Treatment of Lyme Disease
The recommended first-line treatment for Lyme disease is doxycycline 100 mg twice daily for 10-14 days, with alternative treatments including amoxicillin 500 mg three times daily for 14 days and cefuroxime axetil 500 mg twice daily for 14 days. 1
Treatment Algorithm Based on Disease Stage and Presentation
Early Localized Disease (Erythema Migrans)
- First-line: Doxycycline 100 mg twice daily for 10-14 days 1
- Alternatives:
- Amoxicillin 500 mg three times daily for 14 days
- Cefuroxime axetil 500 mg twice daily for 14 days
Special Populations
- Children ≥8 years: Doxycycline (weight-appropriate dosing)
- Children <8 years: Amoxicillin or cefuroxime (doxycycline contraindicated) 1
- Pregnant patients: Avoid doxycycline; use amoxicillin or cefuroxime instead 1
Early Disseminated or Late Disease
Neurologic Manifestations
- Meningitis, cranial neuropathy, radiculoneuropathy:
- Facial nerve palsy without CSF abnormalities: Oral regimen as for erythema migrans for 14 days 1
Cardiac Manifestations (Lyme Carditis)
- Intravenous therapy:
- For mild carditis or after improvement on IV therapy:
- Transition to oral antibiotics (amoxicillin or doxycycline) to complete 14-21 days of total treatment 1
Lyme Arthritis
- Initial treatment: Oral antibiotics for 28 days 1
- Persistent arthritis: IV ceftriaxone for 2-4 weeks if minimal or no response to oral therapy 1
- Treatment failure: Consider rheumatology referral for DMARDs, biologics, intra-articular steroids, or arthroscopic synovectomy 1
Important Clinical Considerations
Diagnosis
- Erythema migrans rash following a tick bite is sufficient for diagnosis without laboratory confirmation 2
- For other manifestations, the CDC recommends two-tier serologic testing: enzyme-linked immunosorbent assay followed by Western blot confirmation 2
- Do not delay treatment while awaiting serologic confirmation in suspected Lyme carditis 1
Monitoring
- For cardiac involvement: ECG monitoring is essential - continuous for hospitalized patients with Lyme carditis, daily for outpatients with mild carditis 1
- Monitor for signs of Lyme carditis: exercise intolerance, palpitations, presyncope, syncope, chest pain, and shortness of breath 1
Common Pitfalls to Avoid
Overtreatment: Extended antibiotic courses beyond recommended durations, combination antibiotic therapy for routine cases, and additional antibiotics for persistent non-specific symptoms without objective evidence of active infection are not recommended 1
Undertreatment: Failure to recognize and appropriately treat disseminated disease can lead to complications
Inappropriate pacemaker placement: Do not rush to implant a permanent pacemaker for heart block, as conduction abnormalities are typically reversible with appropriate antibiotic therapy 1
Misdiagnosis: Southern tick-associated rash illness can mimic erythema migrans but has a different etiology 3
Co-infection oversight: Consider possible co-infections, particularly Anaplasma phagocytophilum, which may require different antibiotic coverage 1
Prevention
- Avoid areas with high tick burdens
- Wear protective clothing
- Use tick repellants (e.g., DEET)
- Perform frequent body checks and bathe following outdoor activities
- Consider prophylaxis with a single dose of doxycycline for high-risk patients (identified Ixodes tick attached for ≥36 hours in areas with ≥20% infection rate) 1, 2
Lyme disease treatment is highly effective when initiated promptly, with excellent prognosis following appropriate antibiotic therapy. The specific clinical manifestations guide treatment selection and duration, with doxycycline offering the advantage of coverage against other potential tick-borne co-infections.