What is the recommended follow-up protocol after a tick bite?

Tick Bite Follow-Up Protocol

After a tick bite, routine antibiotic prophylaxis is NOT recommended; instead, monitor the bite site and patient for 30 days for signs of tick-borne disease, and only consider a single dose of doxycycline prophylaxis if ALL specific high-risk criteria are met within 72 hours of tick removal. 1

Immediate Post-Removal Actions

Remove the tick promptly using fine-tipped tweezers, grasping as close to the skin as possible and pulling upward with steady pressure—avoid burning, petroleum jelly, or other folk remedies as these are ineffective and potentially harmful. 2, 3

• Clean the bite site thoroughly with soap and water, alcohol, or iodine scrub after removal. 1, 2
• Wash hands thoroughly after handling the tick. 2
• If tick mouthparts remain embedded, clean the site and leave them alone—the body will expel them naturally without increasing infection risk. 2

Antibiotic Prophylaxis Decision Algorithm

Prophylaxis is ONLY indicated when ALL five criteria are met simultaneously: 1, 3

1. Tick species: Definitively identified as Ixodes scapularis (blacklegged/deer tick) 1, 3
2. Geographic location: Bite occurred in highly endemic area (≥20% tick infection rate)—parts of New England, mid-Atlantic states, Minnesota, or Wisconsin 1, 3
3. Attachment duration: Tick was attached ≥36 hours (estimated by degree of engorgement) 1, 3
4. Timing: Prophylaxis can be started within 72 hours of tick removal 1, 3
5. No contraindications: Doxycycline is not contraindicated for the patient 1, 3

Prophylaxis Dosing (When All Criteria Met)

• Adults: Single dose of doxycycline 200 mg orally 1, 3
• Children ≥8 years: Single dose of doxycycline 4 mg/kg (maximum 200 mg) 1, 3
• Pregnant women and children <8 years: Doxycycline is relatively contraindicated; do NOT substitute amoxicillin as no effective short-course prophylaxis regimen exists. 1

Important caveat: A 2021 European trial demonstrated 67% relative risk reduction with single-dose doxycycline prophylaxis after Ixodes ricinus bites (number-needed-to-treat = 51), supporting efficacy beyond North American data. 4 However, prophylaxis may prevent Lyme disease but not necessarily other tick-borne diseases like anaplasmosis or babesiosis. 1, 2

Monitoring Protocol (All Patients)

Monitor closely for 30 days after tick removal, regardless of whether prophylaxis was given. 1, 3

Watch for These Specific Signs:

• Expanding skin lesion at bite site (erythema migrans/"bullseye" rash)—pathognomonic for Lyme disease 1, 5
• Flu-like symptoms: fever, headache, myalgias, arthralgias 6, 7
• Petechial rash starting on wrists, forearms, and ankles (suggests Rocky Mountain spotted fever) 2, 7
• Swollen lymph nodes 3

When to Seek Immediate Medical Care:

• Development of erythema migrans at any time during the 30-day period 2, 3
• Fever with rash or severe headache 7
• Any concerning systemic symptoms 1

What NOT to Do: Common Pitfalls

• Do NOT give routine prophylaxis to all tick bites—the risk of infection after any single tick bite is low (1-3% for spotted fever rickettsiae, 5-15% for ehrlichiosis, 10-50% for anaplasmosis in endemic areas). 1
• Do NOT perform routine serologic testing after asymptomatic tick bites—tests are unreliable in early infection. 1
• Do NOT test the tick itself for pathogens—finding Borrelia DNA in a tick does not prove the patient will develop disease. 7, 8
• Do NOT delay tick removal—transmission risk increases significantly after 24-36 hours of attachment. 6, 8, 9
• Do NOT use prophylaxis for Ixodes pacificus (Western blacklegged tick) bites—generally not necessary. 1

Prevention of Future Tick Bites

• Use EPA-registered repellents (DEET, picaridin, IR3535, oil of lemon eucalyptus) on exposed skin. 5, 2, 3
• Apply permethrin to clothing for additional protection. 2
• Wear protective clothing: long sleeves, pants tucked into socks, closed-toe shoes in tick-infested areas. 5, 2
• Perform daily full-body tick checks after outdoor activities. 5, 2, 3

Special Consideration: Wait-and-Watch Approach

For patients early in illness with non-specific symptoms and normal laboratory findings, a 24-48 hour observation period is reasonable before initiating empiric treatment. 1 However, if clinical suspicion for Rocky Mountain spotted fever is high, do NOT delay doxycycline treatment—this disease has 5-10% mortality even with treatment and up to 20% mortality without treatment. 1