What is the recommended management for a healthy adult or child bitten by an Ixodes scapularis tick in a Lyme‑endemic area, including tick removal technique, criteria for doxycycline prophylaxis, alternative antibiotics for pregnancy or young children, treatment considerations for Rocky Mountain spotted fever, tetanus immunization update, and follow‑up monitoring?

Tick Bite Management Guidelines

Immediate Tick Removal

Remove attached ticks immediately using fine-tipped tweezers, grasping the tick's head as close to the skin as possible and pulling upward with steady, even pressure. 1

• Do not burn the tick with matches or heat devices 1
• Do not apply petroleum jelly, nail polish, gasoline, kerosene, or other chemicals 1
• Clean the bite site thoroughly with soap and water, alcohol, or iodine scrub after removal 1, 2
• If mouthparts remain embedded, clean the site and leave them alone—they will be expelled naturally without increasing infection risk 2

Antibiotic Prophylaxis Decision Algorithm

Prophylactic doxycycline is recommended ONLY when ALL three high-risk criteria are met: 1, 3

1. Tick species: Identified as Ixodes scapularis (deer tick/black-legged tick) 1
2. Geographic location: Bite occurred in highly endemic area (parts of New England, mid-Atlantic states, Minnesota, Wisconsin with ≥20% tick infection rates) 1
3. Duration of attachment: Tick was attached for ≥36 hours (estimated by degree of engorgement) 1

Additional requirements for prophylaxis: 1

• Prophylaxis must be administered within 72 hours of tick removal 1
• Doxycycline is not contraindicated for the patient 1

If ALL criteria are met:

• Adults: Single dose of 200 mg oral doxycycline 1
• Children ≥8 years: Single dose of 4.4 mg/kg oral doxycycline (maximum 200 mg) 1

If ANY criterion is NOT met:

• Use a wait-and-watch approach rather than prophylaxis 1, 3
• Do not substitute amoxicillin or other antibiotics for prophylaxis 1

Special Populations

Pregnant women and children <8 years: 1, 3

• Doxycycline is relatively contraindicated 1
• Do not give prophylactic antibiotics; use wait-and-watch approach instead 1
• If Lyme disease develops (erythema migrans), treat with amoxicillin for 14 days 1

Laboratory Testing

Do NOT order serologic testing for asymptomatic patients after a tick bite. 1, 4

• Testing provides no clinical benefit and may lead to false positives 4
• Antibody responses take weeks to develop, making early testing unreliable 4
• Submitting the tick for species identification only is reasonable to determine if prophylaxis criteria are met 1
• Do not test the tick for Borrelia burgdorferi DNA—results do not reliably predict clinical infection 4

Post-Bite Monitoring (30 Days)

Monitor the bite site and patient for: 2, 4

• Erythema migrans: Expanding "bullseye" or solid red rash at bite site 2, 4
• Systemic symptoms: Fever, headache, muscle pain, joint pain, swollen lymph nodes 2
• Rocky Mountain spotted fever signs: Petechial rash starting on wrists, forearms, and ankles 2, 5

If erythema migrans develops:

• Diagnose clinically without laboratory testing 1, 4
• Treat with 10-day course of doxycycline OR 14-day course of amoxicillin or cefuroxime axetil 1

Rocky Mountain Spotted Fever Considerations

If petechial rash and fever develop, start doxycycline immediately—do not delay for laboratory confirmation. 6, 5, 7

• Doxycycline is the treatment of choice for all ages, including children <8 years 6, 5
• Rocky Mountain spotted fever is the most lethal tick-borne illness in the United States 7
• Treatment should begin when disease is suspected based on clinical findings 5, 7

Tetanus Immunization

• Update tetanus immunization if not current (general medical knowledge applies, though not specifically addressed in tick bite guidelines)

Prevention of Future Tick Bites

Use EPA-registered repellents: 1, 3

• Apply DEET, picaridin, IR3535, oil of lemon eucalyptus (OLE), PMD, or 2-undecanone to exposed skin 1
• Apply permethrin to clothing and gear (not directly to skin) 1, 3

Physical protective measures: 1, 3

• Wear long-sleeved shirts, long pants, socks, and closed-toe shoes in tick-infested areas 3
• Perform daily full-body tick checks after outdoor exposure 1, 3
• Wear light-colored clothing to identify crawling ticks more easily 8

Critical Pitfalls to Avoid

• Do NOT give prophylactic antibiotics for all tick bites—only for bites meeting all three high-risk criteria 1
• Do NOT administer prophylaxis beyond 72 hours of tick removal—efficacy data do not support this 1
• Do NOT order routine serologic testing for asymptomatic patients 1, 4
• Do NOT delay tick removal—transmission risk increases significantly after 36 hours of attachment 1, 9
• Remember: A single dose of doxycycline may prevent Lyme disease but does not necessarily prevent other tick-borne diseases (anaplasmosis, babesiosis) 4