Recommended Treatment 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)
- Oral antibiotics for 14 days (range 10-21 days):
- Doxycycline: 100 mg twice daily (adults)
- Amoxicillin: 500 mg three times daily (adults)
- Cefuroxime axetil: 500 mg twice daily (adults) 1
Pediatric Dosing
- For children:
- 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
Early Disseminated or Late Lyme Disease
- For neurological involvement (meningitis or radiculopathy):
- IV ceftriaxone: 2g daily for 14 days (range 10-28 days) 1
- For isolated facial nerve palsy without CSF abnormalities:
- Same oral regimen as for erythema migrans for 14 days 1
- For facial nerve palsy with CSF abnormalities:
- Treatment as for meningitis 1
- For Lyme arthritis that has failed to improve or worsened:
- IV ceftriaxone: 2g daily for 2-4 weeks 1
Important Clinical Considerations
Antibiotic Selection
- Doxycycline has the advantage of covering potential co-infections like Human Granulocytic Anaplasmosis 1
- Macrolide antibiotics are not recommended as first-line therapy due to lower efficacy 1
- First-generation cephalosporins should be avoided 1
Treatment Duration
- Longer duration therapy beyond recommended guidelines has not been shown to be more effective 1, 2
- A study of 607 patients in a Lyme-endemic area showed similar long-term outcomes for patients treated with 10 days versus longer courses of antibiotics, with treatment failure being extremely rare (1%) 2
Post-Treatment Considerations
- Some patients may experience Post-Lyme Disease Syndrome with persistent symptoms after appropriate antibiotic treatment 1
- These persistent symptoms are not due to ongoing infection and do not respond to additional antibiotics 1
- The Infectious Diseases Society of America recommends against additional antibiotic therapy for patients with persistent symptoms who lack objective evidence of reinfection or treatment failure 1
Common Pitfalls to Avoid
- Extending antibiotic treatment beyond recommended durations without evidence of benefit 1
- Using first-generation cephalosporins which are ineffective 1
- Relying solely on serologic testing for diagnosis without clinical correlation 1
- Attributing non-specific symptoms to Lyme disease without objective evidence 1
- Treating "chronic Lyme disease" with prolonged antibiotics when symptoms may be due to non-infectious processes 3
Prophylaxis After Tick Bite
- A single dose of doxycycline is recommended for high-risk patients with:
- Identified Ixodes spp. tick
- Tick attached for ≥36 hours
- Local infection rate of ticks with B. burgdorferi ≥20% 1
The evidence consistently supports short-course antibiotic therapy for early Lyme disease, with treatment selection based on disease stage and patient factors. Longer treatment durations have not demonstrated improved outcomes in controlled studies 1, 2.