What is the recommended treatment for Lyme disease?

Recommended Treatment for Lyme Disease

The recommended first-line treatment for Lyme disease is doxycycline (100 mg twice daily for adults or 4 mg/kg per day in 2 divided doses for children ≥8 years) for 10-21 days, or amoxicillin (500 mg three times daily for adults or 50 mg/kg per day in 3 divided doses for children) for 14-21 days. 1

Treatment Options by Patient Population

Adults and Children ≥8 Years

• Preferred oral regimens (14 days for early Lyme disease) 1:

  • Doxycycline: 100 mg twice daily (adults); 4 mg/kg per day in 2 divided doses (children ≥8 years, maximum 100 mg per dose)
  • Amoxicillin: 500 mg three times daily (adults); 50 mg/kg per day in 3 divided doses (children, maximum 500 mg per dose)
  • Cefuroxime axetil: 500 mg twice daily (adults); 30 mg/kg per day in 2 divided doses (children, maximum 500 mg per dose)

• Doxycycline has the advantage of also treating human granulocytic anaplasmosis (HGA), which may occur simultaneously with Lyme disease 1

Children <8 Years

• Amoxicillin: 50 mg/kg per day in 3 divided doses (maximum 500 mg per dose) for 14 days 2
• Cefuroxime axetil: 30 mg/kg per day in 2 divided doses (maximum 500 mg per dose) for 14 days 2
• Recent evidence suggests doxycycline may be safe for short courses in children <8 years, with usage increasing from 6.9% in 2015 to 67.9% in 2023 3, 4

Pregnant or Lactating Women

• Treatment identical to non-pregnant patients, except doxycycline should be avoided 1
• Amoxicillin is the preferred agent 1

Treatment by Disease Stage

Early Localized Disease (Erythema Migrans)

• Oral therapy with doxycycline, amoxicillin, or cefuroxime axetil for 14 days (10-21 days for doxycycline) 1
• Macrolides (azithromycin, clarithromycin, erythromycin) are less effective and should only be used when patients cannot tolerate first-line agents 2

Early Disseminated Disease

Neurologic Involvement (Meningitis, Cranial Neuropathy)

• Preferred parenteral regimen: Ceftriaxone 2 g IV once daily (adults); 50-75 mg/kg IV per day (children, maximum 2 g) for 14-28 days 1, 5

• Alternative parenteral regimens 1:

  • Cefotaxime: 2 g IV every 8 hours (adults); 150-200 mg/kg per day IV in 3-4 divided doses (children, maximum 6 g per day)
  • Penicillin G: 18-24 million U per day IV divided every 4 hours (adults); 200,000-400,000 U/kg per day divided every 4 hours (children, not to exceed 18-24 million U per day)

• For isolated facial nerve palsy without clinical evidence of meningitis, oral regimens may be adequate 1

• Oral doxycycline (200-400 mg daily) has shown effectiveness for Lyme disease-associated facial palsy and meningitis 6

Cardiac Involvement

• Hospitalization and continuous monitoring for symptomatic patients or those with advanced heart block 1
• Initial parenteral therapy (ceftriaxone) followed by completion with oral regimen 1
• Temporary pacemaker may be required for advanced heart block 1

Late Disease (Arthritis)

• Initial treatment with oral regimens as for early disease 1
• For persistent arthritis after oral therapy, IV ceftriaxone for 2-4 weeks 1
• For antibiotic-refractory arthritis with negative PCR for B. burgdorferi, consider symptomatic therapy (NSAIDs, intra-articular steroids) or rheumatology consultation 1

Important Considerations

Treatment Duration

• Early Lyme disease: 14 days (10 days sufficient for doxycycline) 2
• Neurological Lyme disease: 14-28 days 5
• Late Lyme disease: 28 days 1

Ineffective Treatments to Avoid

• First-generation cephalosporins (e.g., cephalexin) 1, 2
• Fluoroquinolones, carbapenems, vancomycin, metronidazole 1
• Long-term antibiotic therapy beyond recommended durations 1, 5
• Combination antimicrobial therapy, pulsed-dosing 1
• Non-antibiotic approaches: hyperbaric oxygen, ozone, intravenous immunoglobulin, etc. 1

Monitoring and Follow-up

• Most patients respond promptly to appropriate therapy 1
• Less than 10% of patients may not respond to initial therapy 1
• Patients who are more systemically ill at diagnosis may take longer to recover 1
• Consider co-infections (babesiosis, anaplasmosis) in patients with more severe initial symptoms or persistent symptoms despite appropriate therapy 5

Common Pitfalls

• Failing to consider Lyme disease in patients with vague flu-like symptoms in endemic areas during summer months 7
• Using ineffective antibiotics like first-generation cephalosporins 1
• Continuing oral therapy when it has proven ineffective for neurological manifestations 5
• Treating persistent symptoms with prolonged courses of antibiotics without evidence of active infection 8
• Failing to consider co-infections in patients with persistent symptoms 5