What is the recommended treatment for Lyme disease?

Treatment Recommendations for Lyme Disease

The recommended first-line treatment for early Lyme disease is doxycycline (100 mg twice daily), amoxicillin (500 mg three times daily), or cefuroxime axetil (500 mg twice daily) for 14 days (range 10-21 days), with doxycycline being preferred when co-infections like Human Granulocytic Anaplasmosis are suspected. 1

Treatment by Disease Stage

Early Localized Lyme Disease (Erythema Migrans)

• Adult treatment options:

  • Doxycycline: 100 mg twice daily for 14 days (10-21 days)
  • Amoxicillin: 500 mg three times daily for 14 days (10-21 days)
  • Cefuroxime axetil: 500 mg twice daily for 14 days (10-21 days) 1

• Pediatric treatment options:

  • Amoxicillin: 50 mg/kg/day in 3 divided doses (maximum 500 mg per dose)
  • Cefuroxime axetil: 30 mg/kg/day in 2 divided doses (maximum 500 mg per dose)
  • Doxycycline: 4 mg/kg/day in 2 divided doses (maximum 100 mg per dose) for children ≥8 years 1

Evidence supports that 10-day treatment courses have similar long-term outcomes to longer courses for early Lyme disease 2. A study of 607 patients showed treatment failure rates of only 1% across different treatment durations, with no significant clinical differences between 10-day and longer treatment regimens 2.

Early Disseminated Lyme Disease

Neurological Manifestations

• Lyme meningitis or radiculopathy:

  • IV ceftriaxone: 2g daily for 14 days (range 10-28 days) 1

• Facial nerve palsy without CSF abnormalities:

  • Oral regimen as for erythema migrans for 14 days 1

• Facial nerve palsy with CSF abnormalities:

  • Treatment as for meningitis 1

Alternative IV Options for Neurological Disease

• Cefotaxime IV
• Penicillin G IV
• Doxycycline 200-400mg/day in 2 divided doses orally for 10-28 days (for β-lactam allergic patients) 1

Late Disseminated Lyme Disease

Persistent Arthritis

• For arthritis that has failed to improve or worsened:
  • IV ceftriaxone 2g daily for 2-4 weeks 1

Important Clinical Considerations

Antibiotic Selection

• Doxycycline is preferred when there's a possibility of co-infection with other tick-borne pathogens like Human Granulocytic Anaplasmosis 1
• Macrolide antibiotics should be avoided as first-line therapy due to lower efficacy 1
• First-generation cephalosporins are ineffective and should not be used 1

Treatment Duration

• Evidence shows that 10-day courses are generally as effective as longer courses for early Lyme disease 2
• A 14-day course of amoxicillin (500 mg three times daily) has been shown to be highly effective in resolving erythema migrans and preventing progression to later stages 3

Post-Treatment Considerations

• Some patients may experience Post-Lyme Disease Syndrome with persistent symptoms after appropriate treatment
• Extended antibiotic courses beyond recommended durations are not supported by evidence and should be avoided 1
• Persistent symptoms following recommended treatment do not indicate ongoing infection and do not warrant additional antibiotic therapy 1

Common Pitfalls to Avoid

1. Using first-generation cephalosporins, which are ineffective against Borrelia burgdorferi
2. Extending antibiotic treatment beyond recommended durations without evidence of treatment failure
3. Relying solely on serologic testing for diagnosis without clinical correlation
4. Misinterpreting persistent symptoms as requiring additional antibiotics 1
5. Treating "chronic Lyme disease" with prolonged or unending courses of antibiotics for non-infectious problems 4

Prophylaxis

Prophylaxis with a single dose of doxycycline is recommended for high-risk tick bites when:

• The tick is identified as Ixodes species
• The tick was attached for ≥36 hours
• Local infection rate of ticks with B. burgdorferi is ≥20% 1