What is the recommended treatment for a patient diagnosed with Lyme disease?

Lyme Disease Diagnosis and Management

For patients diagnosed with Lyme disease, the recommended first-line treatments are 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). 1

Diagnostic Interpretation

Your patient's test result shows "LYME DISEASE AB,SCR & RFX ​0.90 0.90," which indicates a serologic test for Lyme disease antibodies. However, it's important to note that:

• Serologic testing alone is insufficient for diagnosis in early disease as antibody tests are often negative in the first 2 weeks 1
• Erythema migrans (EM) is the only manifestation of Lyme disease that allows clinical diagnosis without laboratory confirmation 1
• If EM is present, treatment should begin immediately without waiting for serologic test results 1

Treatment Algorithm

Early Localized Disease (Erythema Migrans)

• Adults:

  • Doxycycline 100 mg twice daily for 10 days, OR
  • Amoxicillin 500 mg three times daily for 14 days, OR
  • Cefuroxime axetil 500 mg twice daily for 14 days 1

• Children:

  • Amoxicillin 50 mg/kg/day in 3 divided doses (maximum 500 mg per dose) for 14 days, OR
  • Cefuroxime axetil 30 mg/kg/day in 2 divided doses (maximum 500 mg per dose) for 14 days, OR
  • Doxycycline 4 mg/kg/day in 2 divided doses (maximum 100 mg per dose) for children ≥8 years for 10 days 1

Neurologic Manifestations

• 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

Arthritis

• Initial treatment: Same oral regimens as for erythema migrans, but for 28 days 1
• Arthritis that has failed to improve or worsened: IV ceftriaxone 2g daily for 2-4 weeks 1

Important Considerations

Medication Precautions

• When prescribing doxycycline, advise patients:

  • To avoid excessive sunlight or artificial ultraviolet light
  • To drink fluids liberally to reduce esophageal irritation
  • That absorption is not markedly influenced by food or milk 2
  • That doxycycline may increase the incidence of vaginal candidiasis 2

• Doxycycline may interact with:

  • Anticoagulants (may require dosage adjustment)
  • Antacids containing aluminum, calcium, or magnesium
  • Iron-containing preparations
  • Bismuth subsalicylate
  • Barbiturates, carbamazepine, and phenytoin 2

Common Pitfalls to Avoid

• Overreliance on serology: Do not delay treatment of erythema migrans while waiting for test results 1
• Extended antibiotic therapy: The IDSA strongly recommends against prolonged antibiotic therapy for patients with persistent subjective symptoms after appropriate treatment 1
• Misattributing nonspecific symptoms: "Chronic Lyme disease" without evidence of ongoing B. burgdorferi infection is not supported by evidence 1
• Inappropriate prophylaxis: Only truly high-risk tick bites meeting specific criteria should receive prophylaxis 1
• Using first-generation cephalosporins: These are not effective against Lyme disease 1

Post-Treatment Considerations

• Post-Lyme disease syndrome does not respond to additional antibiotic therapy 1
• For persistent symptoms, consider:
  • Symptom-specific management
  • Physical therapy for musculoskeletal complaints
  • Cognitive behavioral therapy for pain management
  • Evaluation for other conditions (fibromyalgia, chronic fatigue syndrome, autoimmune diseases, endocrine disorders, depression) 1

Recent research has identified piperacillin as a potential alternative treatment that eradicated B. burgdorferi at low concentrations in experimental models 3, but this has not yet been incorporated into clinical guidelines.