Treatment of Borrelia burgdorferi Infection (Lyme Disease)
Doxycycline is the first-line treatment for Borrelia burgdorferi infection in adults and children ≥8 years of age, with amoxicillin and cefuroxime axetil as alternatives for those who cannot take doxycycline. 1
First-Line Treatment Options
Adults and Children ≥8 years:
- Doxycycline: 100 mg twice daily for 14-21 days 1
- Preferred due to excellent efficacy against B. burgdorferi
- Also effective against potential co-infections like Anaplasma phagocytophilum
Children <8 years, Pregnant Women, and Doxycycline-Intolerant Patients:
- Amoxicillin: 500 mg three times daily for adults; 50 mg/kg/day divided into 3 doses for children 1
- Cefuroxime axetil: 500 mg twice daily for adults; 30 mg/kg/day divided into 2 doses for children 1
Treatment Based on Disease Manifestation
Early Localized Disease (Erythema Migrans):
- Oral therapy as above for 14-21 days 1
Neurologic Manifestations:
- Facial nerve palsy without CSF abnormalities: Oral regimen as for erythema migrans for 14 days 1
- Meningitis or radiculopathy: IV ceftriaxone 2g daily for 14 days (range 10-28 days) 1
Lyme Carditis:
- Symptomatic patients: IV ceftriaxone 2g daily for 14-21 days with hospitalization and continuous ECG monitoring 1
- Asymptomatic or minimally symptomatic: Oral regimen may be sufficient 1
Lyme Arthritis:
- Oral regimen for 28 days 1
- For persistent arthritis after initial therapy: second course of oral antibiotics or IV ceftriaxone for 14-28 days 1
Important Clinical Considerations
Treatment Monitoring:
- Clinical reassessment at 7-10 days to ensure symptom improvement 1
- Monitor for adverse effects such as photosensitivity and gastrointestinal symptoms 1
Treatment Response:
- Fever typically subsides within 24-48 hours after appropriate treatment 2
- Lack of response within 48 hours of early treatment with doxycycline may indicate an alternative diagnosis 2
Treatment Failure:
- Treatment failure after appropriate therapy is approximately 1% 1
- Persistent IgM antibodies are common (up to 56% of patients at 6 months) and do not indicate treatment failure 1
Pitfalls to Avoid:
- Delaying treatment: Initiate empiric therapy immediately when Lyme disease is suspected based on clinical and epidemiologic findings 2
- Using ineffective antibiotics: First-generation cephalosporins like cephalexin are ineffective against B. burgdorferi 1
- Extended or combination therapy: Extended antibiotic courses beyond recommended durations or combination antibiotic therapy for routine cases are not recommended 1
- Treating persistent symptoms without evidence of active infection: Additional antibiotics for persistent non-specific symptoms without objective evidence of active infection are not supported by evidence 1
Special Populations
Pregnant Women:
- Doxycycline is contraindicated
- Amoxicillin or cefuroxime are preferred options 1
Children:
- For children <8 years: amoxicillin or cefuroxime 1
- For children ≥8 years: doxycycline, amoxicillin, or cefuroxime 1, 3
- Recent evidence suggests equal effectiveness of doxycycline and ceftriaxone in pediatric Lyme neuroborreliosis regardless of age 3
By following these evidence-based treatment recommendations, clinicians can effectively manage Borrelia burgdorferi infections while minimizing complications and improving patient outcomes.