What are the next steps for treating children with Lyme disease who have not improved after initial antibiotic treatment?

Management of Children with Lyme Disease Who Have Not Improved After Initial Antibiotic Treatment

For children with Lyme disease who have not improved after initial antibiotic treatment, a second course of antibiotics is recommended, with the specific regimen determined by the clinical manifestation and severity of symptoms.

Assessment of Treatment Failure

• Treatment failure should be evaluated 48-72 hours after initiation of antibiotics, as clinical improvement should typically begin within this timeframe 1
• Persistent symptoms may indicate:
  • Resistant bacteria requiring a change in antibiotic therapy 1
  • Concomitant viral infection that would not respond to antibiotics 1
  • Development of a different manifestation of Lyme disease requiring alternative treatment 1

Treatment Recommendations Based on Clinical Manifestation

For Persistent or Recurrent Lyme Arthritis

• First approach: Re-treat with another 4-week course of oral antibiotics if arthritis has shown some improvement 1

  • Options include:
    • Doxycycline (if ≥8 years of age): 100 mg twice daily 1
    • Amoxicillin: 500 mg three or four times daily 1, 2
    • Cefuroxime axetil: age-appropriate dosing 1

• Second approach: If arthritis failed to improve at all or worsened, switch to intravenous therapy with ceftriaxone 2 g daily (50 mg/kg in children) for 2-4 weeks 1

For Persistent Neurologic Manifestations

• Intravenous ceftriaxone (2 g once daily for adults; 50-75 mg/kg/day for children) for 2-4 weeks 1
• Alternative options include intravenous cefotaxime or penicillin G 1
• Response to treatment may be slow and sometimes incomplete 1

Special Considerations

• If multiple courses of antibiotics have failed to improve symptoms, consider:

  • Tympanocentesis or other appropriate sampling for bacteriologic diagnosis and susceptibility testing 1
  • Consultation with specialists such as infectious disease experts or rheumatologists 1
  • For persistent synovitis with negative PCR results for Borrelia in synovial fluid, consider symptomatic treatment with NSAIDs or disease-modifying antirheumatic drugs (DMARDs) 1

• Wait several months before initiating re-treatment with antimicrobial agents for persistent arthritis due to the anticipated slow resolution of inflammation 1

Emerging Research

• Recent research suggests that combination antibiotic therapy may be more effective than monotherapy for persistent Borrelia burgdorferi infection 3
• Combinations that showed promise in preclinical studies include:
  • Doxycycline + ceftriaxone
  • Doxycycline + cefotaxime
  • Dapsone + rifampin 3

Important Caveats

• Avoid intra-articular injections of corticosteroids in patients with Lyme arthritis 1
• For patients with persistent symptoms despite appropriate antibiotic therapy, consider that some symptoms may be due to post-infectious inflammatory processes rather than ongoing infection 2
• Prolonged or indefinite antibiotic courses are not supported by current evidence and may lead to unnecessary adverse effects 2, 4
• If symptoms persist despite multiple treatment attempts, referral to specialists with experience in treating tick-borne diseases is recommended 5

Follow-up Recommendations

• Regular reassessment of symptoms and clinical response is essential 1
• For patients with persistent joint swelling, arthroscopic synovectomy may be considered if significant pain or functional limitation is present 1
• Educate patients and families about the potential for slow resolution of symptoms even after appropriate antibiotic therapy 1, 4