What is the recommended treatment for Lyme disease?

Treatment for Lyme Disease

The recommended first-line treatment for early Lyme disease is oral doxycycline 100 mg twice daily for 10 days, with amoxicillin 500 mg three times daily for 14 days or cefuroxime axetil 500 mg twice daily for 14 days as alternatives. 1

Treatment Algorithm Based on Disease Stage

Early Localized Lyme Disease (Erythema Migrans)

• First-line treatment:

  • Adults: Doxycycline 100 mg twice daily for 10 days
  • Children ≥8 years: Doxycycline 4 mg/kg/day in 2 divided doses (maximum 100 mg per dose) for 10 days 1

• Alternative treatments (if doxycycline contraindicated):

  • Adults: Amoxicillin 500 mg three times daily for 14 days OR Cefuroxime axetil 500 mg twice daily for 14 days
  • Children: Amoxicillin 50 mg/kg/day in 3 divided doses (maximum 500 mg per dose) OR Cefuroxime axetil 30 mg/kg/day in 2 divided doses (maximum 500 mg per dose) 1

• Second-line treatment: Azithromycin (for patients unable to take doxycycline and beta-lactams) 1

Early Disseminated Lyme Disease

Neurological 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

Cardiac Manifestations (Lyme Carditis)

• All patients with heart block: Parenteral antibiotics, specifically 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: 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

Post-Lyme Disease Syndrome Management

• Strong recommendation against further antibiotics for patients without objective evidence of infection 1
• Implement symptomatic management:
  • NSAIDs
  • Physical therapy
  • Cognitive behavioral therapy for pain management
  • Graded exercise programs 1

Prophylaxis After Tick Bite

Prophylaxis is recommended only when ALL 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

Evidence Strength and Clinical Pearls

• The FDA has approved cefuroxime axetil for early Lyme disease, with clinical studies showing it to be as effective as doxycycline in treating erythema migrans 2

• Recent research supports that oral doxycycline is equally effective as intravenous ceftriaxone in the treatment of Lyme neuroborreliosis, which may allow for less invasive treatment in some cases 3

• Studies have shown that extending doxycycline treatment from 10 to 20 days or adding one dose of ceftriaxone to a 10-day course of doxycycline does not enhance therapeutic efficacy in patients with erythema migrans 4

• While doxycycline was historically avoided in children under 8 years due to concerns about tooth staining, recent evidence suggests it may be well-tolerated and effective in young children with Lyme disease when needed, though amoxicillin remains the preferred treatment for non-neurological manifestations in this age group 5

Common Pitfalls to Avoid

• Do not test for Lyme disease in patients with typical amyotrophic lateral sclerosis, relapsing-remitting multiple sclerosis, Parkinson's disease, dementia, or new-onset seizures 1

• Do not extend antibiotic treatment beyond recommended durations as this provides no additional benefit and increases the risk of adverse effects 1

• Do not diagnose "chronic Lyme disease" as this is not recognized as a valid medical diagnosis by major medical societies 1

• Do not overlook cardiac manifestations of Lyme disease, which can present as syncope or heart block and require prompt treatment 6

• Do not miss the opportunity for prophylaxis after a high-risk tick bite, which can prevent development of Lyme disease 1