What is the treatment for Lyme disease?

Treatment of Lyme Disease

The recommended treatment for Lyme disease is oral doxycycline 100 mg twice daily for 10-14 days for most manifestations, with specific alternative regimens for patients who cannot take doxycycline or who have certain clinical presentations. 1, 2

Treatment Based on Disease Stage and Manifestation

Early Localized Lyme Disease (Erythema Migrans)

• First-line treatment: Doxycycline 100 mg twice daily for 10-14 days 1, 2
• Alternatives (for those who cannot take doxycycline):
  • Amoxicillin 500 mg three times daily for 14 days 1, 2
  • Cefuroxime axetil 500 mg twice daily for 14 days 1, 3
  • Azithromycin (less effective, use only if other options contraindicated) 2

Early Disseminated Lyme Disease

Neurologic Manifestations

• Meningitis or radiculopathy: Intravenous ceftriaxone 2 g daily for 14 days (range 10-28 days) 1
• Facial nerve palsy without CSF abnormalities: Oral regimen as for erythema migrans for 14 days 1
• Facial nerve palsy with CSF abnormalities: Treat as meningitis 1

Cardiac Manifestations

• Outpatients with mild carditis: Oral antibiotics (doxycycline, amoxicillin, cefuroxime axetil) for 14-21 days 1
• Hospitalized patients with severe carditis (PR interval >300 ms, arrhythmias, myopericarditis):
  • Initial IV ceftriaxone until clinical improvement, then switch to oral antibiotics 1
  • Consider temporary pacing for symptomatic bradycardia 1
  • Total treatment duration: 14-21 days 1

Late Lyme Disease

Lyme Arthritis

• Initial treatment: Oral antibiotics (doxycycline, amoxicillin, or cefuroxime axetil) for 28 days 1
• For persistent arthritis: Consider a second course of oral antibiotics or IV ceftriaxone for 14-28 days 1
• For antibiotic-refractory arthritis: Symptomatic therapy (NSAIDs, intra-articular steroids) or arthroscopic synovectomy 1

Late Neurologic Disease

• CNS or peripheral nervous system involvement: IV ceftriaxone for 14-28 days 1

Acrodermatitis Chronica Atrophicans

• Oral antibiotics (doxycycline, amoxicillin, or cefuroxime axetil) for 21 days (range 14-28 days) 1

Special Populations

Pregnant Women

• Amoxicillin is preferred over doxycycline (which is contraindicated) 1, 2
• Same duration of therapy as non-pregnant patients 1

Children

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

Coinfections

When Lyme disease coexists with other tick-borne infections, treatment should address all pathogens:

Anaplasmosis Coinfection

• Doxycycline 100 mg twice daily for 10 days (covers both Lyme and anaplasmosis) 1, 2
• For patients who cannot take doxycycline: Rifampin 300 mg twice daily for 7-10 days (for anaplasmosis) PLUS amoxicillin or cefuroxime axetil (for Lyme disease) 1

Babesiosis Coinfection

• Combination therapy with atovaquone plus azithromycin OR clindamycin plus quinine for 7-10 days 1
• For severe babesiosis: Clindamycin IV plus quinine, and consider exchange transfusion 1

Important Clinical Considerations

1. Response to therapy: Fever typically resolves within 48 hours; persistent high-grade fever suggests coinfection or alternative diagnosis 2

2. Treatment failure is rare with appropriate therapy (>90% success rate) 2

3. Jarisch-Herxheimer reactions (transient symptom intensification) may occur in the first 24 hours of treatment but should not be mistaken for treatment failure 2

4. Post-treatment Lyme disease syndrome: For patients with persistent symptoms after standard treatment but without objective evidence of active infection, additional antibiotic therapy is not recommended 1

5. Unproven treatments to avoid: First-generation cephalosporins, fluoroquinolones, combination antibiotics, prolonged antibiotic courses, hyperbaric oxygen, and nutritional supplements 1, 2

Prevention After Tick Bite

• Single dose of doxycycline 200 mg for adults (4.4 mg/kg for children ≥8 years) within 72 hours of tick removal when all criteria are met: identified Ixodes tick attached ≥36 hours, local infection rate ≥20%, and no contraindications to doxycycline 2

The treatment approach should be guided by the clinical manifestation, with most cases of early Lyme disease responding well to standard oral antibiotic regimens. More severe or late manifestations may require parenteral therapy, but extended courses beyond recommendations do not improve outcomes and may increase adverse effects.