Lyme disease is the most common tick-borne infection in the US, caused by Borreliaburgdorferi. Clinical manifestations of this disease most often involve the skin, joints, nervous system, and the heart.

The CDC reports that the majority of people can overcome Lyme disease after receiving a course of antibiotics for several weeks. The most common antibiotic treatment for Lyme infection is a combination of amoxicillin, cefuroxime axel or doxycycline antibiotic is taken for 2–4 weeks.

Symptoms of Lyme disease

• Flu-like illness (fever, chills, sweats, muscle aches, fatigue, nausea and joint pain).
• Some patients have a rash or Bell’s palsy (facial drooping).

Guidelines to treat Lyme disease

STAGE: PROPHYLAXIS

DIAGNOSIS: Confirmed tick bite

DRUG OF CHOICE:

• For Children 8 years old: Doxycycline 4 mg/kg PO x 1 dose (max 200 mg)
• For Adults: Doxycycline 200 mg PO x 1 dose

ALTERNATE THERAPY: None recommended.

COMMENTS: Prophylaxis is recommended only if the patient meets the following criteria:

• Tick identified as an adult or nymphal I. scapularis, estimated to have been attached for 36 hours.
• Prophylaxis must be started within 72 hours of tick removal.
• Local rate of infection of ticks with B. burgdorferi is 20%.
• Doxycycline must not be contraindicated.

STAGE: EARLY LOCALIZED, EARLY DISSEMINATED

1.DIAGNOSIS:

Erythema migrans, with no neurologic or cardiac manifestations

DRUG OF CHOICE:

For Adults:

• Amoxicillin 500 mg PO tid x 14 days
• Doxycycline 100 mg PO bid x 14 days
• Cefuroxime axetil 500 mg PO bid x 14 days

ALTERNATE THERAPY:

• Azithromycin 500mg PO daily x 7–10 days
• Erythromycin 500 mg PO qid x 14–21 days
• Clarithromycin 500 mg PO bid x 14–21 days(if patient is not pregnant)

COMMENTS: Macrolides are not recommended as first-line therapy. They have been less effective than other antimicrobials in clinical trials.

For Children:

• Cefuroxime axetil 30 mg/kg/day PO divided bid x 14 days (max 500 mg/dose)
• Amoxicillin 50 mg/kg/day PO divided tid x 14 days (max 500 mg/dose)
• If 8 years old: Doxycycline 4 mg/kg/day PO divided bid x 14 days (max 100 mg/dose)

ALTERNATE THERAPY

• Azithromycin 10 mg/kg/day PO daily x 7-10 days (max 500 mg/day)
• Clarithromycin 7.5 mg/kg/dose PO bid x 14-21 days (max 500 mg/dose)
• Erythromycin 12.5 mg/kg/dose POqid x 14-21 days (max 500 mg/dose)

COMMENTS:

• Reserve macrolides for patients unable to take first line therapies.
• Observe patients treated with macrolides to ensure resolution of clinical manifestations.

2.DIAGNOSIS:

Lyme meningitis or radiculopathy

DRUG OF CHOICE:

For Children: Ceftriaxone 50–75 mg/kg/dose IV daily x 14 days (max 2 g/dose)

ALTERNATE THERAPY:

• Cefotaxime150–200 mg/kg/day IV divided tid or qid x 14 days (max 6 g/ day)
• Penicillin G 200,000–400,000 units/kg/day IV divided q4h x 14 days (max 18–24 million U/day)
• If 8 years old: Doxycycline 4–8 mg/kg/day po divided bid x 10-28 days (max 100–200 mg/dose)

COMMENTS: None

For Adults: Ceftriaxone 2 g IV daily x 14 days

ALTERNATE THERAPY:

• Penicillin G 18–24 million units/day IV divided q4 h x 14 days
• Cefotaxime 2 g IV q8h x 14 days
• Doxycycline 100–200 mg po/IV bid x 10–28 days – for beta-lactam intolerance

COMMENTS: None.

3.DIAGNOSIS:

Erythema migrans, with no neurologic or cardiac manifestations

DRUG OF CHOICE:

For Adults:

• Doxycycline 100 mg PO bid x 14 days
• Cefuroxime axetil 500 mg po bid x 14 days
• Amoxicillin 500 mg potid x 14 days

ALTERNATE THERAPY:

• Erythromycin 500 mg PO qid x 14–21 days
• Clarithromycin 500 mg PO bid x 14–21 days(if patient is not pregnant)
• Azithromycin 500mg PO daily x 7–10 days

COMMENTS: Macrolides are not recommended as first-line therapy. They have been less effective than other antimicrobials in clinical trials.

STAGE: EARLY LOCALIZED, EARLY DISSEMINATED

1. DIAGNOSIS:

Seventh cranial nerve palsy

DRUG OF CHOICE:

• Patients with normal CSF examinations and those in whom CSF examination is deemed unnecessary because of lack of clinical signs of meningitis:
• Treat them with a 14-day course of the same antibiotics used to treat patients with erythema migrans.

• Patients with both clinical and laboratory evidence of CNS involvement:

Treat with regimens effective against meningitis.

ALTERNATE THERAPY: None recommended.

COMMENTS: None

2. DIAGNOSIS:

Lyme carditis (AV heart block, myopericarditis)

DRUG OF CHOICE:

• Treat with PO antibiotics as for erythema migrans x 14 days
• Hospitalized patients should receive IV antibiotics as for meningitis.

ALTERNATE THERAPY: As for erythema migrans.

COMMENTS: None

3. DIAGNOSIS:

BorrelialLymphocytoma
DRUG OF CHOICE:
Treat with same medications recommended for erythema migrans.

ALTERNATE THERAPY: None recommended.

COMMENTS: None

STAGE: LATE LYME

1. DIAGNOSIS:

Lyme arthritis

DRUG OF CHOICE:

For Adults:

• Doxycycline 100 mg PO bid x 28 days
• Cefuroxime axetil 500 mg PO bid x 28 days
• Amoxicillin 500 mg PO tid x 28 days

For Children:

• Cefuroxime axetil 30 mg/kg/day PO divided bid x 28 days (max 500 mg/dose)
• Amoxicillin 50 mg/kg/day PO divided tid x 28 days (max 500 mg/dose)
• If 8 years old: Doxycycline 4 mg/kg/day PO divided bid x 28 days (max 100 mg/dose)

ALTERNATE THERAPY
: None recommended.

COMMENTS:

• If arthritis has improved but not resolved, a second 4-week course of PO antibiotics may be used.
• If arthritis has worsened or not improved, retreat with 2-4 weeks of IV ceftriaxone.
• Consider waiting several months before retreating due to slow resolution of inflammation after treatment.
• Symptomatic treatment may include NSAIDs, corticosteroids, and DMARDs.

2. DIAGNOSIS:

Late neurologic

DRUG OF CHOICE:

For Adults: Ceftriaxone 2g IV dailyx 14-28 days

ALTERNATE THERAPY:

• Cefotaxime 2 g IV q8hx 14-28 days
• Penicillin G18–24 million units/daydivided q4h x 14-28 days

For Children: Ceftriaxone 50–75 mg/kg/dose IV daily x 14-28 days (max 2 g/dose)

ALTERNATE THERAPY:

• Cefotaxime 150–200 mg/kg/day IV divided tid or qid x 14-28 days (max 6 g/day)
• Penicillin G 200,000–400,000 units/kg/day IV divided q4h x 14-28 days (max 18–24 million U/day)

COMMENTS: Response to treatment is usually slow and may be incomplete. Re-treatment is not recommended unless Relapse is shown by reliable objective measures.

3. DIAGNOSIS:

Acrodermatitischronicaatrophicans
DRUG OF CHOICE:
For Adults:

• Doxycycline 100 mg PO bid x 21 days
• Cefuroxime axetil 500 mg PO bid x 21 days
• Amoxici llin 500 mg PO tid x 21 days

ALTERNATE THERAPY: None recommended.

For Children:

• Amoxicillin 50 mg/kg/day PO divided tid x 21 days (max 500 mg/dose)
• Cefuroxime axetil 30 mg/kg/day PO divided bid x 21 days (max 500 mg/dose)
• If 8 years old:Doxycycline 4 mg/kg/day PO divided bid x 21 days (max 100 mg/dose)

ALTERNATE THERAPY: None recommended.

COMMENTS: NONE