Bartonellosis, Gentamicin and treatment failures in Lyme disease?

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<A HREF= " http://www.emedicine.com/med/INFECTIOUS_DISEASES.htm " >Click here:

eMedicine Medicine, Ob/Gyn, Psychiatry, and Surgery : INFECTIOUS

DISEASES</A>

http://www.emedicine.com/med/INFECTIOUS_DISEASES.htm

(link to infectious disease review articles --- click " bartonellosis " )

<A

HREF= " http://aac.asm.org/cgi/reprint/39/11/2387?view=reprint & pmid=8585713 " >Click

here: http://aac.asm.org/cgi/reprint/39/11/2387.pdf</A>

http://aac.asm.org/cgi/reprint/39/11/2387?view=reprint & pmid=8585713

(antibiotic susceptibiliities for Bartonella species)

<A HREF= " http://jac.oupjournals.org/cgi/content/full/46/5/811 " >Click here: J.

Antimicrob. Chemother. -- Rolain et al. 46 (5): 811</A>

http://jac.oupjournals.org/cgi/content-nw/full/46/5/811/T

(Bactericidal effect of antibiotics on Bartonella and Brucella spp.: clinical

implications,

Jean-Marc Rolain, Max Maurin and Didier Raoult<A

HREF= " http://jac.oupjournals.org/cgi/content/full/46/5/#FN1 " >*</A>)

<A HREF= " http://cmr.asm.org/cgi/reprint/9/3/273.pdf " >Click here:

http://cmr.asm.org/cgi/reprint/9/3/273.pdf</A>

http://cmr.asm.org/cgi/reprint/9/3/273.pdf

(20 page review article on Bartonella quintana)

<A

HREF= " http://aac.asm.org/cgi/content/full/45/11/2977?maxtoshow= & HITS=10 & hits=10 & \

RESULTFORMAT= & author1=Maurin%2C+M & searchid=1024894690253_2844 & stored_search= & FIR\

STINDEX=0 & search_url=http%3A%2F%2Fjournals.asm.org%2Fcgi%2Fsearch " >Click here:

AAC -- Maurin and Raoult 45 (11): 2977</A>

http://aac.asm.org/cgi/content/full/45/11/2977?maxtoshow= & HITS=10 & hits=10 &

RESULTFORMAT= & author1=Maurin%2C+M & searchid=1024894690253_2844 & stored_search= &

FIRSTINDEX=0 & search_url=http%3A%2F%2Fjournals.asm.org%2Fcgi%2Fsearch

(Use of Aminoglycosides in Treatment of Infections Due to Intracellular

Bacteria, M. Maurin<A

HREF= " http://aac.asm.org/cgi/content/full/45/11/#FN150 " >*</A> and D. Raoult)

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Interesting point made in some of these publications is that ONLY GENTAMICIN

is BACTERICIAL for Bartonella. Gentamicin is a drug that is only available

IV or IM. Gentamicin is typically given over a 2-3 week period and requires

blood level monitoring (peak and trough values). Cephaloporins may also

affect blood levels and gentamicin dosages may need to be adjusted if the

drug is administered with Rocephin, for example. The drug needs to be

monitored due to its potential nephrotoxicity, and it may also cause hearing

loss.

There appears to be no consistent view on how to treat bartonellosis. There

are marked discrepancies between what appears to work in vitro and what works

clinically. While B. henselae is said to be self-limited, you will also read

that relapses are common if only monotherapy is used.

Tetracycline class drugs, Zithromax, Bactrim or Septra, the quinolones (for

example, Cipro), Rifampin and Gentamicin are considered the most effective

drugs from a clinical standpoint. One of the authors of some of these

publications, Max Maurin, continually points out that only Gentamicin has

been shown to be bactericial for bartonella. If you search Medline for

" Maurin M, " you will find he has done a lot of interesting work on

intracellular infections, btw.

Another point I read is that where there is CNS involvement due to

Bartonella, the use of 2 agents is highly preferred because monotherapy is

known to fail. Bartonella may also cause an encephalopathy and cranial never

problems, similar to Lyme disease.

Like Lyme disease, the blood tests are unreliable and serologies are

frequently negative.

If the addition of an aminoglycoside (i.e., Gentamicin) is so important in

the treatment of bartonellosis and if relapse is as common as the authors

state --- AND if it as difficult to diagnose as the authors state --- then

undiagnosed or inadequately treated bartonellosis could account for some

treatment failures in the context of what we are calling " Lyme disease. "

Drugs found to be clinically important in the treatment of bartonellosis,

specifically co-trimazole (i.e., Bactrim, Septra), the quinolones (for

example, Cipro), Rifampin and Gentamicin) are NOT antimicrobials typically

prescribed in the context of " Lyme disease. " Thus, even the empiric treatment

that many patients are getting is not going to provide coverage for

bartonellosis.

The question of using Rifampin is also interesting here because veterinarians

are now using the combination of doxycycline and Rifampin to treat refractory

ehrlichiosis in dogs. Theoretically, the combination of doxycycline and

Rifampin would cover bartonellosis and persistent ehrlichiosis. However, if

Gentamicin is the ONLY bactericial agent for bartonella, there may be no

getting around administering a drug that poses a financial burden, and a

burden on physicians and patients in terms of drug monitoring and potential

side-effects.

From an empiric standpoint, my impression has been that Lyme disease patients

that have had aminoglycosides as part of their treatment regimen have

demonstrated more sustained improvement. Certainly, we know that borrelia is

sensitive to various aminoglycosides, but it has never been determined that

an aminoglycoside is essential for its eradication in vivo. If there are

other coinfections present, however, that *do* require the use of an

aminoglycoside -- this could explain why some patients have seemed to do

better with aminoglycosides.

I am curious whether anyone shares my impression of the efficacy of

aminoglycosides in the context of Lyme disease. Yes? No? Other thoughts?

Lynn