What is the recommended treatment for Lyme disease?

Treatment of Lyme Disease

The treatment of Lyme disease depends on the stage and manifestations of disease, with oral antibiotics (doxycycline, amoxicillin, or cefuroxime axetil) for 14-21 days as first-line therapy for early disease, and parenteral antibiotics reserved for CNS involvement or severe manifestations. 1

Early Localized Disease (Erythema Migrans)

Oral antibiotic regimens are the standard of care for early Lyme disease: 1

• Doxycycline 100 mg twice daily for 14-21 days (can be as short as 10 days with doxycycline) 1, 2
• Amoxicillin 500 mg three or four times daily for 14-21 days 1, 2
• Cefuroxime axetil for 14-21 days 1, 2

For patients intolerant of first-line agents, alternative options include: 1

• Azithromycin 500 mg daily for 7-10 days (lower efficacy, requires close monitoring) 1
• Clarithromycin or erythromycin (if not pregnant) 1

Doxycycline should be avoided in pregnant/lactating women and children under 8 years old due to risk of tooth and bone disorders. 1, 3

Neurologic Lyme Disease

Cranial Nerve Palsy (Isolated Facial Palsy)

Patients with isolated seventh cranial nerve palsy and normal CSF can be treated with oral antibiotics for 14-21 days. 1

• Lumbar puncture is indicated if there is strong clinical suspicion of CNS involvement (severe/prolonged headache, nuchal rigidity) 1
• Those with CSF pleocytosis should receive parenteral therapy 1
• No recommendation exists for or against corticosteroids 1

Meningitis, Radiculoneuritis, or CNS Involvement

Parenteral antibiotics are required for 14 days (range 10-28 days): 1, 2

• IV ceftriaxone 2 g once daily (preferred) 1
• IV cefotaxime 2 g every 8 hours 1
• IV penicillin G 18-24 million units daily divided every 4 hours 1
• Oral doxycycline 200-400 mg daily may be used in non-pregnant adults intolerant of β-lactams 1

For parenchymal brain or spinal cord involvement, IV antibiotics are strongly recommended over oral therapy. 1

Lyme Carditis

Treatment approach depends on severity and setting: 1

Outpatient Management

• Oral antibiotics (doxycycline, amoxicillin, cefuroxime axetil, or azithromycin) for 14-21 days 1, 2

Hospitalized Patients

• Initial IV ceftriaxone until clinical improvement, then switch to oral antibiotics to complete 14-21 days total 1
• Hospital admission with continuous ECG monitoring is required for: 1
  • PR interval >300 milliseconds
  • Second- or third-degree AV block
  • Symptomatic patients (syncope, dyspnea, chest pain)
  • Clinical manifestations of myopericarditis 1

Temporary pacing is recommended over permanent pacemaker for symptomatic bradycardia that cannot be managed medically, as conduction abnormalities typically resolve with antibiotic therapy. 1

Lyme Arthritis

Oral antibiotics for 28 days are first-line therapy: 1, 2

• Doxycycline, amoxicillin, or cefuroxime axetil 1

For patients with partial response after initial oral therapy: 4, 5

• Consider observation or a second 28-day course of oral antibiotics 4, 5

For minimal or no response to oral therapy: 4, 5, 2

• IV ceftriaxone for 2-4 weeks 4, 5

For antibiotic-refractory arthritis (PCR-negative synovial fluid): 1

• Symptomatic therapy with NSAIDs, intra-articular corticosteroids, or DMARDs (e.g., hydroxychloroquine) 1
• Consider arthroscopic synovectomy 1, 5

Critical Pitfalls to Avoid

Do not treat based on positive serology alone without objective clinical findings: 4

• IgM antibodies commonly persist for months to years after successful treatment 4
• Positive IgM does not indicate treatment failure or active infection 4
• Treatment failure rate with appropriate initial therapy is approximately 1% 4, 5

Do not provide additional antibiotic therapy for persistent nonspecific symptoms without objective evidence of active disease: 1, 4, 2

• Objective signs required include: documented joint swelling/effusion, CSF abnormalities, objective neurologic findings, or documented conduction abnormalities 4
• Persistent subjective symptoms alone do not warrant retreatment 4, 2

Avoid these ineffective or harmful therapies: 1

• First-generation cephalosporins, fluoroquinolones, vancomycin, metronidazole, benzathine penicillin G, long-term antibiotic therapy, or combination antimicrobials for standard Lyme disease 1

Consider coinfection with Babesia or Anaplasma in patients with: 1

• High-grade fever persisting >48 hours despite appropriate antibiotics 1
• Unexplained leukopenia, thrombocytopenia, or anemia 1
• More severe initial symptoms than typical for Lyme disease alone 1

Special Populations

Pregnant patients should be treated identically to non-pregnant patients except doxycycline must be avoided. 1

Children under 8 years should receive amoxicillin rather than doxycycline. 1