline 200 mg/d and rifampin 900 mg/d orally for 45 days; 2) doxycycline 200 mg/d orally for 45 days and streptomycin 1 g/d IM for three weeks; 3) TMP-SMZ 320-1600 mg/d and rifampin 900 mg/d orally for 45 days. All regimens require a combination of two antibiotics and a prolonged course for total recovery, although casual relapses may occur. The doxycycline-rifampin combination shows the most favorable efficacy/safety ratio, and either antibiotic alone was used successfully in pregnant women by some investigators. The TMP-SMZ-rifampin combination is recommended in children below 8 years of age. Osteoarticular infections can be treated with doxycycline plus rifampin for 3 to 6 months, and streptomycin during the first 2 or 3 weeks. In nervous system complications, the preferred treatment is TMP-SMZ plus rifampin for 3 to 6 months. Brucellar endocarditis should be treated parenterally with streptomycin or gentamycin combined with TMP-SMZ, rifampin and doxycycline, and often requires valvular replacement. Many other antibiotics have been used with good clinical responses in the treatment of brucellosis, e.g., chloramphenicol, erythromycin, ampicillin, and more recently cephalosporins, thienamycin and fluoroquinolones; however, more cases have to be studied before any of these agents is definitely chosen for the treatment of brucellosis.
在确定了活性药物治疗方法40年后，布鲁氏菌病的治疗仍然存在选择正确抗生素和治疗疗程的问题。实际上，要求可能很复杂，因为必须选择在体外具有活性、能轻易扩散到组织和细胞中且不会产生细菌耐药性的抗生素。处方疗程还必须足够长，不仅要实现治愈，还要消除布鲁氏菌菌株。必须找到符合这一最终标准且不会导致毒性作用或损害患者自身免疫反应的抗生素。成年男性和非孕女性的急性败血性布鲁氏菌病可通过以下三种方案有效治疗：1）强力霉素200mg/d和利福平900mg/d口服，持续45天；2）强力霉素200mg/d口服45天，链霉素1g/d肌肉注射，持续三周；3）复方磺胺甲恶唑320 - 1600mg/d和利福平900mg/d口服，持续45天。所有方案都需要联合使用两种抗生素并进行较长疗程的治疗才能完全康复，不过可能会偶发复发情况。强力霉素 - 利福平联合用药显示出最有利的疗效/安全性比，一些研究人员在孕妇中单独使用这两种抗生素均取得了成功。8岁以下儿童推荐使用复方磺胺甲恶唑 - 利福平联合用药。骨关节感染可用强力霉素加用利福平治疗3至6个月，最初2或3周加用链霉素。对于神经系统并发症，首选治疗方法是复方磺胺甲恶唑加用利福平治疗3至6个月。布鲁氏菌性心内膜炎应采用链霉素或庆大霉素联合复方磺胺甲恶唑、利福平及强力霉素进行胃肠外给药治疗，且通常需要进行瓣膜置换。在布鲁氏菌病治疗中还使用了许多其他抗生素，临床反应良好，例如氯霉素、红霉素、氨苄青霉素，以及最近使用的头孢菌素、硫霉素和氟喹诺酮类；然而，在确定将这些药物中的任何一种用于布鲁氏菌病治疗之前，还需要研究更多病例。
