From the Guidelines
The recommended approach for this 69-year-old female with an embedded tick is prompt and proper tick removal, as outlined in the 2024 American Heart Association and American Red Cross guidelines for first aid 1. Using fine-tipped tweezers, grasp the tick as close to the skin's surface as possible and pull upward with steady, even pressure. Avoid twisting or jerking the tick, which can cause mouthparts to break off in the skin. After removal, clean the bite area with rubbing alcohol, an iodine scrub, or soap and water. The patient should monitor for symptoms of tick-borne illness over the next 30 days, including fever, rash (particularly an expanding bull's-eye pattern), fatigue, headache, muscle/joint pain, or neck stiffness. Prophylactic antibiotics are not routinely recommended after tick bites unless certain criteria are met, such as the tick being an adult or nymphal I. scapularis tick attached for ≥36 hours, and the patient being in a highly endemic region 1. Since the patient has no current symptoms of infection, observation is appropriate. The risk of disease transmission is related to the duration of tick attachment, with most pathogens requiring at least 24-48 hours of feeding to transmit infection, as noted in the guidelines 1. Proper tick removal and disposal (in alcohol, sealed bag, or flushing) prevents further exposure. The patient should follow up if any symptoms develop, as early treatment of tick-borne illnesses improves outcomes. Key considerations for the patient include:
- Monitoring for symptoms of tick-borne illness
- Understanding the importance of prompt tick removal
- Recognizing the signs of infection, such as fever, rash, or joint pain
- Following up with a healthcare provider if symptoms develop It is essential to prioritize the patient's morbidity, mortality, and quality of life when making decisions about tick bite management, and to base these decisions on the most recent and highest-quality evidence available, such as the 2024 American Heart Association and American Red Cross guidelines for first aid 1.
From the Research
Patient Presentation
The patient is a 69-year-old female who presents for evaluation in urgent care after a tick bite to her right knee. The tick is still intact and embedded in the skin. She denies any fever, neck pain, joint pain, or rash.
Risk of Lyme Disease
- The patient is at risk of developing Lyme disease, which is the most common tick-borne disease in the United States 2.
- The disease is transmitted to humans through the bite of the Ixodes tick (Ixodes scapularis and Ixodes pacificus) and typically requires the tick to feed for at least 36 hours for transmission of the causative bacterium, Borrelia burgdorferi, to occur 2.
Clinical Features and Diagnosis
- The clinical features of Lyme disease include early localized infection with erythema migrans, fever, malaise, fatigue, headache, myalgias, and arthralgias, followed by early disseminated infection with neurologic, musculoskeletal, or cardiovascular symptoms and multiple erythema migrans lesions, and late disseminated infection with intermittent swelling and pain of one or more joints (especially knees) 2.
- Diagnosis is usually made clinically, but laboratory tests may be used to confirm the diagnosis.
Treatment Options
- Treatment options for Lyme disease include doxycycline or amoxicillin, with cefuroxime axetil or erythromycin as alternative options 2.
- For patients with acute disseminated Lyme disease, oral doxycycline and parenteral ceftriaxone have been shown to be equally effective in preventing late manifestations of the disease 3.
- A network meta-analysis found that oral amoxicillin, azithromycin, injectable ceftriaxone, and injectable cefotaxime were effective for treating Lyme disease, while cefuroxime and penicillin were safe for treating the disease 4.
- Another study found that 14-day oral doxycycline was not inferior to 14-day intravenous ceftriaxone in treating adult European patients with early disseminated Lyme borreliosis manifested as multiple erythema migrans 5.
- Doxycycline has also been shown to be as effective as ceftriaxone in treating patients with chronic Lyme borreliosis with symptoms suggesting central nervous system involvement, but without overt clinical signs of it 6.