What is the treatment for Lyme disease?

Treatment of Lyme Disease

For early Lyme disease with erythema migrans, treat with oral doxycycline 100 mg twice daily for 10-14 days in adults and children ≥8 years old, or amoxicillin 500 mg three times daily for 14 days in younger children and pregnant patients. 1, 2

Early Localized Disease (Erythema Migrans)

First-Line Oral Regimens

Adults and children ≥8 years:

• Doxycycline 100 mg twice daily for 10-14 days is the preferred agent 1, 3
• Doxycycline has the critical advantage of treating concurrent human granulocytic anaplasmosis (HGA), which may coexist in up to 10% of cases 2
• Patients must avoid sun exposure due to photosensitivity risk and take with 8 ounces of fluid to prevent esophageal irritation 2, 4

Children <8 years and pregnant/lactating patients:

• Amoxicillin 50 mg/kg/day divided into 3 doses (maximum 500 mg per dose) for 14 days 2
• Alternative: Cefuroxime axetil 30 mg/kg/day in 2 divided doses (maximum 500 mg per dose) for 14 days 2
• Doxycycline must be avoided in pregnancy and young children 1

Agents to Avoid

• First-generation cephalosporins (cephalexin) are completely ineffective and should never be used 1, 2
• Fluoroquinolones, carbapenems, vancomycin, metronidazole, and azithromycin are not recommended 1
• Macrolides (azithromycin, clarithromycin) are significantly less effective and should only be used when patients cannot tolerate first-line agents 2

Early Neurologic Disease

Meningitis or Radiculopathy

Parenteral therapy is required:

• Ceftriaxone 2 g IV once daily (or 50-75 mg/kg/day in children, maximum 2 g) for 14 days (range 10-28 days) 1, 2
• Alternative: Cefotaxime 2 g IV every 8 hours or penicillin G 18-24 million units/day divided every 4 hours 1

Isolated Cranial Nerve Palsy (Facial Nerve Palsy)

Oral therapy is sufficient if no meningeal signs:

• Use the same oral regimens as for erythema migrans for 14-21 days 1
• Lumbar puncture is indicated only if severe headache, nuchal rigidity, or other CNS symptoms are present 1
• If CSF shows pleocytosis, switch to parenteral therapy as for meningitis 1
• No recommendation can be made regarding corticosteroid use 1

Lyme Carditis

Outpatient Management

• Oral antibiotics (doxycycline, amoxicillin, or cefuroxime) for 14-21 days for mild cases 1

Hospitalization Criteria

Admit patients with any of the following:

• PR interval >300 milliseconds 1
• Second- or third-degree AV block 1
• First-degree block with PR ≥300 milliseconds (can rapidly progress) 1
• Symptomatic bradycardia, syncope, dyspnea, chest pain, or signs of myopericarditis 1

Hospitalized patients:

• Start with IV ceftriaxone 2 g daily until clinical improvement, then switch to oral antibiotics to complete 14-21 days total 1
• Continuous cardiac monitoring is mandatory 1
• Use temporary pacing for symptomatic bradycardia rather than permanent pacemaker 1

Lyme Arthritis

Initial Treatment

• Oral antibiotics for 28 days (doxycycline, amoxicillin, or cefuroxime) 1
• Serum antibody testing is preferred over PCR or culture for diagnosis 1

Persistent or Recurrent Arthritis

• Consider a second 28-day course of oral antibiotics if partial improvement occurred 1
• If no improvement after oral therapy and synovial fluid PCR is negative, switch to symptomatic treatment with NSAIDs, intra-articular corticosteroids, or DMARDs (hydroxychloroquine) rather than more antibiotics 1
• Arthroscopic synovectomy may reduce duration of joint inflammation 1

Late Neurologic Disease

For CNS or peripheral nervous system involvement:

• IV ceftriaxone 2 g daily for 14-28 days 1, 5
• Alternative: IV cefotaxime or penicillin G 1
• Response is typically slow and may be incomplete 1

Critical Pitfalls to Avoid

Coinfection Recognition

Consider coinfection with Babesia or Anaplasma if:

• High fever persists >48 hours despite appropriate Lyme treatment 1
• Unexplained leukopenia, thrombocytopenia, or anemia present 1
• Patient more systemically ill than typical for Lyme disease alone 1

Post-Treatment Lyme Disease Syndrome

Do NOT prescribe additional antibiotics for:

• Persistent nonspecific symptoms (fatigue, pain, cognitive impairment) without objective signs of active infection 1
• Patients lacking evidence of reinfection or treatment failure 1
• Prolonged antibiotic therapy has no proven benefit and may cause harm 1, 2

Monitoring Expectations

• Most patients respond promptly to appropriate therapy 2
• Complete resolution may be delayed beyond treatment duration—this is normal 1
• Patients who are more systemically ill at diagnosis may take longer to respond 2
• Less than 10% fail to respond to initial appropriate therapy 2