Antibiotics Effective Against Bartonella Infections

First-Line Treatment Options

The Centers for Disease Control and Prevention recommends doxycycline as a first-line treatment for bartonellosis based on case series evidence (AII) 1
The Centers for Disease Control and Prevention recommends erythromycin as a first-line agent for most Bartonella infections (AII) 1
Treatment should be administered for at least 3 months for standard infections (AII) 2
For central nervous system involvement or severe infections, doxycycline with or without rifampin is the treatment of choice (AIII) 1
For Bartonella endocarditis, the American Heart Association recommends the combination of doxycycline plus gentamicin for optimal outcomes (IIa/B) 3

The Centers for Disease Control and Prevention recommends clarithromycin or azithromycin as effective alternatives with good clinical response (BIII) 1
Azithromycin is particularly recommended for patients who may have difficulty with the more frequent dosing schedule of doxycycline or erythromycin 2
For Bartonella henselae specifically, the Infectious Diseases Society of America recommends doxycycline or azithromycin, with or without rifampin, as treatment options (C-III) 4

For Bartonella bacilliformis, the Infectious Diseases Society of America recommends chloramphenicol, ciprofloxacin, doxycycline, ampicillin, or trimethoprim-sulfamethoxazole (B-III) 4
For Bartonella henselae, the Infectious Diseases Society of America recommends doxycycline or azithromycin, with or without rifampin, as the preferred options (C-III) 4
For suspected Bartonella endocarditis, the American Heart Association recommends ceftriaxone (2g/day) plus gentamicin for 2 weeks, with or without doxycycline for 6 weeks total (IIa/B) 3, 5

The Centers for Disease Control and Prevention states that penicillins and first-generation cephalosporins have no in vivo activity and should not be used for bartonellosis (DII) 1
The Centers for Disease Control and Prevention states that quinolones and trimethoprim-sulfamethoxazole have variable in vitro activity and inconsistent clinical response and are not recommended (DIII) 1

The Centers for Disease Control and Prevention recommends erythromycin for Bartonella infections during pregnancy 6
The Centers for Disease Control and Prevention states that tetracyclines (including doxycycline) should be avoided during pregnancy due to risk of hepatotoxicity and fetal teeth/bone staining (EII) 1
For immunocompromised patients (CD4+ count <200 cells/μL), the Centers for Disease Control and Prevention recommends long-term suppression with doxycycline or a macrolide after initial treatment (AIII) 1
Suppression can be discontinued after 3-4 months of therapy when CD4+ count remains >200 cells/μL for >6 months (CIII) 1
Some specialists recommend continuing therapy until Bartonella titers have decreased by fourfold (CIII) 1

Patients treated with oral doxycycline should be cautioned about pill-associated ulcerative esophagitis, which occurs most often when a dose is taken with only a small amount of liquid or at night just before retiring (AIII) 2