From the Guidelines
For a patient presenting with a skin rash suggestive of Lyme disease, empiric treatment is recommended without waiting for test results, as supported by the most recent guidelines from the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR) 1. The preferred treatment is doxycycline 100 mg orally twice daily for 10-14 days for adults.
- Alternative options include:
- amoxicillin 500 mg three times daily
- cefuroxime axetil 500 mg twice daily for 14-21 days for those who cannot take doxycycline (pregnant women, children under 8, or those with allergies). Children should receive weight-based dosing:
- doxycycline 4 mg/kg/day divided twice daily (if ≥8 years old)
- amoxicillin 50 mg/kg/day divided three times daily
- cefuroxime 30 mg/kg/day divided twice daily. Early treatment is crucial because it prevents progression to later stages of Lyme disease, which can affect the heart, joints, and nervous system. The characteristic erythema migrans rash (bull's-eye appearance) is diagnostic and highly specific for Lyme disease, making laboratory testing unnecessary for initial treatment decisions, as stated in the guidelines 1. Serologic testing in early disease often yields false negatives since antibodies take several weeks to develop, so waiting for test results could delay necessary treatment and lead to disease progression. In patients with potential tick exposure in a Lyme disease endemic area who have 1 or more skin lesions compatible with erythema migrans, clinical diagnosis rather than laboratory testing is recommended 1. This approach is supported by the guidelines, which emphasize the importance of prompt treatment to prevent complications and improve patient outcomes. The treatment options and recommendations are also supported by earlier studies, such as the 2006 guidelines from the Infectious Diseases Society of America 1.
From the Research
Diagnosis and Treatment of Lyme Disease
- Lyme disease is typically diagnosed clinically, with serologic testing used to support the diagnosis 2, 3, 4
- The disease is usually treated with doxycycline or amoxicillin, with cefuroxime axetil or erythromycin used as alternatives 5, 2, 6
- Late or severe disease may require intravenous ceftriaxone or penicillin G 2
Empirical Treatment
- Empirical treatment may be considered in patients with symptoms suggestive of Lyme disease, particularly in endemic areas or with known exposures to ticks 3
- A high clinical suspicion should be present for patients in endemic areas or with known exposures to ticks 3
- The decision to test or treat empirically should be based on the individual patient's presentation and risk factors 2, 3
Treatment Outcomes
- Studies have shown that cefuroxime axetil and doxycycline are effective in treating early Lyme disease, with satisfactory clinical outcomes achieved in 93% and 88% of patients, respectively 6
- Amoxicillin has also been shown to be effective in treating early Lyme disease, with total resolution of erythema migrans in 67% of patients 5
- Treatment outcomes are generally better when treatment is started early in the course of the disease 4