What is the recommended treatment for Lyme disease?

Treatment of Lyme Disease

First-line treatment for Lyme disease includes doxycycline 100 mg twice daily for 10 days, amoxicillin 500 mg three times daily for 14 days, or cefuroxime axetil 500 mg twice daily for 14 days, with selection based on disease stage and patient characteristics. 1

Diagnosis and Initial Assessment

• Erythema migrans is the only manifestation that allows clinical diagnosis without laboratory confirmation

  • Typically appears 3-30 days after tick bite
  • Usually >5 cm in diameter
  • May have homogeneous appearance or central clearing with target-like appearance
  • Not typically pruritic or scaly unless fading or treated with topical steroids 1

• Differentiating from tick bite hypersensitivity reaction:

  • Hypersensitivity reactions are usually <5 cm and disappear within 24-48 hours
  • True erythema migrans increases in size over time 1

Treatment Algorithm by Disease Stage

1. Early Localized Disease (Erythema Migrans)

Adult Treatment Options:

• Doxycycline 100 mg twice daily for 10 days
• Amoxicillin 500 mg three times daily for 14 days
• Cefuroxime axetil 500 mg twice daily for 14 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

2. Early Disseminated Disease

For multiple erythema migrans without neurological involvement:

• Same oral regimens as for early localized disease 1

For facial nerve palsy:

• Without CSF abnormalities: Oral regimen as for erythema migrans for 14 days
• With CSF abnormalities: Treatment as for meningitis 1

For meningitis or radiculopathy:

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

3. Late Disease (Arthritis)

For Lyme arthritis:

• Initial treatment with oral regimens as for early disease
• For arthritis that has failed to improve or worsened: IV ceftriaxone 2g daily for 2-4 weeks 1

Evidence on Treatment Effectiveness

Research has demonstrated that:

1. For early disseminated Lyme disease without meningitis, oral doxycycline is equally effective as intravenous ceftriaxone in preventing late manifestations of disease 2

2. For Lyme neuroborreliosis, oral doxycycline has been shown to be equally effective as intravenous ceftriaxone, with the doxycycline regimen being more cost-effective and having a different side effect profile 3

3. Extending doxycycline treatment from 10 to 20 days or adding a single dose of ceftriaxone did not enhance therapeutic efficacy in patients with erythema migrans 4

Prophylaxis After Tick Bite

Prophylaxis is recommended only for high-risk tick bites meeting ALL criteria:

• Identified Ixodes spp. vector tick
• Tick attached for ≥36 hours
• Prophylaxis started within 72 hours of tick removal
• Local infection rate of ticks with B. burgdorferi ≥20% 1

Prophylactic regimen:

• Single dose of doxycycline: 200 mg for adults, 4.4 mg/kg (maximum 200 mg) for children ≥8 years 1

Common Pitfalls to Avoid

1. Diagnostic errors:

   • Relying on serologic testing for early disease diagnosis (often negative in first 2 weeks)
   • Delaying treatment of erythema migrans while waiting for test results 1

2. Treatment errors:

   • Using first-generation cephalosporins (ineffective against Borrelia)
   • Extending antibiotic treatment beyond recommended durations without evidence
   • Treating persistent symptoms (post-Lyme disease syndrome) with additional antibiotics 1

3. Inappropriate prophylaxis:

   • Providing prophylaxis for low-risk tick bites
   • Using antibiotics other than doxycycline for prophylaxis 1

4. Misattribution of symptoms:

   • Attributing non-specific symptoms to Lyme disease without evidence
   • Routine testing for Lyme disease in patients with psychiatric illness, ALS, MS, Parkinson's, dementia, or new-onset seizures is not recommended 1