What is the recommended treatment for Lyme disease?

Lyme Disease Treatment Guidelines

Doxycycline 100mg twice daily for 14 days is the first-line treatment for early Lyme disease, as recommended by the Infectious Diseases Society of America. 1

Treatment by Disease Stage

Early Localized Lyme Disease (Erythema Migrans)

• First-line therapy: Doxycycline 100mg twice daily for 14 days 1
• Alternative regimens (for those who cannot take doxycycline):
  • Amoxicillin 500mg three times daily for 14 days
  • Cefuroxime 500mg twice daily for 14 days

Early Disseminated Lyme Disease

• Neurologic manifestations:

  • Facial nerve palsy without CSF abnormalities: Doxycycline 100mg twice daily for 14 days 1
  • Meningitis or radiculopathy: IV ceftriaxone 2g daily for 14 days (range 10-28 days) 1
  • For more severe neurologic involvement: Doxycycline 200-400mg once daily for 21 days 1

• Cardiac manifestations:

  • Mild cardiac involvement: Oral doxycycline as above
  • Severe cardiac involvement (advanced heart block): IV ceftriaxone 2g once daily for 14-21 days with hospitalization and continuous ECG monitoring 1

Late Lyme Disease

• Lyme arthritis: Doxycycline for 28 days 1
• Late neurologic disease: IV ceftriaxone 2g daily for 14-28 days 1

Special Populations

Children

• ≥8 years: Same doxycycline regimens as adults (adjusted by weight)
• <8 years: Amoxicillin or cefuroxime (due to doxycycline's risk of dental staining) 1, 2

Pregnant Women

• Doxycycline contraindicated 2
• Amoxicillin is the preferred alternative 1

Important Clinical Considerations

Monitoring Treatment Response

• Clinical response should be the primary indicator of treatment success 1
• Serologic testing may remain positive for months to years after successful treatment
• Persistent IgM antibodies are common (up to 56% of patients at 6 months post-treatment) 1
• Clinical reassessment at 7-10 days to ensure symptom improvement

Precautions with Doxycycline

• Advise patients to avoid excessive sunlight or artificial UV light due to photosensitivity risk 2
• Recommend liberal fluid intake to reduce esophageal irritation 2
• Inform patients that absorption is not markedly influenced by food or milk 2
• Monitor for potential side effects including gastrointestinal symptoms 2

Treatment Failures and Common Pitfalls

• Treatment failure after appropriate therapy is approximately 1% 1
• Avoid these common pitfalls:
  • 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
  • Misinterpreting persistent symptoms as ongoing infection when they may be post-treatment syndromes

Risk of Superinfection

• Prolonged antibiotic use may result in overgrowth of nonsusceptible organisms, including fungi 2
• If superinfection occurs, discontinue the antibiotic and institute appropriate therapy 2

Post-Exposure Prophylaxis

• A single dose of doxycycline is recommended for high-risk patients meeting all criteria:
  • Identified Ixodes tick attached for ≥36 hours
  • Local infection rate of ticks with B. burgdorferi ≥20%
  • Prophylaxis can begin within 72 hours of tick removal 1

The evidence strongly supports short-course therapy for most manifestations of Lyme disease, with longer courses reserved for specific complications. Multiple studies have demonstrated that extending treatment beyond the recommended durations does not improve outcomes but increases the risk of adverse effects 3, 4.