What is the recommended treatment for two children, an 8-year-old and a 17-year-old, who are both positive for Borrelia burgdorferi (Lyme disease)?

Treatment for Children with Borrelia burgdorferi (Lyme Disease)

For children with Lyme disease, amoxicillin is the preferred treatment for the 8-year-old, while doxycycline is recommended for the 17-year-old, with specific dosing based on age and weight. 1

First-line Treatment Options

For the 8-year-old child:

• Amoxicillin: 50 mg/kg per day in 3 divided doses (maximum 500 mg per dose) for 14 days (range 14-21 days) 1
• Cefuroxime axetil: 30 mg/kg per day in 2 divided doses (maximum 500 mg per dose) for 14 days (range 14-21 days) 1
• Doxycycline is relatively contraindicated in children under 8 years of age 1

For the 17-year-old adolescent:

• Doxycycline: 4 mg/kg per day in 2 divided doses (maximum 100 mg per dose) for 14 days (range 10-21 days) 1
• Alternative options include amoxicillin or cefuroxime axetil at adult dosages if doxycycline cannot be used 1

Dosing Considerations

• Doxycycline has the advantage of being effective for treatment of human granulocytic anaplasmosis (HGA) which may occur simultaneously with early Lyme disease 1
• Recent research suggests that twice-daily dosing of amoxicillin (25 mg/kg/dose q12h) may provide comparable bactericidal activity to the thrice-daily regimen, potentially improving adherence in children 2
• For the 17-year-old, doxycycline should be taken with 8 ounces of fluid to reduce esophageal irritation and with food to reduce gastrointestinal intolerance 1
• Patients on doxycycline should avoid sun exposure due to risk of photosensitivity 1

Treatment Duration

• 14 days is the standard duration for oral therapy in early Lyme disease 1
• If doxycycline is used, 10 days of therapy is sufficient 1
• For β-lactam antibiotics (amoxicillin, cefuroxime axetil), a full 14-day course is recommended due to their shorter half-life 1

Special Considerations

• If neurological involvement is present (meningitis, radiculopathy), parenteral therapy with ceftriaxone (50-75 mg/kg per day, maximum 2g) is recommended 1
• For isolated facial nerve palsy without other signs of meningitis, oral therapy as described above is usually sufficient 1
• First-generation cephalosporins such as cephalexin are ineffective for Lyme disease and should not be used 1
• Macrolide antibiotics (azithromycin, clarithromycin, erythromycin) should only be used when patients cannot tolerate first-line agents, as they are less effective 1

Monitoring and Follow-up

• Most patients respond promptly and completely to appropriate antibiotic therapy 1
• Less than 10% of individuals do not respond to antibiotic therapy as evidenced by persistent objective clinical manifestations 1
• Patients who are more systemically ill at diagnosis may take longer to have a complete response to therapy 1
• Patients treated with macrolides should be closely observed to ensure resolution of clinical manifestations 1

Common Pitfalls to Avoid

• Using first-generation cephalosporins like cephalexin, which are ineffective against B. burgdorferi 1
• Prescribing fluoroquinolones, carbapenems, or other antibiotics not recommended for Lyme disease 1
• Using long-term antibiotic therapy, which lacks supporting data and may cause harm 1
• Attributing persistent subjective symptoms after treatment to active infection requiring additional antibiotics, when these may be due to post-treatment processes that are no longer antibiotic-sensitive 3, 4