Treatment for Acute Lyme Disease Flare-up
For acute Lyme disease flare-ups, the recommended first-line treatment is doxycycline 100 mg twice daily for 14 days (range 10-21 days), with amoxicillin 500 mg three times daily or cefuroxime axetil 500 mg twice daily as alternatives. 1
Treatment Algorithm Based on Clinical Presentation
Early Localized Disease (Erythema Migrans)
- First-line treatment: Doxycycline 100 mg twice daily for 14 days
- Alternatives:
- Amoxicillin 500 mg three times daily for 14 days
- Cefuroxime axetil 500 mg twice daily for 14 days
Early Disseminated Disease
- Multiple erythema migrans lesions: Same oral regimen as early localized disease 1, 2
- Facial nerve palsy without CSF abnormalities: Oral regimen as for erythema migrans for 14 days 1
- Facial nerve palsy with CSF abnormalities or meningitis: IV ceftriaxone 2g daily for 14 days (range 10-28 days) 1
Late Disease (Arthritis)
- Initial treatment: Same oral regimen as early disease
- For arthritis that has failed to improve or worsened: IV ceftriaxone 2g daily for 2-4 weeks 1
Special Considerations
Pediatric Dosing
- 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, 3
Treatment Selection Factors
- Doxycycline has the advantage of also covering co-infections like Human Granulocytic Anaplasmosis 1
- Amoxicillin is preferred for children under 8 years, although recent evidence suggests doxycycline may be safe and effective in this population as well 3
- Ceftriaxone is equivalent to doxycycline for disseminated disease without meningitis but requires parenteral administration 2
Important Clinical Pearls
- Erythema migrans is the only manifestation sufficiently distinctive to allow clinical diagnosis without laboratory confirmation 1
- Serologic testing may be negative in early disease (first 2 weeks) and should not be relied upon for diagnosis during this period 1
- Persistent antibodies after treatment do not indicate active infection and should not be used to guide additional therapy 1
Common Pitfalls to Avoid
- Using first-generation cephalosporins, which are ineffective against Borrelia burgdorferi 1
- Extending antibiotic treatment beyond recommended durations, which is not supported by evidence 1, 4
- Confusing Post-Lyme Disease Syndrome (persistent symptoms after appropriate treatment) with active infection requiring additional antibiotics 1, 4
- Relying solely on serologic testing for diagnosis of early disease 1
Emerging Research
Recent research has identified piperacillin as a potential alternative treatment that may be effective at lower doses than traditional options and with less impact on the microbiome 5. However, this is still experimental and not yet incorporated into clinical guidelines.