What is the recommended treatment for Lyme disease?

Treatment of Lyme Disease

For early Lyme disease with erythema migrans, treat with oral doxycycline 100 mg twice daily or amoxicillin 500 mg three times daily for 14-21 days; for neurologic involvement with parenchymal brain or spinal cord disease, use IV antibiotics; and for Lyme arthritis, use oral antibiotics for 28 days. 1

Early Localized Disease (Erythema Migrans)

First-line oral antibiotic options:

• Doxycycline 100 mg twice daily for 14-21 days 2, 3
• Amoxicillin 500 mg three to four times daily for 14-21 days, with or without probenecid 500 mg three times daily 4, 2
• Cefuroxime axetil as an alternative second-line option 2, 3

Key considerations for early disease:

• Oral therapy is sufficient even for patients with severe early manifestations 4
• Treatment clears signs and symptoms in approximately 90% of patients with relapse rates less than 5% at 6 months 2
• Avoid doxycycline in pregnant women, breastfeeding women, and children under 8 years old due to risk of tooth and bone disorders 2
• Macrolides (azithromycin, clarithromycin, erythromycin) have lower efficacy and should be avoided as first-line agents 2, 3

Neurologic Lyme Disease

For parenchymal brain or spinal cord involvement:

• Use IV antibiotics over oral antibiotics (strong recommendation) 5
• IV ceftriaxone, cefotaxime, or penicillin G for 14-21 days 1
• Oral doxycycline is an alternative for 14-21 days in select cases 1

For acute neurologic presentations requiring testing:

• Meningitis, painful radiculoneuritis, mononeuropathy multiplex, acute cranial neuropathies (particularly VII, VIII), or spinal cord inflammation with epidemiologically plausible tick exposure warrant testing and treatment 5

For isolated facial nerve palsy:

• Oral therapy is usually sufficient if the patient has no other signs or symptoms and normal cerebrospinal fluid 4
• No recommendation exists for or against corticosteroids 5

Lyme Carditis

Outpatient management:

• Oral antibiotics preferred over IV antibiotics for outpatients 5
• Options include doxycycline, amoxicillin, cefuroxime axetil, or azithromycin 5
• Total duration: 14-21 days 5, 1

Inpatient management:

• Initially use IV ceftriaxone until clinical improvement, then switch to oral antibiotics to complete treatment 5
• Admit patients with PR interval >300 milliseconds, other arrhythmias, or clinical manifestations of myopericarditis for continuous ECG monitoring 5
• For symptomatic bradycardia unresponsive to medical management, use temporary pacing rather than permanent pacemaker implantation 5

Clinical indicators for ECG monitoring:

• Perform ECG only in patients with symptoms consistent with Lyme carditis: dyspnea, edema, palpitations, lightheadedness, chest pain, syncope, exercise intolerance, presyncope, pericarditic pain, elevated troponin, or shortness of breath 5

Lyme Arthritis

Treatment approach:

• Use oral antibiotic therapy for 28 days (strong recommendation) 5, 1
• Oral amoxicillin or doxycycline are first-line options 3

For partial response after first course:

• Mild residual joint swelling after initial treatment: no clear recommendation exists for second course versus observation 5
• Consider excluding other causes of joint swelling, assess medication adherence, and evaluate duration of arthritis prior to initial treatment 5

For treatment failure:

• No or minimal response may require IV ceftriaxone for 2-4 weeks 6

Post-Treatment Management: Critical Decision Algorithm

Step 1: Assess for objective signs of active disease

• Objective findings required: arthritis with documented joint swelling and effusion, meningitis with CSF abnormalities, neuropathy with objective neurologic findings, or carditis with documented conduction abnormalities 6

Step 2: If only nonspecific symptoms present

• Do NOT prescribe additional antibiotics for persistent fatigue, pain, or cognitive impairment without objective evidence of reinfection or treatment failure (strong recommendation) 5, 6, 1
• Treatment failure rate with appropriate initial therapy is approximately 1%; cure rate is approximately 99% 6

Step 3: Interpret serology correctly

• Never treat based on positive IgM serology alone without objective clinical findings 6
• IgM antibodies commonly persist for months or years after successful treatment and do not indicate ongoing infection 6
• Serologic testing cannot distinguish between past treated infection and active disease 6

Common Pitfalls to Avoid

• Do not routinely test for Lyme disease in patients with psychiatric illness, developmental/behavioral disorders, typical ALS, relapsing-remitting MS, Parkinson's disease, dementia, cognitive decline, or new-onset seizures 5
• Do not prescribe prolonged or unending courses of antibiotics for noninfectious problems such as fibromyalgia that may persist after treatment 4
• Do not confuse persistent antibodies with persistent infection 6
• Routine antibiotic prophylaxis after tick bite is not justified even in endemic areas, as infection risk is low 2