What is the treatment course for Lyme disease?

Treatment Course for Lyme Disease

The recommended treatment for Lyme disease consists of specific antibiotic regimens based on disease manifestation, with oral antibiotics for early disease and most manifestations, and intravenous antibiotics reserved for severe neurological involvement, severe carditis, and refractory arthritis. 1, 2

Early Localized and Early Disseminated Lyme Disease

First-line treatments:

• Doxycycline: 100 mg twice daily for 10-14 days (preferred agent) 2
• Amoxicillin: 500 mg three times daily for 14 days 2, 3
• Cefuroxime axetil: 500 mg twice daily for 14 days 2

Special populations:

• Pregnant patients: Avoid doxycycline; use amoxicillin or cefuroxime 2
• Children:
  • Doxycycline (if ≥8 years): 4-8 mg/kg/day in 2 divided doses (max 100 mg/dose)
  • Amoxicillin: 50 mg/kg/day in 3 divided doses (max 500 mg/dose)
  • Cefuroxime: 30 mg/kg/day in 2 divided doses (max 500 mg/dose) 2

Neurologic Manifestations

Facial nerve palsy without CSF abnormalities:

• Oral antibiotics as for early disease for 14 days 2

Meningitis, radiculopathy, or other CNS involvement:

• Intravenous ceftriaxone: 2 g daily for 14-21 days 1, 2
• Alternative IV options: Cefotaxime or penicillin G 2
• Alternative for patients who can tolerate oral medication: Doxycycline 200-400 mg daily in divided doses 2

Cardiac Manifestations

Mild carditis (outpatients):

• Oral antibiotics for 14-21 days 1, 2

Severe carditis (hospitalized patients):

• Initial IV ceftriaxone until clinical improvement
• Then transition to oral antibiotics to complete 14-21 days total 2
• Temporary pacing may be required for symptomatic bradycardia 1, 2

Lyme Arthritis

Initial treatment:

• Oral antibiotics for 28 days 1, 2

For persistent arthritis after initial treatment:

• Partial response (mild residual joint swelling): Consider second course of oral antibiotics for up to 1 month 1
• Minimal or no response (moderate to severe joint swelling): IV ceftriaxone for 2-4 weeks 1

For antibiotic-refractory arthritis:

• Refer to rheumatologist for consideration of:
  • Disease-modifying antirheumatic drugs
  • Biologic agents
  • Intra-articular steroids
  • Arthroscopic synovectomy 1, 2

Other Manifestations

Borrelial lymphocytoma:

• Oral antibiotics for 14 days 1

Acrodermatitis chronica atrophicans:

• Oral antibiotics for 21-28 days 1

Important Clinical Considerations

Treatment efficacy:

• Short-course therapy (10 days) for early Lyme disease has similar long-term outcomes to longer courses 4, 5
• Treatment failure after appropriate therapy is extremely rare (approximately 1%) 4

Coinfection:

• Assess for possible coinfection with Anaplasma phagocytophilum or Babesia microti in patients with:
  • High-grade fever persisting >1 day while on antibiotic treatment
  • Characteristic laboratory abnormalities (thrombocytopenia, leukopenia, anemia) 1, 2

Not recommended:

• Extended antibiotic courses beyond recommended durations
• Combination antibiotic therapy for routine cases
• Additional antibiotics for persistent non-specific symptoms without objective evidence of active infection 1, 2
• Various unproven treatments (pulsed dosing, hyperbaric oxygen, etc.) 1, 2

Monitoring:

• Most patients with early Lyme disease respond rapidly to appropriate antibiotics
• Jarisch-Herxheimer reactions (transient symptom intensification) may occur in the first 24 hours but should not be mistaken for treatment failure 2

By following these evidence-based treatment guidelines, the vast majority of patients with Lyme disease will achieve complete resolution of their infection with minimal risk of long-term complications.