When should you test and empirically treat for Lyme (Lyme disease) borreliosis?

From the Guidelines

Testing and empirical treatment for Lyme disease should be considered when a patient presents with compatible symptoms, such as erythema migrans, and has been in an endemic area with potential tick exposure, with clinical diagnosis being the preferred approach for typical erythema migrans cases, as recommended by the 2020 guidelines 1. When evaluating patients for Lyme disease, it is essential to consider the clinical presentation, exposure history, and endemic area status.

• Typical erythema migrans lesions are pathognomonic for Lyme disease and do not require laboratory testing for diagnosis, according to the Infectious Diseases Society of America (IDSA) guidelines 1.
• For patients with atypical skin lesions, antibody testing may be considered, with a two-tier approach involving an enzyme immunoassay (EIA) or immunofluorescence assay (IFA) followed by Western blot confirmation if the initial result is positive or equivocal.
• Empiric treatment with antibiotics should be initiated immediately in patients with typical erythema migrans, without waiting for test results, to prevent potential complications.
• The first-line treatment for early localized disease is doxycycline 100mg twice daily for 10-14 days, although alternatives like amoxicillin or cefuroxime axetil may be used in certain cases, as outlined in the clinical practice guidelines by the IDSA 1.
• Treatment decisions should prioritize the risk of untreated infection against unnecessary antibiotic exposure, considering the potential for serious complications, including cardiac, neurologic, and rheumatologic manifestations, if Lyme disease is left untreated 1.

From the Research

Testing and Empirical Treatment for Lyme Disease

• The decision to test and empirically treat for Lyme disease should be based on clinical presentation and risk factors, as diagnosis is usually made clinically 2.
• Residents of the coastal Northeast, northwest California, and the Great Lakes region are at highest risk, as well as children and those spending extended time outdoors in wooded areas 2.
• The disease is transmitted to humans through the bite of the Ixodes tick, and typically, the tick must feed for at least 36 hours for transmission of the causative bacterium, Borrelia burgdorferi, to occur 2.
• Testing for Lyme disease begins with an enzyme-linked immunosorbent assay (ELISA), and if the ELISA is positive or borderline, Western blots should be performed for both IgM and IgG antibodies 3.
• Empirical treatment may be considered in patients with a high risk of exposure and clinical symptoms consistent with Lyme disease, such as erythema migrans, fever, malaise, fatigue, headache, myalgias, and arthralgias 2, 4.
• Treatment is typically accomplished with doxycycline or amoxicillin, and late or severe disease requires intravenous ceftriaxone or penicillin G 2, 3.
• Single-dose doxycycline (200 mg orally) can be used as prophylaxis in selected patients, but the effectiveness of this approach is still being studied 2, 5.
• Clinical practice guidelines, such as those developed by the Infectious Diseases Society of America, American Academy of Neurology, and American College of Rheumatology, provide evidence-based recommendations for the prevention, diagnosis, and treatment of Lyme disease 4.