What is the treatment for Lyme disease?

Treatment of Lyme Disease

The recommended first-line treatment for Lyme disease is doxycycline 100 mg twice daily for 10 days for early localized disease, with longer courses and alternative antibiotics indicated for more advanced or complicated manifestations. 1

Diagnosis

Lyme disease diagnosis is primarily based on clinical findings, particularly in early disease with objective signs and known exposure. Key diagnostic elements include:

• Erythema migrans (EM) rash: The pathognomonic skin lesion occurs in 50-70% of patients 2
• Serologic testing: Recommended for later-stage disease using a two-tier approach:
  • Initial ELISA or indirect fluorescent antibody test
  • Confirmatory Western immunoblot for positive or equivocal results 3

Important note: Antibodies often persist for months or years after treatment, so seroreactivity alone cannot be used as a marker of active disease 3.

Treatment Approach Based on Disease Stage

Early Localized Disease (EM rash with/without flu-like symptoms)

• First-line options (10-14 day course) 1:
  • Doxycycline: 100 mg twice daily (adults); 4 mg/kg/day in 2 divided doses (children ≥8 years, max 100 mg per dose)
  • Amoxicillin: 500 mg three times daily (adults); 50 mg/kg/day in 3 divided doses (children, max 500 mg per dose)
  • Cefuroxime axetil: 500 mg twice daily (adults); 30 mg/kg/day in 2 divided doses (children, max 500 mg per dose)

Evidence note: Studies show that 10-day treatment courses for early Lyme disease have similar long-term outcomes to longer courses 4.

Early Disseminated Disease

Neurologic Manifestations

• Facial nerve palsy without CSF abnormalities: Oral regimen as for EM for 14 days 1
• Meningitis or radiculopathy: IV ceftriaxone 2g daily for 14 days (range 10-28 days) 1
• Facial nerve palsy with CSF abnormalities: Treatment as for meningitis 1

Cardiac Manifestations

• Parenteral antibiotics are generally recommended 3

Late Disease

Arthritis

• Initial treatment with oral antibiotics as for early disease
• For persistent or worsening arthritis: IV ceftriaxone 2g daily for 2-4 weeks 1
• If joint swelling persists after initial treatment:
  • Mild residual joint swelling: Second course of oral antibiotics for up to 1 month
  • Moderate to severe joint swelling with minimal response: 2-4 week course of IV ceftriaxone 2g daily 1

Management of Post-Treatment Symptoms

For patients with persistent symptoms after appropriate antibiotic therapy:

• Focus on symptomatic management with non-antibiotic approaches 1
• Avoid additional antibiotic therapy if there's no objective evidence of active infection 1
• Consider:
  • NSAIDs for pain and inflammation
  • Physical therapy
  • Cognitive behavioral therapy for pain management
  • Graded exercise programs 1

Special Considerations

Prophylaxis for Tick Bites

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

• Identified Ixodes 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, max 200 mg for children ≥8 years) 1

Pregnancy and Children

• Doxycycline is contraindicated in pregnant women and children under 8 years 5
• Amoxicillin is the preferred alternative in these populations 1

Common Pitfalls to Avoid

1. Overtreatment: Extended antibiotic courses beyond recommended durations provide no additional benefit and increase risk of adverse effects 1

2. Misinterpreting persistent symptoms: Post-Lyme disease syndrome does not respond to additional antibiotic therapy 1

3. Neglecting alternative diagnoses: Consider other conditions like fibromyalgia in patients with persistent symptoms without objective evidence of infection 1

4. Relying solely on serology: Antibody tests can remain positive long after successful treatment and should not guide retreatment decisions 3

5. Overlooking reinfection: Patients can be reinfected with B. burgdorferi, as previous infection does not confer protective immunity 3

Emerging Treatments

Recent research has identified piperacillin as a potential alternative treatment that eradicates B. burgdorferi at low doses without affecting the microbiome in mouse models 6. While promising, this treatment is not yet part of clinical guidelines.