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Bartonella is susceptible to numerous antibiotics in vitro, but many of these have only bacteriostatic activity; they inhibit reproduction but are not bactericidal; they do not kill the bacteria. Gentamicin and, to a lesser extent, Rifampin have been found to be bactericidal.4 However, Gentamicin may only be bactericidal when the bacteria emerge from the red blood cells and are extracellular.
Based on a 2004 study, antibiotics which may be helpful in the treatment of Bartonella include doxycycline, erythromycin, rifampin, doxycycline with rifampin, doxycycline with gentamicin, gentamicin and ceftriaxone with or without doxycycline, chloramphenicol, ciprofloxacin, or streptomycin.41
The Lyme and Tick-Borne Diseases Research Center at Columbia University has recommended that azithromycin or doxycycline combined with rifampin, clarithromycin, or a fluoroquinolone may be useful regimens.42
Some practitioners have found drugs such as ciprofloxacin (Cipro), levofloxacin (Levaquin), gemifloxacin (Factive), and moxifloxacin (Avelox) to be helpful in those with Bartonella, though these drugs may lead to long-term tendon damage and ruptures, retinal detachment, and a host of other symptoms that may persist long after these medications have been stopped. They may result in what is known as fluoroquinolone toxicity syndrome, or what some term as having been "floxed." Mozayeni has suggested that the risks of these medications may outweigh the benefits, and he rarely uses quinolone antibiotics for the treatment of Bartonella.
Mozayeni generally uses clarithromycin or azithromycin, though there is a higher resistance to azithromycin in animals. He later adds rifampin with clarithromycin. If a patient is on other medications whose metabolism may be impacted by rifampin, he may then use Mycobutin. He has not found a need to treat any of his Bartonella patients with IV therapies except in rare cases where patients cannot take pills. He has noted that antibiotics used for the treatment of Borrelia burgdorferi, the causative agent in Lyme disease, may push Bartonella organisms further into the cells making treatment more challenging.
Both adrenal health and thyroid health should be considered before treating with these antibiotics, especially rifampin, in order to allow the patient to better tolerate the treatment. Mozayeni has found that one pitfall in Bartonella treatment is related to adrenal fatigue. Adrenal issues must be identified and managed to optimize therapy tolerance. Rifampin, a cytochrome P450 inducer, causes a more rapid metabolism of sterol hormones and can lead to severe symptoms where a Herxheimer-like reaction is juxtaposed with a condition of depleted adrenals and low cortisol. This can put the patient into adrenal crisis with greatly amplified symptoms including severe pain and hemodynamic instability. This reaction may be mistaken for a Rifampin allergy and therapy stopped. Thus, withdrawal of a useful drug may result in a lost opportunity to treat and lead to treatment failure.
The pharmaceutical protocol that Mozayeni utilizes in his practice has been shown to work well for many of his patients. If someone is extremely ill and may not be strong enough to tolerate treatment with antibiotics, he may start with herbal antimicrobial and supportive interventions. It will take time and additional data to determine whether or not the herbal approaches prove to perform as well, but they are useful considerations. After an antibiotic regimen is complete, Mozayeni may then move a patient to more natural Bartonella treatment options. These may be more sustainable and can be used for longer-term maintenance therapy if needed.
Once someone is infected with Bartonella, it is possible that they will never fully clear the infection; it may become a matter of how the infection manifests within the body. Response to treatment of any regimen may vary based on the immune status of the host, the response of the immune system, and the infecting Bartonella species.
Alternative Treatment Approaches
While pharmaceutical options for Bartonella treatment are often very helpful, those with chronic Bartonella infection may benefit from looking at natural solutions. These may be combined with pharmaceutical options or used alone.
Mozayeni has an interest in allicin, an extract from garlic, and sulforaphane, a compound derived from cruciferous vegetables. Sulforaphane has broad spectrum antimicrobial properties against both gram-negative and gram-positive bacteria while also being anti-inflammatory, supporting detoxification, and serving as a powerful antioxidant.
Stephen Harrod Buhner is a one of America's preeminent herbalists and wrote Healing Lyme Disease Coinfections: Complementary and Holistic Treatments for Bartonella and Mycoplasma in 2013.43 It contains some of the most current information on herbal and holistic treatment of Bartonella. In the book, Buhner goes into extensive detail on Bartonella characteristics, symptom presentation, cytokine shifts that may occur, and natural treatment options based on his own clinical experience and literature reviews.
Buhner has created a protocol that is outlined in his book and consists of therapeutic options such as Sida acuta, Isatis, Houttuynia, Alchornea cordifolia, Japanese knotweed, EGCG, hawthorn, cordyceps, L-arginine, milk thistle, and others. He further outlines interventions that may be helpful based on specific symptom presentations. The book is a very detailed resource on Bartonella and is highly recommended for anyone who wants to learn more.
Many other natural products or formulations are available that some practitioners have found helpful. These include Beyond Balance MC-BAR-1 and MC-BAR-2; BioPure Quintessence, O3 Oil Gamma, Lyme and Co-Infection Nosode Drops, Cryptolepis, and Czaga (chaga); Byron White Formulas A-BART; Maypa Herbals Formula Bart; Jernigan Nutraceuticals Lymogen, NutraMedix Samento, Banderol, Quina, Cumanda, and Houttuynia; Researched Nutritionals BLt Microbial Balancer #1, CryptoPlus Microbial Balancer #2, and LymPlus Transfer Factor; Deseret Biologicals Bartonella Series Therapy; Woodland Essence C.S.A. Formula; Mountain States Health Products Bartonella Nosode; Professional Formulas Tick Pathogen Nosode Drops; Dr. Zhang's HH and HH-2; freeze-dried garlic, and others. Injectable artesunate administered by a doctor has been found to be of clinical benefit. Some practitioners have found essential oils of clove, thyme, marjoram, melaleuca, cypress, rosemary, and cinnamon to be helpful.
Recently, at the American Academy of Environmental Medicine workshop, low-dose antigen (LDA) therapy for Lyme disease was introduced by Ty R. Vincent, MD, and has reportedly been helpful for those dealing with Bartonella and other Lyme-related issues.
Synergistic Treatment Options
While the underlying microbial burden itself must be addressed, there are a number of synergistic interventions that may improve patient outcomes. Mozayeni has noted that the most proximal cause of symptoms of Bartonella is the small vessel disease, and addressing this aspect of the condition is an important part of the treatment program. Two primary areas of focus include evaluating and treating coagulopathies and reducing inflammation.
Small vessel disease results in a form of brain injury, though the injury does not have to be permanent. Treatment must be approached in a manner very similar to how a brain injury would be treated. The nerves may be stunned or hibernating as a result of trauma; these may be resuscitated with glutathione, hyperbaric oxygen, or other interventions.
Bartonella often causes low grade inflammation in the body. This can manifest in more significant ways, such as inflammatory arthritis or a neurovascular problem, in people with specific MHC (major histocompatibility complex) or HLA (human leukocyte antigen) genetic predispositions. The infection may result in chronic, low-grade, smoldering symptoms even in those that considered themselves to be asymptomatic. How the disease manifests is determined by the biological terrain and how the host immune system responds to the infection and less by the infection itself.
For hypercoagulation, agents that dissolve clots or help to reduce clot formation may be helpful. The more the blood pH is acidic, the more coagulation is likely to be a concern. Substances that alkalinize the body help to reduce microscopic clot formation. High dose vitamin C, apple cider vinegar, and an alkaline diet are useful tools. Incorporating fresh vegetables into the diet both helps alkalinize the system and introduces enzymes that help to break down clots and biofilms (a polysaccharide layer produced by a community of organisms that serves to protect them from antimicrobial therapies).
Boluoke, lumbrokinase, or serrapeptase are commonly considered, as are Wobenzym and Researched Nutritionals InflaQuell. When patients are not improving with or tolerating treatment, Mozayeni's first question is often whether they are keeping up with their enzyme intake; he finds that 80% to 90% of the time they are not. During a Herxheimer reaction, enzymes and alkalinization can often provide relief. If neurological symptoms are severe, low-dose Lovenox or heparin may be considered and often leads to dramatic improvement.
Reducing inflammation using natural options such as curcumin, quercetin, and astaxanthin may be very helpful.
Treatment may include a focus on the health of the lining of the endothelium where Bartonella congregate.
Nitric oxide is produced in the endothelium and may be impaired when the endothelium is unhealthy. Thus, therapies such as Xymogen AngiNOX, Thorne Perfusia Plus, or L-arginine, which increase nitric oxide production, may support blood vessel health. Increasing nitric oxide production may counteract some of the detrimental effects of Bartonella.44 Low-dose baby aspirin may reduce the stickiness of the platelets.
In Chinese medicine, the herb Dan Shen (Salvia miltiorrhiza) is a "blood-invigorating" herb that is thought to make the blood flow more freely and has angiotensin-blocking properties. Vinpocetine is derived from the periwinkle plant and leads to dilation of blood vessels and improved blood flow. Hawthorn berry, in a form called Cratoxy, may support cardiovascular health and dilate the blood vessels. As a blood vessel dilator and platelet inhibitor, Ginkgo biloba may be beneficial.
Prevention and Management of Pet Exposure
In Bartonella patients with pets in the home, consideration should be given to the potential for reexposure from the pet or from fleas or ticks that these animals may bring into the home. Cats represent a higher risk for human exposure, though dogs may present with more symptoms when infected. Anyone infected with Bartonella and living with household animals should consider having their animals evaluated and treated for the infection in order to minimize the potential for reinfection. Veterinarians are generally well versed in testing and treatment of animals with Bartonella. Most importantly, keeping fleas and other vectors from infesting pets will reduce and potentially eliminate the possibility of transmission from a pet to a family member.45
Conclusion
While more and more is being learned about Bartonella and its impact on human health, there are still many unknowns that require further exploration. We are learning and will continue to learn. Very few medical doctors are familiar with Bartonella and people suffer needlessly, as bartonellosis is rarely on the list of differential diagnoses for the conditions that it may cause. Most infectious-disease doctors have very limited or no experience with identifying or treating Bartonella and believe that it is generally a benign condition that resolves without treatment.
Thanks to our animal friends and those who care for them, there is an ever-increasing focus on Bartonella and human health implications. The work of Drs. Ed Breitschwerdt and Robert Mozayeni has enlightened many about this previously underestimated microbe and continues to lead to improved testing and treatment options for both animals and humans. While getting people to recognize Bartonella has been a struggle, the tide is shifting.
Available tests have notably improved over the past several years, and treatment options are available that generally lead patients to higher ground. While there is more work to be done, the mysteries of Bartonella are beginning to unravel. Here's to your health!
In Memoriam
Linda "Angel" Heming worked closely with me for many years on a number of the articles that I have written. She was a warrior in the Lyme community and gave so much of herself to help other people. Given the time commitment required for each article, I was unable to do as many as I once did. A year ago, Linda asked me whom she could get who would interest me enough to do another article. At that time, I responded that an article on Bartonella with Drs. Ed Breitschwerdt and Robert Mozayeni would be compelling. Linda unfortunately became ill with another battle with cancer and passed away in October 2014. It was a great loss to the Lyme community. About a week after she passed, I was connected with a colleague of Drs. Breitschwerdt and Mozayeni, and an opportunity to do this article presented itself. Of course, I couldn't say no, as it was clear to me that Linda was still running the show. You will be missed and truly are an angel!
Upcoming Conference
On July 24, 2015, from 1 to 4 p.m. at the Hyatt Regency in Cambridge, Maryland, there will be a conference on diagnosing and treating Bartonella. Speakers will include Drs. Edward Breitschwerdt and Robert Mozayeni. Conference is open to medical, counseling, and veterinary professionals. Marilyn Williams from the Lyme Disease Association of the Eastern Shore of Maryland is organizing this exciting event. For registration, information contact the LDAESM at easternshoremdlyme@yahoo.com.
Disclaimer
Information is not intended to treat, diagnose, cure, or prevent any disease. Nothing in this text is intended to serve as personal medical advice. All medical decisions should be made only with the guidance of your own medical authority.
Portions of the information presented in this article come from various conferences as well as an interview with Dr. Robert Mozayeni for the purposes of this article.
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