What is the recommended treatment for Lyme disease?

Lyme Disease Treatment

The recommended first-line treatment for early Lyme disease in adults and children ≥8 years is oral doxycycline (100 mg twice daily for 10-14 days), while amoxicillin (500 mg three times daily for 14-21 days) is recommended for children <8 years, pregnant women, and those with contraindications to doxycycline. 1

Treatment by Disease Stage

Early Lyme Disease (Erythema Migrans)

• Adults and children ≥8 years:

  • Doxycycline 100 mg twice daily for 10-14 days 2, 1
  • Alternative: Amoxicillin 500 mg three times daily for 14-21 days 2, 1
  • Alternative: Cefuroxime axetil 500 mg twice daily for 14-21 days 2

• Children <8 years:

  • Amoxicillin 50 mg/kg/day in 3 divided doses (maximum 500 mg per dose) for 14-21 days 1
  • Alternative: Cefuroxime axetil 30 mg/kg/day in 2 divided doses (maximum 500 mg per dose) for 14-21 days 1

Neurologic Lyme Disease

• Meningitis or radiculopathy:

  • Intravenous ceftriaxone 2g daily (adults) or 50-75 mg/kg/day (children) for 14 days (range 10-28 days) 2, 1

• Isolated facial nerve palsy:

  • Can be treated with oral regimens as for early Lyme disease 2

Lyme Arthritis

• Oral antibiotics for 28 days 2, 1
• For persistent arthritis after oral therapy, consider a 2-4 week course of IV ceftriaxone 1

Lyme Carditis

• Oral or parenteral antibiotics for 14-21 days depending on severity 2

Important Clinical Considerations

Antibiotic Selection

Doxycycline is preferred for several reasons:

• Effective against co-infections like Anaplasmosis 1
• More effective than macrolides 2
• Recent evidence suggests short courses may be safe even in children <8 years 3

Treatment Failures and Monitoring

• Fever should subside within 24-48 hours of starting appropriate treatment 1
• If symptoms persist beyond 48 hours, consider alternative diagnoses or co-infections 1
• For persistent symptoms after treatment, evaluate for objective evidence of active infection before considering additional antibiotics 1

Common Pitfalls to Avoid

1. Ineffective treatments that should NOT be used 2, 1:

   • First-generation cephalosporins
   • Fluoroquinolones
   • Combination antibiotics
   • Pulsed-dosing (intermittent dosing)
   • Long-term antibiotic therapy
   • Hyperbaric oxygen
   • Nutritional supplements

2. Macrolides (azithromycin, clarithromycin, erythromycin) should be avoided as first-line therapy due to lower efficacy 2. If used due to other antibiotic intolerances, patients should be closely monitored.

3. Post-Lyme disease syndrome: For patients with persistent nonspecific symptoms following standard treatment who lack objective evidence of reinfection or treatment failure, additional antibiotic therapy is not recommended 1.

4. Side effects to monitor:

   • Doxycycline: photosensitivity, esophageal irritation, gastrointestinal intolerance 1
   • Amoxicillin: drug-induced rashes and diarrhea 1, 4

Special Populations

• Pregnant women: Amoxicillin is preferred over doxycycline due to potential risks to fetal teeth and bone development 1
• Children <8 years: Traditionally treated with amoxicillin due to concerns about tooth staining with doxycycline, though recent evidence suggests short courses of doxycycline may be safe 3
• Patients with neurologic manifestations: A retrospective study showed equal effectiveness of ceftriaxone and doxycycline in children with Lyme neuroborreliosis 5

The evidence strongly supports using doxycycline or amoxicillin as first-line therapy for early Lyme disease, with specific regimens based on disease manifestation, patient age, and pregnancy status.