What is the appropriate treatment and management for a patient suspected of having Lyme disease?

Treatment and Management of Lyme Disease

For early Lyme disease with erythema migrans, treat adults with doxycycline 100 mg twice daily for 14 days (range 10-21 days), or alternatively amoxicillin 500 mg three times daily or cefuroxime axetil 500 mg twice daily for 14-21 days. 1

First-Line Oral Therapy for Early Localized/Disseminated Lyme Disease

Adults:

• Doxycycline 100 mg twice daily for 14 days (range 10-21 days) is the preferred first-line agent 1
• Doxycycline has the added advantage of treating concurrent human granulocytic anaplasmosis (HGA), which may occur simultaneously with Lyme disease 1
• Alternative options: Amoxicillin 500 mg three times daily for 14-21 days OR cefuroxime axetil 500 mg twice daily for 14-21 days 1

Children <8 years old:

• Amoxicillin 50 mg/kg/day in 3 divided doses (maximum 500 mg per dose) for 14-21 days 1
• Alternative: Cefuroxime axetil 30 mg/kg/day in 2 divided doses (maximum 500 mg per dose) for 14-21 days 1

Children ≥8 years old:

• Doxycycline 4 mg/kg/day in 2 divided doses (maximum 100 mg per dose) for 14 days 1

When Macrolides Are Acceptable (But Not Preferred)

Macrolides are strongly discouraged as first-line therapy because they are less effective than doxycycline, amoxicillin, or cefuroxime 1. Reserve them only for patients who cannot tolerate any of the preferred agents 1:

• Azithromycin 500 mg daily for 7-10 days (adults) or 10 mg/kg/day (children, max 500 mg) 1
• Clarithromycin 500 mg twice daily for 14-21 days (adults) or 7.5 mg/kg twice daily (children, max 500 mg per dose) 1
• Patients on macrolides require close monitoring to ensure clinical resolution 1

Neurologic Lyme Disease

Early neurologic manifestations (meningitis, radiculopathy):

• Adults: Ceftriaxone 2 g IV daily for 14 days (range 10-28 days) 1
• Alternatives: Cefotaxime 2 g IV every 8 hours or penicillin G 18-24 million units/day IV divided every 4 hours 1
• Children: Ceftriaxone 50-75 mg/kg IV daily (maximum 2 g) for 14 days 1
• Alternatives: Cefotaxime 150-200 mg/kg/day IV divided into 3-4 doses (max 6 g/day) or penicillin G 200,000-400,000 units/kg/day IV every 4 hours 1

Isolated facial nerve palsy (7th cranial nerve):

• If no meningeal signs and CSF is normal (or CSF not obtained due to lack of clinical suspicion for CNS involvement): Treat with oral regimen (doxycycline, amoxicillin, or cefuroxime) for 14 days 1
• Antibiotics should be given even though they may not hasten resolution of the palsy, to prevent further sequelae 1

Late neurologic disease (CNS or peripheral nervous system involvement):

• Ceftriaxone IV for 2-4 weeks 1
• Response is typically slow and may be incomplete 1

Lyme Carditis

• Oral doxycycline, amoxicillin, or cefuroxime for 14 days (range 14-21 days) for most cases 1, 2
• Consider parenteral therapy for advanced atrioventricular heart block 1

Lyme Arthritis

Without neurologic involvement:

• Oral doxycycline, amoxicillin, or cefuroxime for 28 days 1

Recurrent arthritis after oral therapy:

• Repeat oral regimen for 14-28 days OR switch to parenteral therapy (ceftriaxone) for 14-28 days 1

Antibiotic-refractory arthritis:

• If PCR of synovial fluid is negative and no improvement after IV therapy: Switch to symptomatic treatment with NSAIDs, intra-articular corticosteroids, or DMARDs (hydroxychloroquine) 1
• Arthroscopic synovectomy may reduce duration of joint inflammation 1

Special Populations

Pregnant or lactating women:

• Treat identically to non-pregnant patients except avoid doxycycline 1, 3
• Use amoxicillin or cefuroxime axetil instead 3
• No causal association exists between B. burgdorferi infection and adverse pregnancy outcomes 3

Tick Bite Prophylaxis

Single-dose doxycycline 200 mg (or 4 mg/kg for children ≥8 years, max 200 mg) is recommended ONLY if ALL criteria are met: 1

• Attached tick identified as Ixodes scapularis (deer tick)
• Tick estimated to have been attached ≥36 hours (based on engorgement or known time of attachment)
• Prophylaxis can be started within 72 hours of tick removal
• Local Lyme disease rate ≥20%
• Doxycycline not contraindicated

Do NOT use amoxicillin for prophylaxis due to lack of data on effective short-course regimens and the excellent efficacy of treatment if infection develops 1

Monitoring After Tick Exposure

• Monitor all patients for 30 days after tick removal for development of erythema migrans or viral-like illness 1
• Consider coinfection with HGA or babesiosis if high fever persists >48 hours despite appropriate Lyme treatment, or if unexplained leukopenia, thrombocytopenia, or anemia develops 1

Critical Pitfalls to Avoid

Do NOT use these agents for Lyme disease: First-generation cephalosporins, fluoroquinolones, carbapenems, vancomycin, metronidazole, trimethoprim-sulfamethoxazole, or benzathine penicillin G 1

Do NOT use ceftriaxone for uncomplicated erythema migrans - it is not superior to oral agents and carries higher risk of serious adverse effects 1

Do NOT rely on serology alone for diagnosis - early Lyme disease is a clinical diagnosis based on erythema migrans; serology may be negative in the first several weeks 2, 4

Do NOT use positive serology as a marker of active infection - antibodies persist for months to years after successful treatment 2