What is the recommended treatment for possible Lyme disease?

From the Guidelines

The recommended treatment for possible Lyme disease is prompt antibiotic therapy, typically with doxycycline 100 mg twice daily for 10-14 days for early localized disease. For patients who cannot take doxycycline (such as pregnant women or children under 8), alternatives include amoxicillin 500 mg three times daily for adults or 50 mg/kg/day divided into three doses for children, or cefuroxime axetil 500 mg twice daily for adults or 30 mg/kg/day divided into two doses for children, all for 14-21 days 1.

Key Considerations

• Treatment should begin as soon as Lyme disease is suspected, even before laboratory confirmation in cases with typical symptoms like erythema migrans (the characteristic bull's-eye rash) 1.
• Early treatment is crucial because it prevents progression to later stages of the disease that can affect the heart, joints, and nervous system.
• For suspected tick bites without symptoms, prophylactic treatment with a single 200 mg dose of doxycycline may be considered if the tick was attached for more than 36 hours and the local rate of tick infection with Borrelia burgdorferi is high.
• Patients should be monitored for symptom resolution and potential side effects of antibiotics during treatment.

Special Populations

• Pregnant or lactating patients may be treated in a fashion identical to nonpregnant patients with the same disease manifestation, except that doxycycline should be avoided 1.
• Children under 8 years old should not be given doxycycline; instead, amoxicillin or cefuroxime axetil can be used 1.

Neurologic Involvement

• For adult patients with early Lyme disease and the acute neurologic manifestations of meningitis or radiculopathy, the use of ceftriaxone (2 g once per day intravenously for 14 days; range, 10–28 days) is recommended 1.
• For children, ceftriaxone or cefotaxime administered parenterally is recommended; intravenous penicillin G is an alternative 1.

From the FDA Drug Label

The Jarisch-Herxheimer reaction is a systemic reaction, that may occur after the initiation of penicillin therapy in patients with syphilis or other spirochetal infections (i.e., Lyme disease and Relapsing fever).

The recommended treatment for possible Lyme disease is penicillin G (IV), as it is effective against spirochetal infections, including Lyme disease. However, it is essential to be aware of the potential Jarisch-Herxheimer reaction, which may occur after initiation of therapy.

• Key considerations include:
  • Monitoring for signs of the Jarisch-Herxheimer reaction, such as fever, chills, and myalgias
  • Being aware of the potential for hypersensitivity reactions, including immediate and delayed reactions
  • Closely monitoring patients for signs of adverse reactions, such as neutropenia, Coombs-positive hemolytic anemia, and bleeding diathesis 2

From the Research

Treatment Options for Lyme Disease

The recommended treatment for Lyme disease varies depending on the stage and severity of the disease.

• For early localized infection, oral doxycycline or amoxicillin are commonly used 3.
• For early disseminated infection, intravenous ceftriaxone or penicillin G may be necessary 3.
• For late disseminated infection, treatment may involve a combination of antibiotics, including doxycycline, amoxicillin, or ceftriaxone 3.

Antibiotic Efficacy

Studies have compared the efficacy of different antibiotics in treating Lyme disease:

• A network meta-analysis found that oral amoxicillin, oral azithromycin, injectable ceftriaxone, and injectable cefotaxime were effective for treating Lyme disease 4.
• A randomized controlled trial found that oral doxycycline was equally effective as intravenous ceftriaxone in treating Lyme neuroborreliosis 5.
• A systematic review found that doxycycline, penicillin G, ceftriaxone, and cefotaxime were efficacious in treating European Lyme neuroborreliosis, but the quality of evidence was mostly low to very low 6.

Treatment Duration

The duration of treatment for Lyme disease also varies:

• For early localized infection, treatment typically lasts for 2-4 weeks 3.
• For early disseminated infection, treatment may last for 4-6 weeks 3.
• For late disseminated infection, treatment may last for several months 3.
• A practice parameter review found that there is no compelling evidence that prolonged treatment with antibiotics has any beneficial effect in post-Lyme syndrome 7.