Systematic review and meta-analysis of randomized clinical trials in the treatment of human brucellosis

Background

Brucellosis is a persistent health problem in many developing countries throughout the world, and the search for simple and effective treatment continues to be of great importance.

Methods and Findings

A search was conducted in MEDLINE and in the Cochrane Central Register of Controlled Trials (CENTRAL). Clinical trials published from 1985 to present that assess different antimicrobial regimens in cases of documented acute uncomplicated human brucellosis were included. The primary outcomes were relapse, therapeutic failure, combined variable of relapse and therapeutic failure, and adverse effect rates. A meta-analysis with a fixed effect model was performed and odds ratio with 95% confidence intervals were calculated. A random effect model was used when significant heterogeneity between studies was verified.Comparison of combined doxycycline and rifampicin with a combination of doxycycline and streptomycin favors the latter regimen (OR = 3.17; CI95% = 2.05–4.91). There were no significant differences between combined doxycycline-streptomycin and combined doxycycline-gentamicin (OR = 1.89; CI95% = 0.81–4.39). Treatment with rifampicin and quinolones was similar to combined doxycycline-rifampicin (OR = 1.23; CI95% = 0.63–2.40). Only one study assessed triple therapy with aminoglycoside-doxycycline-rifampicin and only included patients with uncomplicated brucellosis. Thus this approach cannot be considered the therapy of choice until further studies have been performed. Combined doxycycline/co-trimoxazole or doxycycline monotherapy could represent a cost-effective alternative in certain patient groups, and further studies are needed in the future.

Conclusions

Although the preferred treatment in uncomplicated human brucellosis is doxycycline-aminoglycoside combination, other treatments based on oral regimens or monotherapy should not be rejected until they are better studied. Triple therapy should not be considered the current treatment of choice.     

Effect of rifampicin and doxycycline on the chemiluminescence of leukocytes]

The effect of rifampicin and doxycycline on spontaneous and zymosan-induced chemiluminescence of polymorphonuclear leukocytes was studied on guinea pigs. The cells were incubated in the presence of the antibiotics, washed and stimulated by zymosan. Under such conditions rifampicin in therapeutic doses of 0.1 to 10 micrograms/kg and doxycycline in a dose of 100 micrograms/kg potentiated the leukocyte chemiluminescence. Investigation of the antibiotics effect on the cells without washing failed because of the direct interference of rifampicin and doxycycline with the cell-independent stage of the chemiluminescent reaction.     

Effect of antibiotics on Francisella tularensis]

The minimum inhibitory concentrations of rifampicin, doxycycline, sisomicin, ciprofloxacin and phosmidomycin for various strains of Francisella tularensis were 0.5 to 2.0, 0.5 to 2.0, 0.125 to 0.4, 0.625 to 0.125 and 2.0 to 12.5 micrograms/ml, respectively. Ciprofloxacin and sisomicin had a marked bactericidal effect. The bactericidal effect of rifampicin was insignificant. Doxycycline and phomidomycin had practically no such effect. All the antibiotics had a post effect. The level of the post-antibiotic effect was different and depended on the antibiotic concentration.     

Efficacy of plague prophylaxis with streptomycin, tetracycline, and rifampicin in simultaneous immunization of white mice by resistant EV NRIEG strain]

Tetracycline, doxycycline, streptomycin and rifampicin were used for prophylaxis of experimental plague in albino mice (Yersinia pestis 231, approximately 1000 LD50). The antibiotics were administered 5 hours after the infection for 5 days. Tetracycline and doxycycline provided survival of 60 to 75% of the animals, while the respective figure for streptomycin and rifampicin was 100%, but streptomycin and rifampicin inhibited development of plague immunity evident from a lower protection index (PI) by 3-4 orders. The PI for the tetracyclines lowered by 2 orders. Simultaneous prophylaxis with the tetracyclines and immunization by Y. pestis EV Rifr R(SmTc) (10(6) microbial cells) provided not only higher percentage of the animal survival (80-90%) but also development of sufficient plague immunity: PI of 1.0 x 10(5)--5.0 x 10(5). When the animals were infected with Y. pestis 231 R(SmTc) the use of the tetracyclines failed, whereas the use of doxycycline and simultaneous vaccination by EV Rifr R(SmTc) provided survival of 70-85% of the animals. Successive use of inefficient streptomycin (for 2 days) and efficient rifampicin (for 3 days) provided survival only of 30% of the mice. A similar regimen of the successive use of the inefficient and efficient antibiotics (the total term of 5 days) started simultaneously with immunization by EV Rifr R(SmTc) provided survival of 80% of the animals. The use of combined specific and urgent prophylaxis of plague infection due not only to antibiotic susceptible but also to antibiotic resistant strains of the plague pathogen was shown promising.     

Synergistic action of some antibacterial agents in studies on albino mice with experimental plague caused by Fr- phenotype strain of the plague microbe]

Possible use of ciprofloxacin combinations with some other antibiotics such as rifampicin, ampicillin, cefotaxime, doxycycline and amikacin was studied on albino mice with experimental plague caused by the pathogen strain (approximately 1000 LD50) deprived of the ability to produce the capsular antigen, fraction I (Fra- phenotype). The combination of ciprofloxacin with ampicillin or doxycycline had no effect on the increase of the survival rate (t<2) evident of inexpediency of its use in the infection caused by the Fra- strains of the plague microbe. The combination of ciprofloxacin and cefotaxime used in definite doses had some effect (t=2.6). The most significant synergistic effect was observed with the use of ciprofloxacin in combination with amikacin or rifampicin (t>3.3-9.0) which made the combination most promising.     

替加环素与米诺环素治疗布鲁菌病的进展

布鲁菌病是由布鲁菌引起的人畜共患传染性疾病，由带菌动物通过多种途径传染给易感人群，可侵犯人体各器官系统。目前推荐的抗布鲁菌治疗方案为多西环素、利福平、喹诺酮类、氨基糖类等抗菌药物组合的二联或者三联抗菌方案，但治疗无效率和疾病复发率仍较高。替加环素和米诺环素作为四环素类药物，经体外实验证明均可有效抑制布鲁菌，且50%最小抑菌浓度（50% minimal inhibitory concentration，MIC50） 和 90%最小抑菌浓度（90% minimal inhibitory concentration，MIC90）均较低。临床研究亦证实，包含替加环素和米诺环素的联合抗菌方案具有较低的治疗无效率和疾病复发率。因此，替加环素和米诺环素可作为治疗布鲁菌病的候选用药。本文就布鲁菌病传统治疗方案以及替加环素和米诺环素的抗菌效果进行综述。     

Evaluation of modern antibiotics efficacy at experimental Northern Asia rickettsiosis]

Comparative investigation of antibiotics therapy efficacy at experimental murine Northern Asia rickettsiosis was performed. The efficacy was evaluated by the determination of protective activity in per cent and by the pathogen erradication. The investigated antibiotics may be ranged in the following order (by the diminishing efficacy): ansamycins (azorif, rifapentine, rifampicin), tetracyclines (doxycycline), macrolides (azitromycin, sumamed), carbapenems (imipenem/cilastatin), fluoroquinolones (lomefloxacin, pefloxacin). Rifampicin and its derivatives--azorif, rifapentine, along with doxycycline and azitromycm can be recommended for clinical trials at experimental rickettsiosis profilaxy and treatment in natural infection focus.     

Increasing the effectiveness of antibiotic therapy by correcting immunologic disorders with vitamin A in patients with brucellosis

Experimental studies and clinical trials were performed on possible increase of antibiotic therapy efficacy in brucellosis patients by correction of the immunity disorders with vitamin A. It was experimentally shown that vitamin A increased cellular immunity and accelerated sanation of guinea pigs sensitized with Brucella abortus 19 BA. The clinical trials demonstrated that the use of vitamin A in a dose of 33,000 IU thrice a day for 10 to 12 days during the complex treatment of patients with acute (36 persons) and subacute (57 persons) brucellosis lowered the average period of manifestation of the disease clinical signs and formation of the antibodies, increased the skin allergic sensitivity, the lymphocyte blast cell transformation, the total number and subpopulations of the active T-cells, theophylline-resistant lymphocytes, phagocytic and metabolic activity of neutrophils, showed 1.5- and 2-fold increased in the frequency of the infection transformation into a chronic process in patients with acute or subacute brucellosis, respectively.     

Brugia malayi: effects of antibacterial agents on larval viability and development in vitro

Recent studies have suggested that intracellular Wolbachia bacteria are necessary for reproduction and survival of adult filarial worms. We now report results of in vitro studies of effects of antibacterial antibiotics (tetracycline, rifampicin, chloramphenicol, azithromycin, and doxycycline) on Brugia malayi infective larvae (L3) motility and molting. All of the antibiotics tested except chloramphenicol decreased L3 motility by 50% or more at 10 days, with minimal effective concentrations (MECs) of 20-100 microg/ml. Tetracyclines, rifampicin, and chloramphenicol inhibited L3 to L4 molting by 12 days in a concentration- and time-dependent manner, with MECs in the range of 1-20 microg/ml. These studies show that antibiotics active against Rickettsiaceae inhibit B. malayi L3 molting at low concentrations in vitro; higher concentrations kill the larvae. While it is possible that antibiotics directly affect filarial L3, we believe it is more likely that the effects seen are indirect effects related to bacterial killing.     

Detection of IgM Antibrucella Antibody in the Absence of IgGs: A Challenge for the Clinical Interpretation of Brucella Serology

The use of enzyme-linked immunosorbent assay (ELISA) for the detection of IgG and IgM antibodies antibrucella has become widespread in the diagnosis of human brucellosis. IgM anti-Brucella antibodies are indicative of acute infection. Between 2009–2013, 5307 patients were evaluated for serologic diagnosis at the Microbiology Laboratory of the Albacete General Hospital. A ELISA IgM-positive, IgG-negative anti-Brucella antibody serology pattern was detected in 17 of those patients. Epidemiology data, symptoms, laboratory data, treatment and outcome from these patients were reviewed. Sixteen patients presented with musculoskeletal pain, fatigue and/or fever and 1 was asymptomatic. Five patients received treatment with doxycycline combined with rifampin, gentamycin or streptomycin during 6–12 weeks, with no improvement. None of the 17 patients were finally diagnosed with brucellosis. Our results indicate that anti-Brucella IgM positive serology, per se, is not enough to diagnose acute brucellosis and other methods should be used for confirmation. Brucella serology data should be interpreted taking into account the patient''s clinical history and epidemiological context.     

Indices of phagocytosis of S and R forms of Brucella in patients with acute and chronic brucellosis caused by Brucella abortus

The characteristics of phagocytosis (phagocytic activity and phagocytic index) in patients with acute and chronic brucellosis have been studied with B. abortus S- and R-forms used as its objects. The study has revealed that higher characteristics of phagocytosis with respect to B. abortus S-forms are observed in patients with acute brucellosis, whereas in patients with chronic brucellosis taking a benign course phagocytosis is more intensive in respect of R-forms. In patients with frequent exacerbations of chronic brucellosis differences in the characteristics of phagocytosis with respect to B. abortus S- and R-forms are not statistically valid.     

Synergism between Medihoney and Rifampicin against Methicillin-Resistant Staphylococcus aureus (MRSA)

Skin and chronic wound infections caused by highly antibiotic resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) are an increasing and urgent health problem worldwide, particularly with sharp increases in obesity and diabetes. New Zealand manuka honey has potent broad-spectrum antimicrobial activity, has been shown to inhibit the growth of MRSA strains, and bacteria resistant to this honey have not been obtainable in the laboratory. Combinational treatment of chronic wounds with manuka honey and common antibiotics may offer a wide range of advantages including synergistic enhancement of the antibacterial activity, reduction of the effective dose of the antibiotic, and reduction of the risk of antibiotic resistance. The aim of this study was to investigate the effect of Medihoney in combination with the widely used antibiotic rifampicin on S. aureus. Using checkerboard microdilution assays, time-kill curve experiments and agar diffusion assays, we show a synergism between Medihoney and rifampicin against MRSA and clinical isolates of S. aureus. Furthermore, the Medihoney/rifampicin combination stopped the appearance of rifampicin-resistant S. aureus in vitro. Methylglyoxal (MGO), believed to be the major antibacterial compound in manuka honey, did not act synergistically with rifampicin and is therefore not the sole factor responsible for the synergistic effect of manuka honey with rifampicin. Our findings support the idea that a combination of honey and antibiotics may be an effective new antimicrobial therapy for chronic wound infections.     

恩替卡韦联合血浆置换治疗慢性乙型重型肝炎的研究

目的初步探讨恩替卡韦联合血浆置换治疗慢性乙型重型肝炎患者的疗效。方法选取40例慢性乙型重型肝炎患者,在常规内科治疗及恩替卡韦0.5 mg/d抗病毒治疗基础上联合血浆置换治疗。同时选取38例慢重肝患者为对照组,给予常规内科治疗及恩替卡韦0.5 mg/d抗病毒治疗。比较2组患者在慢性乙型重型肝炎早、中和晚期存活率的差异。结果联合血浆置换组生存率为72.5%,而对照组生存率为50%(χ2=4.168,P=0.041)。其中,中期慢重肝患者联合血浆置换治疗,其生存率为72.2%,而对照组生存率为38.9%(χ2=4.050,P=0.044),早期和晚期慢重肝患者联合血浆置换治疗,其生存率与对照组比差异无统计学意义(P0.05)。结论慢性乙型重型肝炎中期患者采用恩替卡韦联合血浆置换治疗能提高患者生存率。     

Rifampicin for lepromatous leprosy: nine years' experience.

Over 100 patients with lepromatous leprosy were treated with rifampicin in a series of pilot, uncontrolled, and controlled trials in 1968-77. The rapid bactericidal effect of rifampicin on Mycobacterium leprae was confirmed. Clinical improvement became apparent sometimes as early as 14 days after the start of treatment. Nevertheless, a few persisting viable M leprae were detected as long as five years after the start of treatment with rifampicin either by itself or in combination with the bacteriostatic drug thiambutosine. Treatment with rifampicin and dapsone for six months reduced the number of persisting leprosy bacteria more than treatment with dapsone alone. Although rifampicin proved more effective than dapsone, it is unlikely that used by itself if can significantly shorten the length of treatment in lepromatous leprosy. Therefore initial intensive combined treatment with two or more bactericidal drugs (including rifampicin) warrants further investigation in both untreated leprosy and lepromatous leprosy resistant to dapsone.     

MicroRNA Expression Patterns of CD8+ T Cells in Acute and Chronic Brucellosis

Although our knowledge about Brucella virulence factors and the host response increase rapidly, the mechanisms of immune evasion by the pathogen and causes of chronic disease are still unknown. Here, we aimed to investigate the immunological factors which belong to CD8+ T cells and their roles in the transition of brucellosis from acute to chronic infection. Using miRNA microarray, more than 2000 miRNAs were screened in CD8+ T cells of patients with acute or chronic brucellosis and healthy controls that were sorted from peripheral blood with flow cytometry and validated through qRT-PCR. Findings were evaluated using GeneSpring GX (Agilent) 13.0 software and KEGG pathway analysis. Expression of two miRNAs were determined to display a significant fold change in chronic group when compared with acute or control groups. Both miRNAs (miR-126-5p and miR-4753-3p) were decreased (p <0.05 or fold change > 2). These miRNAs have the potential to be the regulators of CD8+ T cell-related marker genes for chronic brucellosis infections. The differentially expressed miRNAs and their predicted target genes are involved in MAPK signaling pathway, cytokine-cytokine receptor interactions, endocytosis, regulation of actin cytoskeleton, and focal adhesion indicating their potential roles in chronic brucellosis and its progression. It is the first study of miRNA expression analysis of human CD8+ T cells to clarify the mechanism of inveteracy in brucellosis.     

A simple enzyme immunoassay for detecting brucellosis antibodies

Abstract A simple enzyme immunoassay was developed and evaluated for serological diagnosis of brucellosis in 25 patients with various forms of brucellosis and 292 control patients with other conditions and disorders. All brucellosis patients gave a positive test with the initial sample. In 3 acute, febrile brucellosis patients with follow-up sera taken during therapy a sharp drop in specific antibody was noted. There was a less pronounced antibody reduction in 1 chronic and 2 relapse patients and an antibody increase in 1 chronic and 1 relapse case. All control samples gave negative results. In addition, the assay was evaluated as a screening test with 315 sera from 'healthy' individuals living in a brucellosis focus and representing 15% of that population. 11.5% (34/293) of subjects with no reported history of brucellosis and 45% (10/22) of cases treated in the past gave a positive test result. The agreement in those samples between the assay and the serum agglutination test was 95.5%.     

Free and bound Brucella antigen and the level of circulating immune complexes in brucellosis patients

The aggregate hemagglutination test has been shown to be a highly sensitive and specific method for the detection of infectious antigenemia in different forms of brucellosis, permitting the determination of free Brucella antigen in 34% of patients with the acute form of the disease and in 53% of patients with the chronic course of brucellosis. The results of the determination of the quantitative level of circulating immune complexes (CIC) indicate that in the acute form of the disease their level exceeds the CIC level observed in the chronic course of brucellosis. The preliminary dissociation of CIC in the patients' blood sera has been found to increase the overall release of Brucella antigen to 80%.     

Effect of antibiotic therapy and vaccine therapy on the phagocytic reaction in mice infected with Staphylococcus

The time course of changes in the activity, intensity and completeness of phagocytosis with leukocytes of the peritoneal exudate was studied on mice with experimental staphylococcal infection treated with rifampicin, lincomycin and inactivated staphylococcal vaccine used alone or in combination. It was shown that immunization of the animals with inactivated staphylococcal vaccine promoted stimulation of the phagocytic defense. Rifampicin and lincomycin applied therapeutically induced a decrease in the activity, intensity and completeness of phagocytosis. It should be noted that rifampicin had a less pronounced inhibitory effect than lincomycin. The combined use of vaccine and antibiotics with therapeutic purposes promoted an increase in phagocytosis as compared to the use of the antibiotics alone. The combined therapy sometimes resulted in completeness of phagocytosis making it reach the control values (the 10th and 15th days, rifampicin and vaccine). It should be noted that a more pronounced stimulation of the activity, intensity and completeness of the phagocytosis was observed with the use of the combination of rifampicin and the vaccine.     

Enrofloxacin and Macrolides Alone or in Combination with Rifampicin as Antimicrobial Treatment in a Bovine Model of Acute Chlamydia psittaci Infection

Chlamydia psittaci is a zoonotic bacterium with a wide host range that can cause respiratory disease in humans and cattle. In the present study, effects of treatment with macrolides and quinolones applied alone or in combination with rifampicin were tested in a previously established bovine model of respiratory C. psittaci infection. Fifty animals were inoculated intrabronchially at the age of 6–8 weeks. Seven served as untreated controls, the others were assigned to seven treatment groups: (i) rifampicin, (ii) enrofloxacin, (iii) enrofloxacin + rifampicin, (iv) azithromycin, (v) azithromycin + rifampicin, (vi) erythromycin, and (vii) erythromycin + rifampicin. Treatment started 30 hours after inoculation and continued until 14 days after inoculation (dpi), when all animals were necropsied. The infection was successful in all animals and sufficient antibiotic levels were detected in blood plasma and tissue of the treated animals. Reisolation of the pathogen was achieved more often from untreated animals than from other groups. Nevertheless, pathogen detection by PCR was possible to the same extent in all animals and there were no significant differences between treated and untreated animals in terms of local (i.e. cell count and differentiation of BALF-cells) and systemic inflammation (i.e. white blood cells and concentration of acute phase protein LBP), clinical signs, and pathological findings at necropsy. Regardless of the reduced reisolation rate in treated animals, the treatment of experimentally induced respiratory C. psittaci infection with enrofloxacin, azithromycin or erythromycin alone or in combination with rifampicin was without obvious benefit for the host, since no significant differences in clinical and pathological findings or inflammatory parameters were detected and all animals recovered clinically within two weeks.