What is the recommended treatment duration for Lyme disease, specifically until the erythema migrans (EM) rash resolves?

From the Guidelines

Lyme disease treatment should continue for the full prescribed course, typically 10-21 days, even if the characteristic bull's-eye rash (erythema migrans) disappears earlier. For adults, doxycycline 100mg twice daily for 10-14 days is the standard treatment, while children under 8 may receive amoxicillin 50mg/kg/day divided into three doses for 14-21 days 1. Alternative medications include cefuroxime axetil or azithromycin if the primary options cannot be used. Stopping antibiotics when the rash resolves risks incomplete eradication of Borrelia burgdorferi bacteria, potentially leading to more serious complications like arthritis, neurological problems, or cardiac issues. The rash often fades before the infection is fully cleared because the visible inflammation subsides while bacteria may still be present in the body.

Some key points to consider in the treatment of Lyme disease include:

• The recommended duration of treatment is 14 days (range, 10–21 days for doxycycline and 14–21 days for amoxicillin or cefuroxime axetil) 1
• Doxycycline has the advantage of being effective for treatment of HGA (but not for babesiosis), which may occur simultaneously with early Lyme disease 1
• Doxycycline is relatively contraindicated during pregnancy or lactation and in children <8 years of age 1
• Antibiotics recommended for children are amoxicillin (50 mg/kg per day in 3 divided doses [maximum of 500 mg per dose]), cefuroxime axetil (30 mg/kg per day in 2 divided doses [maximum of 500 mg per dose]), or, if the patient is intolerant of b-lactam antibiotics, increasing evidence indicates that doxycycline (200–400 mg per day in 2 divided doses orally for 10–28 days) may be adequate 1

Complete the entire antibiotic course as prescribed by your healthcare provider to ensure the infection is thoroughly eliminated, even if symptoms improve or disappear early in treatment. It is essential to follow the recommended treatment guidelines to minimize the risk of complications and ensure the best possible outcome for patients with Lyme disease 1.

From the FDA Drug Label

By these procedures, it was possible to confirm the physician diagnosis of early Lyme disease in 281 (79%) of the 355 study patients. The efficacy data summarized below are specific to this “validated” patient subset, while the safety data summarized below reflect the entire patient population for the 2 studies Analysis of the submitted clinical data for evaluable patients in the “validated” patient subset yielded the following results: Table 7: Clinical Effectiveness of Cefuroxime Axetil Tablets Compared to Doxycycline in the Treatment of Early Lyme Disease Part I (1 Month Posttreatment)* Part II (1 Year Posttreatment)† Cefuroxime Axetil Doxycycline Cefuroxime Axetil Doxycycline (n = 125) (n = 108) (n = 105‡) (n = 83‡) Satisfactory clinical outcome§ 91% 93% 84% 87% Clinical cure/success 72% 73% 73% 73% Clinical improvement 19% 19% 10% 13%

The treatment duration for early Lyme disease with cefuroxime axetil is 20 days.

• The primary goal of treating Lyme disease is to eliminate the infection.
• Clinical improvement is observed in patients treated with cefuroxime axetil. However, the FDA drug label does not explicitly state that treatment should continue until the rash goes away. Key points to consider:
• Cefuroxime axetil is effective in treating early Lyme disease.
• Treatment duration is 20 days, regardless of the rash's presence.
• Clinical outcomes are favorable with cefuroxime axetil treatment 2.

From the Research

Treatment of Lyme Disease

• The treatment of Lyme disease typically involves the use of antibiotics, with oral amoxicillin and doxycycline being first-line treatment options 3.
• Alternative second-line options include phenoxymethylpenicillin, cefuroxime axetil, and azithromycin 3.
• The efficacy of oral doxycycline, amoxicillin, and cefuroxime axetil for treating Lyme disease has been established in multiple trials 4.

Duration of Treatment

• The duration of treatment for Lyme disease can vary, but a 10-day course of oral doxycycline is often effective for treating erythema migrans 4.
• A 14-day course of oral doxycycline may be recommended for early neurologic Lyme disease in ambulatory patients 4.
• The treatment should be continued until the rash has resolved, and the patient's symptoms have improved 5, 6, 7.

Resolution of Erythema Migrans

• Studies have shown that cefuroxime axetil and doxycycline are effective in resolving erythema migrans, with a satisfactory clinical outcome achieved in 93% and 88% of patients, respectively 7.
• Another study found that at the completion of treatment, there was total resolution of erythema migrans in 67% of the amoxicillin group, 92% of the low-dose cefuroxime group, and 87% of the high-dose cefuroxime group 5.

Safety and Tolerability

• Cefuroxime axetil and doxycycline have been shown to be well-tolerated, with some patients experiencing drug-related adverse events such as diarrhea, photo-sensitivity reactions, and Jarisch-Herxheimer reactions 7.
• Mild diarrhea occurred in a small number of participants in each group, with one patient being diagnosed and treated for Clostridium difficile-associated diarrhea 5.