What is the recommended treatment for Lyme meningitis?

Treatment of Lyme Meningitis

For Lyme meningitis, intravenous ceftriaxone at 2g once daily for 14 days (range 10-28 days) is the recommended first-line treatment for adults, while children should receive parenteral ceftriaxone or cefotaxime. 1, 2

Treatment Recommendations by Age Group

Adults

• First-line therapy: Ceftriaxone 2g IV once daily for 14 days (range 10-28 days) 1, 2
• Alternatives:
  • Cefotaxime IV (parenteral therapy) 1
  • Penicillin G IV (parenteral therapy) 1
  • Doxycycline 200-400mg/day in 2 divided doses orally for 10-28 days (for β-lactam allergic patients) 1

Children

• First-line therapy:
  • Ceftriaxone IV (dosage based on weight) 1, 2
  • Cefotaxime IV (alternative) 1
• Alternatives:
  • Penicillin G IV 1
  • Children ≥8 years: Oral doxycycline 4-8mg/kg/day in 2 divided doses (maximum 100-200mg per dose) 1

Evidence Supporting Treatment Recommendations

The treatment recommendations for Lyme meningitis are primarily based on small case series rather than large randomized controlled trials 1. However, the evidence consistently shows that:

1. Patients with Lyme meningitis respond well to intravenous antibiotics 1
2. Ceftriaxone is preferred due to its convenient once-daily dosing 1, 3
3. European trials have demonstrated that cefotaxime and ceftriaxone are equally effective 1
4. A 10-14 day course of antibiotic therapy has been associated with highly favorable outcomes in both adults and children 1

The FDA-approved labeling for ceftriaxone specifically indicates its use for meningitis, including that caused by Haemophilus influenzae, Neisseria meningitidis, or Streptococcus pneumoniae 3. While not specifically mentioning Borrelia burgdorferi, the clinical guidelines support its use in Lyme meningitis.

Management of Special Situations

Increased Intracranial Pressure

• If papilledema or sixth cranial nerve palsy is present (indicating increased intracranial pressure):
  • Systemic antibiotic therapy typically addresses this issue
  • Consider additional measures if needed:
    • Serial lumbar punctures
    • Corticosteroids
    • Acetazolamide 1
  • CSF shunting may be necessary in rare cases of vision loss 1

Facial Nerve Palsy

• With CSF abnormalities: Treat as for meningitis 2
• Without CSF abnormalities: Oral regimen as for erythema migrans for 14 days 2

Diagnostic Considerations

Before initiating treatment, proper diagnosis is essential:

• Look for concurrent erythema migrans lesion or history of one within the preceding 1-2 months 1
• Laboratory support for diagnosis is required in the absence of erythema migrans 1
• Helpful diagnostic tests include:
  • Two-tier serology testing (most patients with neurologic Lyme disease are seropositive) 1
  • Tests for intrathecal production of antibody to B. burgdorferi 1
  • PCR for B. burgdorferi DNA in CSF (limited availability of quality testing) 1, 4

Treatment Duration and Follow-up

The standard duration of therapy is 10-14 days, with some cases requiring up to 28 days 1, 2. Extended antibiotic courses beyond recommended durations are explicitly discouraged as they have not shown greater efficacy and may lead to unnecessary side effects 2.

Important Caveats and Pitfalls

1. Doxycycline use: While oral doxycycline has been used successfully in Europe for Lyme meningitis, experience in the United States is limited 1. Recent research is exploring the comparative effectiveness of oral doxycycline versus IV ceftriaxone for Lyme meningitis in children 5.

2. Post-treatment symptoms: Some patients may experience persistent symptoms after appropriate antibiotic treatment (Post-Lyme Disease Syndrome), but these do not respond to additional antibiotics 2.

3. Contraindications for ceftriaxone:

   • Do not use with calcium-containing solutions
   • Contraindicated in hyperbilirubinemic neonates and premature neonates 3

4. Avoid prolonged therapy: There is no evidence supporting antibiotic treatment beyond the recommended duration, and prolonged therapy may lead to complications 2, 6.