What are the effective therapies for Lyme disease (Lyme borreliosis)?

From the Guidelines

The most effective therapy for Lyme disease is antibiotic treatment, with the specific regimen depending on the stage and severity of infection, and doxycycline (100mg twice daily for 10-14 days) is the first-line treatment for adults, as recommended by the Infectious Diseases Society of America (IDSA) in their 2020 guidelines 1. For early localized Lyme disease, the treatment options include:

• Doxycycline (100mg twice daily for 10-14 days) for adults
• Amoxicillin (500mg three times daily for 14-21 days) or cefuroxime axetil (500mg twice daily for 14-21 days) for children under 8 years old and pregnant women who should avoid doxycycline, as stated in the clinical practice guidelines by the IDSA 1 For early disseminated or late Lyme disease, treatment duration typically extends to 14-28 days. In cases of Lyme carditis or neurological involvement, intravenous antibiotics like ceftriaxone (2g daily for 14-28 days) may be necessary, as recommended in the 2020 guidelines by the IDSA, American Academy of Neurology (AAN), and American College of Rheumatology (ACR) 1. Treatment should begin as soon as Lyme disease is diagnosed or strongly suspected, even before laboratory confirmation in cases with the characteristic erythema migrans rash. Early treatment is crucial to prevent progression to later stages of disease, which can involve the joints, nervous system, and heart. Most patients recover completely with appropriate antibiotic therapy, though some may experience persistent symptoms that require additional supportive care. Patients should complete the full course of antibiotics even if symptoms resolve early to ensure complete eradication of the Borrelia burgdorferi bacteria. The choice of antibiotic regimen should be based on individual factors such as side effect profile, ease of administration, and ability to tolerate oral medication, as stated in the 2020 guidelines by the IDSA, AAN, and ACR 1. It is essential to note that macrolide antibiotics are not recommended as first-line therapy for early Lyme disease due to their lower efficacy compared to other antimicrobials, as stated in the clinical practice guidelines by the IDSA 1. In addition, first-generation cephalosporins, such as cephalexin, are ineffective for the treatment of Lyme disease and should not be used, as stated in the clinical practice guidelines by the IDSA 1. The preferred antibiotic duration for acute neurologic manifestations of Lyme disease without parenchymal involvement of the brain or spinal cord is 14-21 days, as recommended in the 2020 guidelines by the IDSA, AAN, and ACR 1. Overall, the treatment of Lyme disease should be guided by the most recent and highest-quality evidence, and patients should be closely monitored for response to treatment and potential side effects, as stated in the clinical practice guidelines by the IDSA 1 and the 2020 guidelines by the IDSA, AAN, and ACR 1.

From the FDA Drug Label

Doxycycline is indicated for the treatment of the following infections: ... Relapsing fever due to Borrelia recurrentis. The answer to effective therapies for Lyme disease is not directly stated in the label, as Lyme disease is not explicitly mentioned. However, Borrelia recurrentis is a type of Borrelia, and doxycycline is indicated for the treatment of relapsing fever due to Borrelia recurrentis.

• Key points:
  • Doxycycline is used to treat various bacterial infections.
  • The label mentions Borrelia recurrentis, but not Borrelia burgdorferi, which is the causative agent of Lyme disease.
  • No direct conclusion can be drawn about the effectiveness of doxycycline for Lyme disease based on this label 2.

From the Research

Effective Therapies for Lyme Disease

• The efficacy and safety of antibiotics for treating Lyme disease is still controversial 3.
• Oral amoxicillin (1.5 g/day), oral azithromycin (0.5 g/day), injectable ceftriaxone, and injectable cefotaxime were found to be effective for treating Lyme disease 3.
• Cefuroxime and penicillin were found to be safe for treating Lyme disease 3.
• Amoxicillin was effective for treating erythema migrans (range of ORs, 1.18 to 25.66) 3.

Antibiotic Treatment Options

• Doxycycline or amoxicillin can be used as treatment for Lyme disease, with cefuroxime axetil or erythromycin as alternative options 4.
• Late or severe disease requires intravenous ceftriaxone or penicillin G 4.
• Penicillin, ceftriaxone, cefotaxime, and doxycycline are effective in treating nervous system Lyme disease 5, 6.
• Oral doxycycline is equally effective as intravenous ceftriaxone in the treatment of Lyme neuroborreliosis 7.

Treatment Duration and Outcome

• The majority of people with Lyme disease have good outcomes, and symptoms resolve by 12 months regardless of the antibiotic used 5.
• A minority of participants did not improve sufficiently, and some were retreated 5.
• There is no compelling evidence that prolonged treatment with antibiotics has any beneficial effect in post-Lyme syndrome 6.