What is the recommended treatment for chronic Lyme disease?

Treatment of Chronic Lyme Disease

There is no recommended antibiotic treatment for chronic Lyme disease as it is not recognized as a legitimate medical diagnosis requiring antimicrobial therapy according to current clinical guidelines. 1, 2

Understanding "Chronic Lyme Disease"

The term "chronic Lyme disease" has been used inconsistently to describe various clinical situations:

• Patients with objective evidence of late Lyme disease (should be termed "late Lyme disease")
• Patients with subjective symptoms after appropriate treatment (post-Lyme disease syndrome)
• Patients with chronic symptoms without evidence of Borrelia burgdorferi infection

According to the Infectious Diseases Society of America (IDSA), prolonged antibiotic therapy has not proven to be useful and is not recommended for patients with chronic subjective symptoms after receiving appropriate treatment for Lyme disease 1.

Evidence Against Extended Antibiotic Treatment

• Controlled treatment trials have not shown benefit of extended antibiotic courses
• The largest controlled trials of patients with post-Lyme disease complaints found no benefit from additional antibiotic therapy 1
• Prolonged courses of antibiotics are associated with considerable harm and are not supported by evidence 2, 3

Post-Lyme Disease Syndrome

Some patients experience persistent symptoms after receiving appropriate treatment for Lyme disease. These symptoms may include:

• Musculoskeletal pain
• Cognitive complaints
• Fatigue
• Radicular pain
• Paresthesias

The American College of Rheumatology (ACR) notes that post-Lyme disease syndrome does not respond to additional antibiotic therapy, and extended antibiotic courses beyond recommended durations are not supported by evidence 2.

Appropriate Management Approach

For patients with persistent symptoms after appropriate Lyme disease treatment:

1. Rule out other conditions that might explain symptoms:

   • Fibromyalgia
   • Chronic fatigue syndrome
   • Autoimmune diseases
   • Endocrine disorders
   • Depression or other psychiatric conditions

2. Avoid inappropriate antibiotic use:

   • Extended antibiotic courses beyond recommended durations
   • Multiple courses of different antibiotics
   • Combination antibiotic regimens without evidence

3. Address symptoms with appropriate non-antimicrobial approaches:

   • Symptom-specific management
   • Physical therapy for musculoskeletal complaints
   • Cognitive behavioral therapy for pain management
   • Treatment of any identified comorbid conditions

Common Pitfalls to Avoid

• Misattributing nonspecific symptoms to "chronic Lyme disease" without evidence of ongoing B. burgdorferi infection 4
• Relying on unvalidated laboratory tests to diagnose "chronic Lyme disease"
• Prescribing prolonged or unending courses of antibiotics for noninfectious problems 5
• Missing opportunities for more appropriate management of patients' symptoms 4
• Routine testing for Lyme disease in patients with psychiatric illness, amyotrophic lateral sclerosis, multiple sclerosis, Parkinson's disease, dementia, or new-onset seizures 2

Legitimate Treatment for Actual Lyme Disease

For patients with confirmed Lyme disease (not "chronic Lyme"), appropriate treatment includes:

• Early localized disease: 10-14 days of oral antibiotics (doxycycline, amoxicillin, or cefuroxime axetil) 2
• Neurologic involvement: IV ceftriaxone 2g daily for 14 days (range 10-28 days) 2
• Lyme arthritis: Oral regimen for 28 days; if persistent, IV ceftriaxone for 2-4 weeks 2

Remember that true Lyme disease is microbiologically curable in virtually all patients, regardless of disease duration, with appropriate antibiotic therapy 4.