Treatment of Lyme Disease
The first-line treatment for Lyme disease consists of oral antibiotics including 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 the specific choice depending on disease stage and patient factors. 1
Treatment Based on Disease Stage
Early Localized Lyme Disease (Erythema Migrans)
- First-line oral antibiotics:
- Doxycycline: 100 mg twice daily for 10 days (adults); 4 mg/kg/day in 2 divided doses (maximum 100 mg per dose) for children ≥8 years 1
- Amoxicillin: 500 mg three times daily for 14 days (adults); 50 mg/kg/day in 3 divided doses (maximum 500 mg per dose) for children 1
- Cefuroxime axetil: 500 mg twice daily for 14 days (adults); 30 mg/kg/day in 2 divided doses (maximum 500 mg per dose) for children 1
- Second-line: Azithromycin for patients unable to take doxycycline and beta-lactams 1
Clinical studies have demonstrated that cefuroxime axetil is as effective as doxycycline in treating early Lyme disease, with 91% of patients showing satisfactory clinical outcomes at 1 month post-treatment and 84% at 1 year post-treatment 2.
Early Disseminated Lyme Disease
Neurological Involvement
- 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
Cardiac Involvement (Lyme Carditis)
- Parenteral antibiotics: Intravenous ceftriaxone 1
- Hospitalization criteria:
- Symptomatic patients
- Second or third-degree AV block
- First-degree heart block with PR interval >300 milliseconds 1
- Temporary pacemaker: Recommended for symptomatic bradycardia and high-grade AV block not responding quickly to antibiotics 1
Late Lyme Disease
Arthritis
- Initial treatment: Same oral regimens as for early disease
- For arthritis that has failed to improve or worsened: IV ceftriaxone 2g daily for 2-4 weeks 1
Special Considerations
Prophylaxis After Tick Bite
Prophylaxis is recommended only when ALL of the following criteria are met:
- 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
Post-Lyme Disease Syndrome Management
- Not recommended: Long-term antibiotics for patients without objective evidence of ongoing infection 1
- Recommended approach: Symptom-specific management including NSAIDs, physical therapy, cognitive behavioral therapy for pain, and graded exercise programs 1
Common Pitfalls and Caveats
Misdiagnosis: Two-tier serological testing is recommended for diagnosis, consisting of initial screening with enzyme immunoassay (EIA) or immunofluorescence assay (IFA), followed by confirmation with Western blot if the result is positive or equivocal 1.
Inappropriate testing: Patients with typical amyotrophic lateral sclerosis, relapsing-remitting multiple sclerosis, Parkinson's disease, dementia, or new-onset seizures should not be tested for Lyme disease 1.
Overtreatment: Prolonged antibiotic therapy beyond recommended durations provides no additional benefit and increases the risk of adverse effects 1.
"Chronic Lyme disease": This is not recognized as a valid medical diagnosis by major medical organizations. Persistent symptoms after treatment should be approached with symptom-specific management rather than continued antibiotics 1.
Adverse effects: Doxycycline has a higher risk of photosensitivity reactions (9% vs 0% with cefuroxime), while cefuroxime has a higher risk of diarrhea (11% vs 3% with doxycycline) 2.
By following these evidence-based guidelines for the treatment of Lyme disease, clinicians can effectively manage this infection while minimizing unnecessary treatments and potential complications.