Is Augmentin (amoxicillin-clavulanate) an appropriate treatment for Central Nervous System (CNS) Lyme disease?

Treatment for Central Nervous System (CNS) Lyme Disease

For Central Nervous System (CNS) Lyme disease, intravenous ceftriaxone (2g once daily for 14-21 days) is the recommended first-line treatment due to its excellent CNS penetration and convenient once-daily dosing. 1

First-Line Treatment Options

• IV ceftriaxone (2g once daily for 14-21 days) is the preferred parenteral regimen for CNS Lyme disease 1
• Alternative parenteral options include:
  • IV cefotaxime (2g every 8 hours or 150-200 mg/kg/day divided into 3-4 doses, maximum 6g/day) 1, 2
  • IV penicillin G (18-24 million units per day divided every 4 hours) 1, 2

Why Augmentin (Amoxicillin-Clavulanate) is NOT Appropriate

• Augmentin (amoxicillin-clavulanate) is not recommended for CNS Lyme disease treatment 2, 1
• The guidelines specifically recommend parenteral antibiotics (ceftriaxone, cefotaxime, or penicillin G) for CNS involvement due to their superior CNS penetration 2, 1
• While amoxicillin alone is used for early Lyme disease without CNS involvement, it is not recommended for CNS disease 3, 4
• The addition of clavulanate does not improve efficacy against Borrelia burgdorferi and is not mentioned in any treatment guidelines for Lyme disease 2, 1

Treatment Based on Neurological Manifestations

• For Lyme meningitis, encephalitis, or myelitis (parenchymal CNS involvement), parenteral antibiotics are strongly recommended 1
• Treatment duration for CNS Lyme disease is typically 14 days (range 14-28 days) 2
• In patients with increased intracranial pressure, additional interventions such as serial lumbar punctures may be necessary 1

Special Considerations

• Pregnant patients should receive the same treatment as non-pregnant patients with CNS Lyme disease, except doxycycline should be avoided 2
• Children with CNS Lyme disease should receive weight-based dosing of parenteral antibiotics 4
• Clinical improvement is the most reliable indicator of treatment success, not laboratory testing 1

Important Pitfalls to Avoid

• Do not use oral antibiotics like Augmentin for CNS Lyme disease as they have inadequate CNS penetration 1, 5
• Avoid using first-generation cephalosporins, fluoroquinolones, carbapenems, vancomycin, metronidazole, and tinidazole as they are ineffective against B. burgdorferi 2, 1
• Avoid long-term antibiotic therapy, pulsed-dosing, or combination antimicrobials as these approaches lack supporting evidence and may cause harm 2, 1
• Do not misinterpret persistent symptoms after appropriate treatment as evidence of ongoing infection requiring additional antibiotics 6

Treatment Efficacy

• Most patients with CNS Lyme disease respond well to appropriate antibiotic therapy 7
• Approximately 90% of patients show good response to recommended treatment regimens 8
• The small minority of patients (<10%) who have persistent symptoms after treatment may have post-treatment Lyme disease syndrome rather than active infection 8

In conclusion, Augmentin (amoxicillin-clavulanate) is not an appropriate treatment for CNS Lyme disease. Parenteral antibiotics, particularly ceftriaxone, are the standard of care for this condition due to their superior CNS penetration.