What treatment is recommended for Lyme disease?

Treatment for Lyme Disease

The recommended first-line treatment for Lyme disease is oral doxycycline (100 mg twice daily for 10-14 days) for adults and children ≥8 years old, or amoxicillin (500 mg three times daily for 14 days) for children <8 years, pregnant women, and those with contraindications to doxycycline. 1, 2

Treatment by Disease Stage

Early Localized or Early Disseminated Lyme Disease (with erythema migrans)

• First-line oral regimens (14 days):

  • Doxycycline: 100 mg twice daily (10-14 days sufficient)
  • Amoxicillin: 500 mg three times daily
  • Cefuroxime axetil: 500 mg twice daily 1

• Pediatric dosing:

  • Doxycycline: 4 mg/kg/day in 2 divided doses (maximum 100 mg per dose) for children ≥8 years
  • Amoxicillin: 50 mg/kg/day in 3 divided doses (maximum 500 mg per dose)
  • Cefuroxime axetil: 30 mg/kg/day in 2 divided doses (maximum 500 mg per dose) 1

Important note: Doxycycline has the advantage of also treating potential co-infection with Human Granulocytic Anaplasmosis (HGA) 2

Neurologic Lyme Disease

• Facial nerve palsy without meningitis:

  • Oral regimens as above for 14 days 1, 3

• Meningitis or radiculopathy:

  • Parenteral therapy (14 days, range 10-28 days):
    • Ceftriaxone: 2 g IV once daily (adults), 50-75 mg/kg IV once daily (children, max 2 g)
    • Alternative: Cefotaxime or Penicillin G 1

Lyme Carditis

• Outpatients: Oral antibiotics (same as early disease) for 14-21 days
• Hospitalized patients: Initial IV ceftriaxone until clinical improvement, then switch to oral antibiotics to complete 14-21 days of total therapy 1
• Symptomatic bradycardia: Use temporary pacing modalities rather than permanent pacemakers 1

Lyme Arthritis

• Initial treatment: Oral antibiotic therapy for 28 days (same agents as early disease) 1
• Persistent arthritis after initial treatment:
  • With minimal response: 2-4 week course of IV ceftriaxone
  • With partial response: Consider second course of oral antibiotics 1

Special Populations

• Pregnant/lactating women: Amoxicillin is preferred (doxycycline contraindicated) 1, 2
• Children <8 years: Traditionally amoxicillin was preferred, but recent evidence suggests short courses of doxycycline may be safe and effective 4, 5

Treatment Failures and Common Pitfalls

• Do not use first-generation cephalosporins (e.g., cephalexin) as they are ineffective 1, 2
• Avoid macrolides as first-line therapy due to lower efficacy 1
• Avoid prolonged antibiotic courses for persistent non-specific symptoms (fatigue, pain, cognitive impairment) without objective evidence of active infection 1
• Do not use unproven treatments such as combination antibiotics, pulsed dosing, hyperbaric oxygen, or nutritional supplements 1

Monitoring and Follow-up

• Most patients with early Lyme disease respond well to appropriate antibiotic therapy
• For patients with persistent symptoms after treatment, look for objective evidence of treatment failure (e.g., arthritis, meningitis, neuropathy) before considering additional antibiotics 1
• Consider rheumatology referral for persistent arthritis after appropriate antibiotic courses 1

Key point: Oral doxycycline is as effective as IV ceftriaxone for most manifestations of Lyme disease except for parenchymal involvement of the brain or spinal cord 1, 6