What is the recommended treatment for Lyme borreliosis?

Treatment of Lyme Borreliosis

Doxycycline 100mg twice daily for 10-21 days is the first-line treatment for early Lyme disease, with treatment duration and route varying based on disease manifestation. 1

Treatment Recommendations by Disease Stage

Early Localized Lyme Disease (Erythema Migrans)

• First-line options:

  • Doxycycline 100mg twice daily for 10-14 days (adults) 1
  • Amoxicillin 500mg three times daily for 14 days (alternative) 1
  • Cefuroxime axetil 500mg twice daily for 14 days (alternative) 1

• For children:

  • Amoxicillin (preferred for children <8 years) 2, 1
  • Cefuroxime axetil 2, 1
  • Doxycycline (if ≥8 years of age) 2, 1

Lyme Arthritis

• Oral therapy for 28 days: 2

  • Doxycycline 100mg twice daily
  • Amoxicillin 500mg three times daily
  • Cefuroxime axetil 500mg twice daily

• For persistent/recurrent joint swelling:

  • Second 4-week course of oral antibiotics (if arthritis has improved but not resolved) 2
  • Intravenous ceftriaxone 2g daily for 2-4 weeks (if arthritis failed to improve or worsened) 2

Neurologic Lyme Disease

• Facial nerve palsy without CSF abnormalities:

  • Oral regimen as for erythema migrans for 14 days 1

• Meningitis, radiculopathy, or facial palsy with CSF abnormalities:

  • IV ceftriaxone 2g daily for 14 days (range 10-28 days) 1
  • Oral doxycycline is equally effective as IV ceftriaxone for Lyme neuroborreliosis (based on recent evidence) 3
    • Doxycycline 100mg twice daily for 4 weeks has shown equivalent efficacy to IV ceftriaxone 3
    • Doxycycline penetrates the blood-brain barrier adequately at 200mg twice daily dosing 4

Lyme Carditis

• Outpatients: Oral antibiotics 1
• Hospitalized patients: Initial IV ceftriaxone until clinical improvement, then switch to oral antibiotics 1

Treatment Considerations

Medication Selection

• Doxycycline has advantages:
  • Effective against co-infections like anaplasmosis 5
  • Achieves adequate CSF penetration at appropriate doses 4
  • More cost-effective than IV ceftriaxone 6
  • Equally effective as ceftriaxone for neuroborreliosis 3

Common Pitfalls to Avoid

1. Inappropriate antibiotic selection:

   • First-generation cephalosporins are ineffective and should not be used 1
   • Avoid probenecid with amoxicillin as it may impair penetration into brain parenchyma 2

2. Treatment duration errors:

   • Extending antibiotic courses beyond recommended durations is not supported by evidence 1
   • Using combination antibiotic therapy for routine cases is unnecessary 1

3. Post-treatment management:

   • Additional antibiotics for persistent non-specific symptoms without objective evidence of active infection are not recommended 1
   • Clinical response should be the primary indicator of treatment success, not serologic testing 1
   • Persistent symptoms after appropriate treatment (Post-Lyme Disease Syndrome) do not respond to additional antibiotics 1

4. Diagnostic errors:

   • Relying solely on serologic testing without clinical correlation 1
   • Attributing non-specific symptoms to Lyme disease without objective evidence 1

Special Situations

Persistent Symptoms After Treatment

• If arthritis persists despite IV therapy and PCR of synovial fluid is negative, consider:
  • NSAIDs
  • Intra-articular corticosteroid injections (only after infection cleared)
  • Disease-modifying antirheumatic drugs
  • Arthroscopic synovectomy for persistent synovitis with significant pain/limitation 2

Pregnancy Considerations

• Doxycycline is contraindicated in pregnancy
• Amoxicillin is the preferred agent for pregnant women

By following these evidence-based recommendations, clinicians can effectively treat Lyme borreliosis while minimizing unnecessary antibiotic use and avoiding common treatment pitfalls.