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, amoxicillin 500 mg three times daily, or cefuroxime axetil 500 mg twice daily for 14 days (range 10-21 days for doxycycline, 14-21 days for amoxicillin or cefuroxime). 1

Early Localized and Early Disseminated Lyme Disease

First-Line Oral Antibiotic Options for Adults

• Doxycycline 100 mg twice daily for 10-21 days is highly effective and has the added advantage of treating co-infections like human granulocytic anaplasmosis that may be transmitted simultaneously 1
• Amoxicillin 500 mg three times daily for 14-21 days is equally effective and preferred in pregnancy, lactation, and children under 8 years 1
• Cefuroxime axetil 500 mg twice daily for 14-21 days serves as an alternative β-lactam option 1

Pediatric Dosing

• Amoxicillin 50 mg/kg/day in 3 divided doses (maximum 500 mg per dose) 1
• Cefuroxime axetil 30 mg/kg/day in 2 divided doses (maximum 500 mg per dose) 1
• Doxycycline 4 mg/kg/day in 2 divided doses (maximum 100 mg per dose) for children ≥8 years 1

Macrolides: Last Resort Only

• Macrolides are NOT recommended as first-line therapy because they are less effective than other options 1
• Reserve azithromycin (500 mg daily for 7-10 days), clarithromycin (500 mg twice daily for 14-21 days), or erythromycin (500 mg four times daily for 14-21 days) only for patients with true intolerance to doxycycline, amoxicillin, AND cefuroxime 1
• Patients on macrolides require close monitoring to ensure clinical resolution 1

Neurologic Lyme Disease

Lyme Meningitis and CNS Involvement

• IV ceftriaxone 2 g once daily (or 50-75 mg/kg/day for children, maximum 2 g) for 14-28 days is the preferred treatment 1
• Alternative IV options include cefotaxime 2 g every 8 hours (150-200 mg/kg/day in children, maximum 6 g/day) or penicillin G 18-24 million units/day in divided doses every 4 hours 1
• Oral doxycycline 200-400 mg/day in 2 divided doses for 10-28 days may be adequate for neurologic Lyme disease 1

Facial Nerve Palsy (Seventh Cranial Nerve)

• Antibiotics should be given to prevent further sequelae, even though they may not hasten resolution of the palsy itself 1
• If no meningeal signs and normal CSF (or CSF not obtained): treat with standard oral regimen for 14-21 days 1
• If CSF shows pleocytosis or clinical signs of meningitis: treat as Lyme meningitis with IV antibiotics 1
• Lumbar puncture is indicated when there is strong clinical suspicion of CNS involvement (severe/prolonged headache, nuchal rigidity) 1

Lyme Carditis

Risk Stratification and Monitoring

• Obtain ECG in any patient with Lyme disease presenting with lightheadedness, syncope, palpitations, dyspnea, chest pain, or edema 1, 2
• Hospitalize with continuous cardiac monitoring if PR interval >300 milliseconds, other arrhythmias, or clinical manifestations of myopericarditis 1, 2
• Hospitalization is also recommended for symptomatic patients and those with second- or third-degree AV block, or first-degree block with PR ≥300 milliseconds 1

Antibiotic Treatment

• Outpatients with Lyme carditis: oral antibiotics (doxycycline, amoxicillin, cefuroxime, or azithromycin) for 14-21 days 1, 2
• Hospitalized patients: initiate IV ceftriaxone until clinical improvement, then switch to oral antibiotics to complete 14-21 days total 1, 2

Cardiac Management

• For symptomatic bradycardia requiring pacing: use temporary pacing modalities rather than permanent pacemaker, as conduction abnormalities typically resolve with antibiotic treatment 1, 2
• Expert cardiology consultation is recommended for advanced heart block 1

Lyme Arthritis

Antibiotic Regimen

• Oral antibiotics for 28 days is the recommended initial treatment 1
• Use the same oral agents as for early Lyme disease (doxycycline, amoxicillin, or cefuroxime) 1

Management of Persistent Arthritis

• If partial improvement after first oral course: consider a second 4-week course of oral antibiotics 1
• If no improvement after oral therapy: consider IV ceftriaxone, but only if PCR of synovial fluid/tissue is positive 1
• If arthritis persists despite IV therapy and PCR is negative: symptomatic treatment with NSAIDs, intra-articular corticosteroids, or DMARDs (hydroxychloroquine) with rheumatology consultation 1

Post-Treatment Lyme Disease Syndrome

Do NOT prescribe additional antibiotics for patients with persistent nonspecific symptoms (fatigue, pain, cognitive impairment) following standard treatment who lack objective evidence of reinfection or treatment failure. 1, 2

• This is a strong recommendation based on moderate-quality evidence showing no benefit from prolonged antibiotic therapy 1
• Objective evidence of treatment failure includes active arthritis, meningitis, or neuropathy—not subjective symptoms alone 1, 2
• These patients require symptomatic management, not antimicrobial therapy 2

Special Populations

Pregnancy and Lactation

• Treat identically to non-pregnant patients with the same disease manifestation, except avoid doxycycline 1
• Use amoxicillin or cefuroxime as first-line agents 1

Children Under 8 Years

• Avoid doxycycline due to risk of dental staining 1
• Use amoxicillin or cefuroxime axetil as first-line therapy 1

Common Pitfalls to Avoid

• Do not dismiss cardiac symptoms in Lyme disease patients without ECG evaluation—these may represent life-threatening Lyme carditis requiring immediate treatment 2
• Do not use macrolides as first-line therapy—they are significantly less effective than doxycycline, amoxicillin, or cefuroxime 1
• Do not place permanent pacemakers in acute Lyme carditis—conduction abnormalities typically resolve with antibiotics, and temporary pacing suffices 1, 2
• Do not continue antibiotics indefinitely for post-treatment symptoms—this represents a non-infectious process unresponsive to antimicrobials 1, 2
• Do not treat asymptomatic seropositive patients—seropositivity alone without clinical manifestations does not warrant treatment 1