Lyme disease medical therapy: Difference between revisions

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{{Lyme disease}}
{{Lyme disease}}
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==Overview==
==Overview==
The mainstay of therapy for Lyme disease is antimicrobial therapy. Antimicrobial therapy may include either [[doxycycline]], [[amoxicillin]], [[cephalosporin]]s, or [[macrolide]]s. Individuals who remove attached ticks should be monitored closely for signs and symptoms of tick-borne diseases for up to 30 days.
The mainstay of therapy for [[Lyme disease]] is [[antimicrobial]] therapy. [[Antimicrobial]] therapy may include [[doxycycline]], [[amoxicillin]], [[cephalosporin]]s, or [[macrolide]]s. The choice of [[antimicrobial]] therapy depends on the [[Lyme disease history and symptoms#Symptoms|stage of  Lyme disease]]. Individuals who remove attached [[ticks]] should be monitored closely for signs and symptoms of [[tick-borne diseases]] for up to 30 days.


==Medical Therapy==
==Medical Therapy==
===Lyme boreliosis (non-neuroborreliosis)===
===Lyme borreliosis (non-neuroborreliosis)===
* 1. '''Early Lyme Disease'''<ref>{{cite journal |vauthors=Wormser GP, Dattwyler RJ, Shapiro ED, Halperin JJ, Steere AC, Klempner MS, Krause PJ, Bakken JS, Strle F, Stanek G, Bockenstedt L, Fish D, Dumler JS, Nadelman RB |title=The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America |journal=Clin. Infect. Dis. |volume=43 |issue=9 |pages=1089–134 |year=2006 |pmid=17029130 |doi=10.1086/508667 |url=}}</ref>
'''Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for treatment of Lyme disease'''<ref name="pmid17029130">{{cite journal| author=Wormser GP, Dattwyler RJ, Shapiro ED, Halperin JJ, Steere AC, Klempner MS et al.| title=The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2006 | volume= 43 | issue= 9 | pages= 1089-134 | pmid=17029130 | doi=10.1086/508667 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17029130  }} </ref>
:* 1.1 '''Erythema migrans'''
* '''1 Stage 1 - early localized Lyme disease'''
::* 1.1.1 '''Adult'''
** 1.1 '''Erythema migrans'''
:::* Preferred regimen (1): [[Doxycycline]] 100 mg PO bid for 10-21 days   
*** 1.1.1 '''Adult'''
:::* Preferred regimen (2): [[Amoxicillin]] 500 mg PO tid for 14-21 days
**** Preferred regimen (1): [[Doxycycline]] 100 mg PO q12h for 10-21 days '''(avoid in [[pregnancy]])'''    
:::* Preferred regimen (3): [[Cefuroxime axetil]] 500 mg bid for 14-21 days
**** Preferred regimen (2): [[Amoxicillin]] 500 mg PO q8h for 14-21 days
:::* Alternative regimen (1): [[Azithromycin]] 500 mg PO qd for 7–10 days   
**** Preferred regimen (3): [[Cefuroxime axetil]] 500 mg q12h for 14-21 days
:::* Alternative regimen (2): [[Clarithromycin]] 500 mg PO bid for 14–21 days (if the patient is not pregnant)
**** Alternative regimen (1): [[Azithromycin]] 500 mg PO q6h for 7–10 days   
:::* Alternative regimen (3): [[Erythromycin]] 500 mg PO qid for 14–21 days
**** Alternative regimen (2): [[Clarithromycin]] 500 mg PO q12h for 14–21 days '''(avoid in [[pregnancy]])'''
**** Alternative regimen (3): [[Erythromycin]] 500 mg PO q6h for 14–21 days
*** 1.1.2 '''Pediatric'''
**** 1.1.2.1 '''Children < 8 years of age'''
***** Preferred regimen (1): [[Amoxicillin]] 50 mg/kg PO per day q8h (maximum, 500 mg per dose) 
***** Preferred regimen (2): [[Cefuroxime axetil]] 30 mg/kg PO per day in 2 divided doses (maximum, 500 mg per dose)
***** Alternative regimen (1): [[Azithromycin]] 10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[Clarithromycin]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
***** Alternative regimen (3): [[Erythromycin]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
****1.1.2.2 '''Children ≥ 8 years of age'''
***** Preferred regimen (1): [[Doxycycline]] 4 mg/kg/day PO q12h (maximum, 100 mg per dose）
***** Alternative regimen (1): [[Azithromycin]] 10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[Clarithromycin]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose) 
***** Alternative regimen (3): [[Erythromycin]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
** 2.1 '''When erythema migrans cannot be reliably distinguished from community-acquired bacterial [[cellulitis]]'''
*** 2.1.1 '''Adult'''
**** Preferred regimen (1): [[Amoxicillin-Clavulanate]] 500 mg PO q8h
*** 2.1.2  '''Pediatric'''
**** Preferred regimen (1):  [[Amoxicillin-Clavulanate]] 50 mg/kg/day PO q8h (maximum, 500 mg per dose)


::* 1.1.2 '''Pediatric'''
* 2 '''Stage 2 - early disseminated Lyme disease'''
:::* 1.1.2.1 '''children < 8 years of age'''  
** 2.1 '''Lyme carditis'''
::::* Preferred regimen (1): [[Amoxicillin]] 50 mg/kg PO per day in 3 divided doses (maximum of 500 mg per dose)  
**: '''Note (1):''' A [[parenteral]] regimen is recommended at the start of therapy for patients who have been hospitalized for [[cardiac monitoring]]; oral regimen may be substituted to complete a course of therapy or to treat ambulatory patients.
::::* Preferred regimen (2): [[Cefuroxime axetil]] 30 mg/kg PO per day in 2 divided doses（maximum, 500 mg per dose)
**: '''Note (2)''': A temporary [[pacemaker]] may be required for patients with advanced [[heart block]].
::*1.1.2.2 '''children ≥ 8 years of age'''
**: '''Note (3):''' Patients treated with [[Macrolide|macrolides]] should be closely observed to ensure resolution of the clinical manifest.
::::* Preferred regimen (1): [[Doxycycline]] 4 mg/kg PO per day in 2 divided doses （maximum, 100 mg per dose）
*** 2.1.1 '''Adult'''
::::* Preferred regimen (2): [[Azithromycin]] 10 mg/kg PO qd (maximum, 500 mg qd)
**** Parenteral regimen
::::* Preferred regimen (3): [[Clarithromycin]] 7.5 mg/kg PO bid (maximum, 500 mg per dose)
***** Preferred regimen (1): [[Ceftriaxone]] 2 g IV q24h for 14 (14–21) days
::::* Preferred regimen (4): [[Erythromycin]] 12.5 mg/kg PO qid (maximum, 500 mg per dose)
***** Alternative regimen (1): [[Cefotaxime]] 2 g IV q8h for 14 (14–21) days
***** Alternative regimen (2): [[Penicillin G]] 18–24 MU/day IV q4h for 14 (14–21) days '''(patients with normal [[renal function]])'''
**** Oral regimen
***** Preferred regimen (1): [[Amoxicillin]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[Doxycycline]] 100 mg PO q12h for 14 (14–21) days '''(avoid in [[pregnancy]])'''
***** Preferred regimen (3): [[Cefuroxime]] 500 mg PO q12h for 14 (14–21) days
***** Alternative regimen (1): [[Azithromycin]] 500 mg PO q6h for 7–10 days  
***** Alternative regimen (2): [[Clarithromycin]] 500 mg PO q12h for 14–21 days '''(avoid in [[pregnancy]])'''
***** Alternative regimen (3): [[Erythromycin]] 500 mg PO q6h for 14–21 days
*** 2.1.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[Ceftriaxone]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** Alternative regimen (1): [[Cefotaxime]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
***** Alternative regimen (2): [[Penicillin G]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day) '''(patients with normal [[renal function]])'''
**** Oral regimen
***** Preferred regimen (1):  [[Amoxicillin]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Preferred regimen (2): [[Doxycycline]] '''(for children aged ≥ 8 years)''' 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
***** Preferred regimen (3): [[Cefuroxime]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Alternative regimen (1): [[Azithromycin]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** Alternative regimen (2): [[Clarithromycin]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
***** Alternative regimen (3):  [[Erythromycin]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)
** 2.2 '''Borrelial lymphocytoma'''
*** The same regimens used to treat patients with [[erythema migrans]] ([[Lyme disease medical therapy#Medical Therapy|see above]])  


:* 1.2 '''When erythema migrans cannot be reliably distinguished from community-acquired bacterial cellulitis'''
* 3 '''Stage 3 - Late disseminated Lyme Disease'''
::* Preferred regimen: [[Amoxicillin-Clavulanate]] 500 mg PO tid
** 3.1 '''Lyme arthritis'''
::* Pediatric regimen: [[Amoxicillin-Clavulanate]] 50 mg/kg per day in 3 divided doses (maximum, 500 mg per dose)
*** 3.1.1 '''Adult'''
**** Preferred regimen (1): [[Doxycycline]] 100 mg PO q12h for 28 days '''(avoid in [[pregnancy]])'''
**** Preferred regimen (2): [[Amoxicillin]] 500 mg PO q8h for 28 days
**** Preferred regimen (3): [[Cefuroxime axetil]] 500 mg PO q12h for 28 days
*** 3.1.2 '''Pediatric'''
**** Preferred regimen (1): [[Amoxicillin]] 50 mg/kg/day PO q8h for 28 days   (maximum, 500 mg per dose)
**** Preferred regimen (1): [[Cefuroxime axetil]] 30 mg/kg/day PO q12h for 28 days (maximum, 500 mg per dose)
**** Preferred regimen (1): [[Doxycycline]] '''(for children aged ≥ 8 years)''' 4 mg/kg/day PO q12h for 28 days  (maximum, 100 mg per dose)
**:'''Note:''' Patients with persistent or recurrent [[joint swelling]] after a recommended course of oral [[antibiotic]] therapy are suggested re-treatment with another 4-week course of oral [[antibiotics]] or with a 2–4 week course of [[ceftriaxone]].
** 3.2 '''Patients with arthritis and objective evidence of neurologic disease'''
*** 3.2.1 '''Adult'''
**** Preferred regimen (1): [[Ceftriaxone]] 2 g IV q24h for 2–4 weeks
**** Alternative regimen (1): [[Cefotaxime]] 2 g IV q8h for 2–4 weeks
**** Alternative regimen (2): [[Penicillin G]] 18–24 MU/day IV q4h for 2-4 weeks '''(patients with normal [[renal function]])'''
*** 3.2.2 '''Pediatric'''
**** Preferred regimen (1): [[Ceftriaxone]] 50–75 mg/kg IV q24h for 2–4 weeks (maximum, 2 g)
**** Preferred regimen (1): [[Cefotaxime]] 150–200 mg/kg/day IV q6–8h for 2–4 weeks (maximum, 6 g per day)
**** Alternative regimen (1): [[Penicillin G]] 200,000–400,000 U/kg/day IV q4h for 14 for 2–4 weeks (maximum, 18–24 million U per day) '''(patients with normal [[renal function]])'''
** 3.3 '''Acrodermatitis chronica atrophicans'''
*** Preferred regimen (1): [[Doxycycline]] 100 mg PO q12h for 21 days '''(avoid in [[pregnancy]])'''
*** Preferred regimen (2): [[Amoxicillin]] 500 mg PO q8h for 21 days
*** Preferred regimen (3): [[Cefuroxime axetil]] 500 mg PO q12h for 21 days


:* 1.3. '''Lyme carditis, adult'''<ref>{{Cite journal| doi = 10.1086/508667| issn = 1537-6591| volume = 43| issue = 9| pages = 1089–1134| last1 = Wormser| first1 = Gary P.| last2 = Dattwyler| first2 = Raymond J.| last3 = Shapiro| first3 = Eugene D.| last4 = Halperin| first4 = John J.| last5 = Steere| first5 = Allen C.| last6 = Klempner| first6 = Mark S.| last7 = Krause| first7 = Peter J.| last8 = Bakken| first8 = Johan S.| last9 = Strle| first9 = Franc| last10 = Stanek| first10 = Gerold| last11 = Bockenstedt| first11 = Linda| last12 = Fish| first12 = Durland| last13 = Dumler| first13 = J. Stephen| last14 = Nadelman| first14 = Robert B.| title = The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America| journal = Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America| date = 2006-11-01| pmid = 17029130}}</ref>
* 4. '''Post–Lyme Disease Syndromes'''
::* Parenteral regimen
** Preferred regimen: Further [[antibiotic]] therapy for [[Lyme disease]] should not be given unless there are objective findings of active disease (including physical findings, abnormalities on [[Cerebrospinal fluid|cerebrospinal]] or [[synovial fluid]] analysis, or changes on formal [[Neuropsychological assessment|neuropsychologic testing]])
:::* Preferred regimen: [[Ceftriaxone]] 2 g IV q24h for 14 (14–21) days
:::* Alternative regimen: [[Cefotaxime]] 2 g IV q8h for 14 (14–21) days {{or}} [[Penicillin G]] 18–24 million U/day IV q4h for 14 (14–21) days
::* Oral regimen
:::* Preferred regimen: [[Amoxicillin]] 500 mg tid for 14 (14–21) days {{or}} [[Doxycycline]] 100 mg bid for 14 (14–21) days {{or}} [[Cefuroxime]] 500 mg bid for 14 (14–21) days
:::* Alternative regimen: [[Azithromycin]] 500 mg PO qd for 7–10 days {{or}} [[Clarithromycin]] 500 mg PO bid for 14–21 days (if the patient is not pregnant) {{or}} [[Erythromycin]] 500 mg PO qid for 14–21 days
:::: Note (1): Parenteral regimen is recommended at the start of therapy for patients who have been hospitalized for cardiac monitoring; oral regimen may be substituted to complete a course of therapy or to treat ambulatory patients.
:::: Note (2): A temporary pacemaker may be required for patients with advanced heart block.
:::: Note (3): Patients treated with macrolides should be closely observed to ensure resolution of the clinical manifestations.
 
:* '''Lyme carditis, pediatric'''<ref>{{Cite journal| doi = 10.1086/508667| issn = 1537-6591| volume = 43| issue = 9| pages = 1089–1134| last1 = Wormser| first1 = Gary P.| last2 = Dattwyler| first2 = Raymond J.| last3 = Shapiro| first3 = Eugene D.| last4 = Halperin| first4 = John J.| last5 = Steere| first5 = Allen C.| last6 = Klempner| first6 = Mark S.| last7 = Krause| first7 = Peter J.| last8 = Bakken| first8 = Johan S.| last9 = Strle| first9 = Franc| last10 = Stanek| first10 = Gerold| last11 = Bockenstedt| first11 = Linda| last12 = Fish| first12 = Durland| last13 = Dumler| first13 = J. Stephen| last14 = Nadelman| first14 = Robert B.| title = The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America| journal = Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America| date = 2006-11-01| pmid = 17029130}}</ref>
::* Parenteral regimen
:::* Preferred regimen: [[Ceftriaxone]] 50–75 mg/kg IV q24h (maximum, 2 g) for 14 (14–21) days
:::* Alternative regimen: [[Cefotaxime]] 150–200 mg/kg/day IV q6–8h (maximum, 6 g per day) for 14 (14–21) days {{or}} [[Penicillin G]] 200,000–400,000 U/kg/day IV q4h (not to exceed 18–24 million U per day) for 14 (14–21) days
::* Oral regimen
:::* Preferred regimen: [[Amoxicillin]] 50 mg/kg/day PO tid (maximum, 500 mg per dose) for 14 (14–21) days {{or}} [[Doxycycline]] (for children aged ≥ 􏱢8 years) 4 mg/kg/day PO bid (maximum, 100 mg per dose) for 14 (14–21) days {{or}} [[Cefuroxime]] 30 mg/kg/day PO bid (maximum, 500 mg per dose) for 14 (14–21) days
:::* Alternative regimen: [[Azithromycin]] 10 mg/kg/day (maximum of 500 mg per day) for 7–10 days {{or}} [[Clarithromycin]] 7.5 mg/kg PO bid (maximum of 500 mg per dose) for 14–21 days {{or}} [[Erythromycin]] 12.5 mg/kg PO qid (maximum of 500 mg per dose) for 14–21 days
:::: Note (1): Parenteral regimen is recommended at the start of therapy for patients who have been hospitalized for cardiac monitoring; oral regimen may be substituted to complete a course of therapy or to treat ambulatory patients
:::: Note (2): A temporary pacemaker may be required for patients with advanced heart block
:::: Note (3): Patients treated with macrolides should be closely observed to ensure resolution of the clinical manifestations
 
:* 1.4 '''Borrelial lymphocytoma'''
::* Preferred regimen: The same regimens used to treat patients with erythema migrans (see above)
* 2. '''Late Lyme Disease'''
:* 2.1 '''Lyme arthritis'''
::* Preferred regimen (1): [[Doxycycline]] 100 mg PO bid
::* Preferred regimen (2): [[Amoxicillin]] 500 mg PO tid
::* Alternative regimen: [[Cefuroxime axetil]] 500 mg PO bid for 28 days
::* Pediatric regimen: [[Amoxicillin]] 50 mg/kg per day in 3 divided doses (maximum 500 mg per dose) {{or}} [[Cefuroxime axetil]] 30 mg/kg per day in 2 divided doses (maximum,500 mg per dose); (≥8 years of age) [[Doxycycline]] 4 mg/ kg per day in 2 divided doses (maximum, 100 mg per dose)
::* Note: For patients who have persistent or recurrent joint swelling after a recommended course of oral antibiotic therapy, we recommend re-treatment with another 4-week course of oral antibiotics or with a 2–4 weeks course of [[Ceftriaxone]] IV
:* 2.2 '''Patients with arthritis and objective evidence of neurologic disease'''
::* Preferred regimen: [[Ceftriaxone]] IV for 2–4 weeks
::* Alternative regimen (1): [[Cefotaxime]] IV
::* Alternative regimen (2): [[Penicillin G]] IV
::* Pediatric regime: [[Ceftriaxone]] {{or}} [[Cefotaxime]] {{or}} [[Penicillin G]]
:* 2.3 '''Acrodermatitis chronica atrophicans'''
::* Preferred regimen (1): [[Doxycycline]] 100 mg PO bid for 21 days
::* Preferred regimen (2): [[Amoxicillin]] 500 mg PO tid for 21 days
::* Preferred regimen (3): [[Cefuroxime axetil]] 500 mg PO bid for 21 days
* 3. '''Post–Lyme Disease Syndromes'''
::* Preferred regimen: Further antibiotic therapy for Lyme disease should not be given unless there are objective findings of active disease (including physical findings, abnormalities on cerebrospinal or synovial fluid analysis, or changes on formal neuropsychologic testing)


===Lyme neuroborreliosis===
===Lyme neuroborreliosis===
* 1. '''Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines'''<ref>{{Cite journal| doi = 10.1086/508667| issn = 1537-6591| volume = 43| issue = 9| pages = 1089–1134| last1 = Wormser| first1 = Gary P.| last2 = Dattwyler| first2 = Raymond J.| last3 = Shapiro| first3 = Eugene D.| last4 = Halperin| first4 = John J.| last5 = Steere| first5 = Allen C.| last6 = Klempner| first6 = Mark S.| last7 = Krause| first7 = Peter J.| last8 = Bakken| first8 = Johan S.| last9 = Strle| first9 = Franc| last10 = Stanek| first10 = Gerold| last11 = Bockenstedt| first11 = Linda| last12 = Fish| first12 = Durland| last13 = Dumler| first13 = J. Stephen| last14 = Nadelman| first14 = Robert B.| title = The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America| journal = Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America| date = 2006-11-01| pmid = 17029130}}</ref>
* 1. '''Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines'''<ref name="pmid17029130">{{cite journal| author=Wormser GP, Dattwyler RJ, Shapiro ED, Halperin JJ, Steere AC, Klempner MS et al.| title=The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2006 | volume= 43 | issue= 9 | pages= 1089-134 | pmid=17029130 | doi=10.1086/508667 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17029130  }} </ref>
:* 1.1 '''Early neurologic disease'''
** 1.1 '''Early neurologic disease (Stage 2 - early disseminated Lyme disease)'''
::* 1.1.1 '''Cranial nerve palsy (adult)'''
*** 1.1.1 '''Cranial nerve palsy'''
:::* Preferred regimen (1): [[Amoxicillin]] 500 mg PO tid for 14 (14–21) days
**** 1.1.1.1 '''Adult'''
:::* Preferred regimen (2): [[Doxycycline]] 100 mg PO bid for 14 (14–21) days
***** Preferred regimen (1): [[Amoxicillin]] 500 mg PO q8h for 14 (14–21) days
:::* Preferred regimen (3): [[Cefuroxime]] 500 mg PO bid for 14 (14–21) days
***** Preferred regimen (2): [[Doxycycline]] 100 mg PO q12h for 14 (14–21) days '''(avoid in pregnancy)'''
:::* Alternative regimen (1): [[Azithromycin]] 500 mg PO qd for 7–10 days  
***** Preferred regimen (3): [[Cefuroxime]] 500 mg PO q12h for 14 (14–21) days
:::* Alternative regimen (2): [[Clarithromycin]] 500 mg PO bid for 14–21 days
***** Alternative regimen (1): [[Azithromycin]] 500 mg PO q6h for 7–10 days
:::* Alternative regimen (3): [[Erythromycin]] 500 mg PO qid for 14–21 days
***** Alternative regimen (2): [[Clarithromycin]] 500 mg PO q12h for 14–21 days
:::*Note: Avoid clarithromycin among pregnant women
***** Alternative regimen (3): [[Erythromycin]] 500 mg PO q6h for 14–21 days
::* 1.1.2 '''Cranial nerve palsy (pediatric)'''
**** 1.1.1.2. '''Pediatric'''
:::* Preferred regimen (1): [[Amoxicillin]] 50 mg/kg/day PO tid (maximum 500 mg/dose) for 14 (14–21) days
***** Preferred regimen (1): [[Amoxicillin]] 50 mg/kg/day PO q8h for 14 (14–21) days (maximum, 500 mg/dose)  
:::* Preferred regimen (2): [[Doxycycline]] (for children aged ≥ 8 years) 4 mg/kg/day PO q12h (maximum 100 mg/dose) for 14 (14–21) days 
***** Preferred regimen (2): [[Doxycycline]] '''(for children aged ≥ 8 years)''' 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg/dose)
:::* Preferred regimen (3): [[Cefuroxime]] 30 mg/kg/day PO q12h (maximum 500 mg/dose) for 14 (14–21) days
***** Preferred regimen (3): [[Cefuroxime]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg/dose)
:::* Alternative regimen (1): [[Azithromycin]] 10 mg/kg/day PO (maxmium 500 mg/dose) for 7–10 days
***** Alternative regimen (1): [[Azithromycin]] 10 mg/kg/day PO q6h for 7–10 days (maximum, 500 mg/day)  
:::* Alternative regimen (2): [[Clarithromycin]] 7.5 mg/kg PO bid (maximum 500 mg/dose) for 14–21 days
***** Alternative regimen (2): [[Clarithromycin]] 7.5 mg/kg PO q12h for 14–21 days (maximum, 500 mg/dose)
:::* Alternative regimen (3): [[Erythromycin]] 12.5 mg/kg PO bid (maximum 500 mg/dose) for 14–21 days
***** Alternative regimen (3): [[Erythromycin]] 12.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg/dose)
::* 1.1.3 '''Meningitis or radiculopathy (adult)'''
*** 1.1.2 '''Meningitis or radiculopathy'''
:::* Preferred regimen: [[Ceftriaxone]] 2 g IV q24h for 14 (10–28) days
**** 1.1.2.1 '''Adult'''
:::* Alternative regimen (1): [[Cefotaxime]] 2 g IV q8h for 14 (10–28) days
***** Preferred regimen (1): [[Ceftriaxone]] 2 g IV q24h for 14 (10–28) days
:::* Alternative regimen (2): [[Penicillin G]] 18–24 MU/day IV q4h for 14 (10–28) days
***** Alternative regimen (1): [[Cefotaxime]] 2 g IV q6-8h for 14 (10–28) days
:::* Note: for non-pregnant adult patients intolerant of β-lactam agents, [[Doxycycline]] 200–400 mg/day PO/IV q12h may be considered.
***** Alternative regimen (2): [[Penicillin G]] 18–24 MU/day IV q4h for 14 (10–28) days '''(patients with normal [[renal function]])'''
::* 1.1.4 '''Meningitis or radiculopathy (pediatric)'''
***:'''Note:''' For adult patients intolerant of [[Beta-lactam antibiotic|β-lactam agents]], [[doxycycline]] '''(avoid in [[pregnancy]])''' 200–400 mg/day PO/IV q12h may be considered.
:::* Preferred regimen: [[Ceftriaxone]] 50–75 mg/kg IV q24h (maximum, 2 g/day) for 14 (10–28) days
**** 1.1.2.2 '''Pediatric'''
:::* Alternative regimen (1): [[Cefotaxime]] 150–200 mg/kg/day IV q6-8h (maximum, 6 g/day) for 14 (10–28) days  
***** Preferred regimen (1): [[Ceftriaxone]] 50–75 mg/kg IV q24h for 14 (10–28) days (maximum, 2 g/day)
:::* Alternative regimen (2): [[Penicillin G]] 200,000–400,000 U/kg/day IV q4h (maximum, 18–24 MU/day) for 14 (10–28) days
***** Alternative regimen (1): [[Cefotaxime]] 150–200 mg/kg/day IV q6-8h for 14 (10–28) days  (maximum, 6 g/day)   
:::* Note: for children ≥ 8 years of age intolerant of β-lactam agents, [[Doxycycline]] 4–8 mg/kg/day PO/IV q12h, maximum 200–400 mg/day may be considered
***** Alternative regimen (2): [[Penicillin G]] 200,000–400,000 U/kg/day IV q4h for 14 (10–28) days (maximum, 18–24 MU/day) '''(patients with normal [[renal function]])'''
:* 1.2 '''Late neurologic disease'''
***:'''Note:''' For children intolerant of [[Beta-lactam antibiotic|β-lactam agents]], [[doxycycline]] '''(children aged ≥ 8 years)''' 4–8 mg/kg/day PO/IV q12h (maximum, 200–400 mg/day may be considered)
::* 1.2.1 '''Central or peripheral nervous system disease (adult)'''
** 1.2 '''Late neurologic disease (Stage 3 - late disseminated Lyme disease)'''
:::* Preferred regimen: [[Ceftriaxone]] 2 g IV q24h for 14 (10–28) days
*** 1.2.1 '''Central or peripheral nervous system disease'''
:::* Alternative regimen (1): [[Cefotaxime]] 2 g IV q8h for 14 (10–28) days
**** 1.2.1.1 '''Adult'''
:::* Alternative regimen (2): [[Penicillin G]] 18–24 MU/day IV q4h for 14 (10–28) days
***** Preferred regimen: [[Ceftriaxone]] 2 g IV q24h for 14 (10–28) days
::* 1.2.2 '''Central or peripheral nervous system disease (pediatric)'''
***** Alternative regimen (1): [[Cefotaxime]] 2 g IV q8h for 14 (10–28) days
:::* Preferred regimen: [[Ceftriaxone]] 50–75 mg/kg IV q24h (maximum, 2 g/day) for 14 (10–28) days.
***** Alternative regimen (2): [[Penicillin G]] 18–24 MU/day IV q4h for 14 (10–28) days '''(patients with normal [[renal function]])'''
:::* Alternative regimen (1): [[Cefotaxime]] 150–200 mg/kg/day IV q6–8h (maximum, 6 g/day) for 14 (10–28) days
**** 1.2.1.2 '''Pediatric'''
:::* Alternative regimen (2): [[Penicillin G]] 200,000–400,000 U/kg/day IV q4h (maximum, 18–24 MU/day) for 14 (10–28) days
***** Preferred regimen: [[Ceftriaxone]] 50–75 mg/kg IV q24h for 14 (10–28) days (maximum, 2 g/day)
* 2. '''American Academy of Neurology (AAN) Practice Parameter'''<ref>{{Cite journal| doi = 10.1212/01.wnl.0000265517.66976.28| issn = 1526-632X| volume = 69| issue = 1| pages = 91–102| last1 = Halperin| first1 = J. J.| last2 = Shapiro| first2 = E. D.| last3 = Logigian| first3 = E.| last4 = Belman| first4 = A. L.| last5 = Dotevall| first5 = L.| last6 = Wormser| first6 = G. P.| last7 = Krupp| first7 = L.| last8 = Gronseth| first8 = G.| last9 = Bever| first9 = C. T.| last10 = Quality Standards Subcommittee of the American Academy of Neurology| title = Practice parameter: treatment of nervous system Lyme disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology| journal = Neurology| date = 2007-07-03| pmid = 17522387}}</ref>
***** Alternative regimen (1): [[Cefotaxime]] 150–200 mg/kg/day IV q6–8h for 14 (10–28) days  (maximum, 6 g/day)  
:* 2.1 '''Meningitis'''
***** Alternative regimen (2): [[Penicillin G]] 200,000–400,000 U/kg/day IV q4h for 14 (10–28) days (maximum, 18–24 MU/day) '''(patients with normal [[renal function]])'''
::* Preferred regimen (1): [[Ceftriaxone]] 2 g IV q24h for 14 days
::* Preferred regimen (2):[[Cefotaxime]] 2 g IV q8h for 14 days 
::* Preferred regimen (3):[[Penicillin G]] 18–24 MU/day q4h for 14 days
::* Alternative regimen: [[Doxycycline]] 100–200 mg BID for 14 days
::* Pediatric regimen: [[Ceftriaxone]] 50–75 mg/kg/day IV q24h, max 2 g/day {{or}} [[Cefotaxime]] 150–200 mg/kg/day IV q6–8h, max 6 g/day {{or}} [[Penicillin G]] 200,000–400,000 U/kg/day IV q4h, max 18–24 MU/day {{or}} [[Doxycycline]] (≥ 8 y/o) 4–8 mg/kg/day q12h, max 200 mg/day
:* 2.2 '''Any neurologic syndrome with CSF pleocytosis'''
::* Preferred regimen (1): [[Ceftriaxone]] 2 g IV q24h for 14 days
::* Preferred regimen (2): [[Cefotaxime]] 2 g IV q8h for 14 days 
::* Preferred regimen (3): [[Penicillin G]] 18–24 MU/day IV q4h for 14 days
::* Alternative regimen: [[Doxycycline]] 100–200 mg BID for 14 days
::* Pediatric regimen: [[Ceftriaxone]] 50–75 mg/kg/day IV q24h, max 2 g {{or}} [[Cefotaxime]] 150–200 mg/kg/day IV q6–8h, max 6 g/day {{or}} [[Penicillin G]] 200,000–400,000 U/kg/day q4h, max 18–24 MU/day {{or}} [[Doxycycline]] (≥ 8 y/o) 4–8 mg/kg/day q12h, max 200 mg/day
:* 2.3 '''Peripheral nervous system disease (radiculopathy, diffuse neuropathy, mononeuropathy multiplex, cranial neuropathy; normal CSF)'''
::* Preferred regimen: [[Doxycycline]] 100–200 mg BID for 14 days
::* Alternative regimen (1): [[Ceftriaxone]] 2 g IV q24h for 14 days 
::* Alternative regimen (2): [[Cefotaxime]] 2 g IV q8h for 14 days 
::* Alternative regimen (3): [[Penicillin G]] 18–24 MU/day IV q4h for 14 days
::* Pediatric regimen: [[Doxycycline]] (≥ 8 y/o) 4–8 mg/kg/day q12h, max 200 mg/day {{or}} [[Ceftriaxone]] 50–75 mg/kg/day IV q24h, max 2 g/day {{or}} [[Cefotaxime]] 150–200 mg/kg/day IV q6–8h, max 6 g/day {{or}} [[Penicillin G]] 200,000–400,000 U/kg/day IV q4h, max 18–24 MU/day; [[Doxycycline]] (≥ 8 y/o) 4–8 mg/kg/day q12h, max 200 mg/day
:* 2.4 '''Encephalomyelitis'''
::* Preferred regimen (1): [[Ceftriaxone]] 2 g IV q24h for 14 days
::* Preferred regimen (2): [[Cefotaxime]] 2 g IV q8h for 14 days 
::* Preferred regimen (3): [[Penicillin G]] 18–24 MU/day q4h for 14 days
::* Pediatric regimen: [[Ceftriaxone]] 50–75 mg/kg/day IV q24h, max 2 g/day {{or}} [[Cefotaxime]] 150–200 mg/kg/day IV q6–8h, max 6 g/day {{or}} [[Penicillin G]] 200,000–400,000 U/kg/day IV q4h, max 18–24 MU/day
:* 2.5 '''Encephalopathy'''
::* Preferred regimen (1): [[Ceftriaxone]] 2 g IV q24h for 14 days
::* Preferred regimen (2): [[Cefotaxime]] 2 g IV q8h for 14 days 
::* Preferred regimen (3): [[Penicillin G]] 18–24 MU/day q4h for 14 days
::* Pediatric regimen: [[Ceftriaxone]] 50–75 mg/kg/day IV q24h, max 2 g/day {{or}} [[Cefotaxime]] 150–200 mg/kg/day IV q6–8h, max 6 g/day {{or}} [[Penicillin G]] 200,000–400,000 U/kg/day IV q4h, max 18–24 MU/day
:* 2.6 '''Post-treatment Lyme syndrome'''
::* Preferred regimen: symptomatic management
::* Note: Antibiotic therapy is not indicated


* 2 '''American Academy of Neurology (AAN) Practice Parameter'''<ref>{{Cite journal| doi = 10.1212/01.wnl.0000265517.66976.28| issn = 1526-632X| volume = 69| issue = 1| pages = 91–102| last1 = Halperin| first1 = J. J.| last2 = Shapiro| first2 = E. D.| last3 = Logigian| first3 = E.| last4 = Belman| first4 = A. L.| last5 = Dotevall| first5 = L.| last6 = Wormser| first6 = G. P.| last7 = Krupp| first7 = L.| last8 = Gronseth| first8 = G.| last9 = Bever| first9 = C. T.| last10 = Quality Standards Subcommittee of the American Academy of Neurology| title = Practice parameter: treatment of nervous system Lyme disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology| journal = Neurology| date = 2007-07-03| pmid = 17522387}}</ref>
** 2.1 '''Meningitis'''
*** 2.1.1 '''Adult'''
**** Preferred regimen (1): [[Ceftriaxone]] 2 g IV q24h for 14 days
**** Preferred regimen (2): [[Cefotaxime]] 2 g IV q8h for 14 days
**** Preferred regimen (3): [[Penicillin G]] 18–24 MU/day q4h for 14 days '''(patients with normal [[renal function]])'''
**** Alternative regimen (1): [[Doxycycline]] 100–200 mg q12h for 14 days '''(avoid in [[pregnancy]])'''
*** 2.1.2 '''Pediatric'''
**** Preferred regimen (1): [[Ceftriaxone]] 50–75 mg/kg/day IV q24h (maximum, 2 g/day)
**** Preferred regimen (2): [[Cefotaxime]] 150–200 mg/kg/day IV q6–8h (maximum, 6 g/day)
**** Preferred regimen (3): [[Penicillin G]] 200,000–400,000 U/kg/day IV q4h (maximum, 18–24 MU/day) '''(patients with normal [[renal function]])'''
**** Alternative regimen (1): [[Doxycycline]] '''(for children aged ≥ 8 years)''' 4–8 mg/kg/day q12h (maximum 200 mg/day)
** 2.2 '''Any neurologic syndrome with CSF pleocytosis'''
*** 2.2.1 '''Adult'''
**** Preferred regimen (1): [[Ceftriaxone]] 2 g IV q24h for 14 days
**** Preferred regimen (2): [[Cefotaxime]] 2 g IV q8h for 14 days
**** Preferred regimen (3): [[Penicillin G]] 18–24 MU/day IV q4h for 14 days '''(patients with normal [[renal function]])'''
**** Alternative regimen (1): [[Doxycycline]] 100–200 mg q12h for 14 days '''(avoid in [[pregnancy]])'''
*** 2.2.2 '''Pediatric'''
**** Preferred regimen (1): [[Ceftriaxone]] 50–75 mg/kg/day IV q24h (maximum, 2 g/day)
**** Preferred regimen (2): [[Cefotaxime]] 150–200 mg/kg/day IV q6–8h (maximum, 6 g/day)
**** Preferred regimen (2): [[Penicillin G]] 200,000–400,000 U/kg/day q4h (maximum, 18–24 MU/day) '''(patients with normal [[renal function]])'''
**** Alternative regimen (1): [[Doxycycline]] '''(for children aged ≥ 8 years)''' 4–8 mg/kg/day q12h (maximum 200 mg/day)
** 2.3 '''Peripheral nervous system disease (radiculopathy, diffuse neuropathy, mononeuropathy multiplex, cranial neuropathy; normal CSF)'''
*** 2.3.1 '''Adult'''
**** Preferred regimen (1): [[Doxycycline]] 100–200 mg q12h for 14 days '''(avoid in [[pregnancy]])'''
**** Alternative regimen (1): [[Ceftriaxone]] 2 g IV q24h for 14 days
**** Alternative regimen (2): [[Cefotaxime]] 2 g IV q8h for 14 days
**** Alternative regimen (3): [[Penicillin G]] 18–24 MU/day IV q4h for 14 days '''(patients with normal [[renal function]])'''
*** 2.3.2 '''Pediatric'''
**** Preferred regimen (1):  [[Doxycycline]] '''(for children aged ≥ 8 years)''' 4–8 mg/kg/day q12h (maximum 200 mg/day)
**** Alternative regimen (1): [[Ceftriaxone]] 50–75 mg/kg/day IV q24h (maximum, 2 g/day)
**** Alternative regimen (2): [[Cefotaxime]] 150–200 mg/kg/day IV q6–8h (maximum, 6 g/day)
**** Alternative regimen (3): [[Penicillin G]] 200,000–400,000 U/kg/day IV q4h (maximum, 18–24 MU/day) '''(patients with normal [[renal function]])'''
** 2.4 '''Encephalomyelitis'''
*** 2.4.1 '''Adult'''
**** Preferred regimen (1): [[Ceftriaxone]] 2 g IV q24h for 14 days
**** Preferred regimen (2): [[Cefotaxime]] 2 g IV q8h for 14 days 
**** Preferred regimen (3): [[Penicillin G]] 18–24 MU/day IV q4h for 14 days '''(patients with normal [[renal function]])'''
*** 2.4.2 '''Pediatric'''
**** Preferred regimen (1): [[Ceftriaxone]] 50–75 mg/kg/day IV q24h (maximum, 2 g/day)
**** Preferred regimen (2): [[Cefotaxime]] 150–200 mg/kg/day IV q6–8h (maximum, 6 g/day)
**** Preferred regimen (3): [[Penicillin G]] 200,000–400,000 U/kg/day IV q4h (maximum, 18–24 MU/day) '''(patients with normal [[renal function]])'''
** 2.5 '''Encephalopathy'''
*** 2.5.1 '''Adult'''
**** Preferred regimen (1): [[Ceftriaxone]] 2 g IV q24h for 14 days
**** Preferred regimen (2): [[Cefotaxime]] 2 g IV q8h for 14 days 
**** Preferred regimen (3): [[Penicillin G]] 18–24 MU/day IV q4h for 14 days '''(patients with normal [[renal function]])'''
*** 2.5.2 '''Pediatric'''
**** Preferred regimen (1):  [[Ceftriaxone]] 50–75 mg/kg/day IV q24h (maximum, 2 g/day)
**** Preferred regimen (2): [[Cefotaxime]] 150–200 mg/kg/day IV q6–8h (maximum, 6 g/day)
**** Preferred regimen (3): [[Penicillin G]] 200,000–400,000 U/kg/day IV q4h (maximum, 18–24 MU/day) '''(patients with normal [[renal function]])'''
** 2.6 '''Post-treatment Lyme syndrome'''
*** Preferred regimen: [[symptomatic]] management
**: '''Note:''' [[Antibiotic]] therapy is not indicated
===Follow-up===  
===Follow-up===  
*Approximately 10 to 20% of patients treated for Lyme disease with a recommended 2-4 week course of antibiotics will develop post-treatment Lyme disease syndrome (PTLDS). Patients report lingering symptoms of fatigue, pain, or joint and muscle aches. In some cases, these can last for more than 6 months.
*Approximately 10 to 20% of patients treated for [[Lyme disease]] with a recommended 2-4 week course of [[Antibiotic|antibiotics]] will develop [[Lyme disease natural history, complications and prognosis|post-treatment Lyme disease syndrome (PTLDS)]]. Patients report lingering symptoms of [[fatigue]], [[pain]], or [[Joint aches|joint]] and [[muscle aches]]. In some cases, these can last for more than 6 months.
*The majority of patients with post-treatment Lyme disease syndrome gradually improve over months/years of the primary infection.
*The majority of patients with [[Lyme disease natural history, complications and prognosis|post-treatment Lyme disease syndrome]] gradually improve over months/years of the primary [[infection]].


==References==
==References==
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[[Category:Spirochaetes]]
[[Category:Disease]]
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[[Category:Infectious disease]]
[[Category:Dermatology]]
[[Category:Dermatology]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Intensive care medicine]]
[[Category:Intensive care medicine]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]
[[Category:Ophthalmology]]
[[Category:Neurology]]
[[Category:Cardiology]]
[[Category:Rheumatology]]

Latest revision as of 22:35, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Anmol Pitliya, M.B.B.S. M.D.[2]

Overview

The mainstay of therapy for Lyme disease is antimicrobial therapy. Antimicrobial therapy may include doxycycline, amoxicillin, cephalosporins, or macrolides. The choice of antimicrobial therapy depends on the stage of Lyme disease. Individuals who remove attached ticks should be monitored closely for signs and symptoms of tick-borne diseases for up to 30 days.

Medical Therapy

Lyme borreliosis (non-neuroborreliosis)

Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for treatment of Lyme disease[1]

  • 1 Stage 1 - early localized Lyme disease
    • 1.1 Erythema migrans
      • 1.1.1 Adult
      • 1.1.2 Pediatric
        • 1.1.2.1 Children < 8 years of age
          • Preferred regimen (1): Amoxicillin 50 mg/kg PO per day q8h (maximum, 500 mg per dose)
          • Preferred regimen (2): Cefuroxime axetil 30 mg/kg PO per day in 2 divided doses (maximum, 500 mg per dose)
          • Alternative regimen (1): Azithromycin 10 mg/kg PO q6h (maximum, 500 mg per day)
          • Alternative regimen (2): Clarithromycin 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
          • Alternative regimen (3): Erythromycin 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
        • 1.1.2.2 Children ≥ 8 years of age
          • Preferred regimen (1): Doxycycline 4 mg/kg/day PO q12h (maximum, 100 mg per dose）
          • Alternative regimen (1): Azithromycin 10 mg/kg PO q6h (maximum, 500 mg per day)
          • Alternative regimen (2): Clarithromycin 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
          • Alternative regimen (3): Erythromycin 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
    • 2.1 When erythema migrans cannot be reliably distinguished from community-acquired bacterial cellulitis
  • 2 Stage 2 - early disseminated Lyme disease
    • 2.1 Lyme carditis
      Note (1): A parenteral regimen is recommended at the start of therapy for patients who have been hospitalized for cardiac monitoring; oral regimen may be substituted to complete a course of therapy or to treat ambulatory patients.
      Note (2): A temporary pacemaker may be required for patients with advanced heart block.
      Note (3): Patients treated with macrolides should be closely observed to ensure resolution of the clinical manifest.
      • 2.1.1 Adult
        • Parenteral regimen
          • Preferred regimen (1): Ceftriaxone 2 g IV q24h for 14 (14–21) days
          • Alternative regimen (1): Cefotaxime 2 g IV q8h for 14 (14–21) days
          • Alternative regimen (2): Penicillin G 18–24 MU/day IV q4h for 14 (14–21) days (patients with normal renal function)
        • Oral regimen
          • Preferred regimen (1): Amoxicillin 500 mg PO q8h for 14 (14–21) days
          • Preferred regimen (2): Doxycycline 100 mg PO q12h for 14 (14–21) days (avoid in pregnancy)
          • Preferred regimen (3): Cefuroxime 500 mg PO q12h for 14 (14–21) days
          • Alternative regimen (1): Azithromycin 500 mg PO q6h for 7–10 days
          • Alternative regimen (2): Clarithromycin 500 mg PO q12h for 14–21 days (avoid in pregnancy)
          • Alternative regimen (3): Erythromycin 500 mg PO q6h for 14–21 days
      • 2.1.2 Pediatric
        • Parenteral regimen
          • Preferred regimen (1): Ceftriaxone 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
          • Alternative regimen (1): Cefotaxime 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
          • Alternative regimen (2): Penicillin G 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day) (patients with normal renal function)
        • Oral regimen
          • Preferred regimen (1): Amoxicillin 50 mg/kg/day PO q8h for 14 (14–21) days (maximum, 500 mg per dose)
          • Preferred regimen (2): Doxycycline (for children aged ≥ 8 years) 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
          • Preferred regimen (3): Cefuroxime 30 mg/kg/day PO q12h for 14 (14–21) days (maximum, 500 mg per dose)
          • Alternative regimen (1): Azithromycin 10 mg/kg PO q6h 7–10 days (maximum, 500 mg per day)
          • Alternative regimen (2): Clarithromycin 7.5 mg/kg PO q12h for 14–21 days (maximum, 500 mg per dose)
          • Alternative regimen (3):  Erythromycin 12.5 mg/kg PO q6h for 14–21 days (maximum,500 mg per dose)
    • 2.2 Borrelial lymphocytoma
  • 3 Stage 3 - Late disseminated Lyme Disease
    • 3.1 Lyme arthritis
      • 3.1.1 Adult
      • 3.1.2 Pediatric
        • Preferred regimen (1): Amoxicillin 50 mg/kg/day PO q8h for 28 days  (maximum, 500 mg per dose)
        • Preferred regimen (1): Cefuroxime axetil 30 mg/kg/day PO q12h for 28 days (maximum, 500 mg per dose)
        • Preferred regimen (1): Doxycycline (for children aged ≥ 8 years) 4 mg/kg/day PO q12h for 28 days  (maximum, 100 mg per dose)
      Note: Patients with persistent or recurrent joint swelling after a recommended course of oral antibiotic therapy are suggested re-treatment with another 4-week course of oral antibiotics or with a 2–4 week course of ceftriaxone.
    • 3.2 Patients with arthritis and objective evidence of neurologic disease
      • 3.2.1 Adult
        • Preferred regimen (1): Ceftriaxone 2 g IV q24h for 2–4 weeks
        • Alternative regimen (1): Cefotaxime 2 g IV q8h for 2–4 weeks
        • Alternative regimen (2): Penicillin G 18–24 MU/day IV q4h for 2-4 weeks (patients with normal renal function)
      • 3.2.2 Pediatric
        • Preferred regimen (1): Ceftriaxone 50–75 mg/kg IV q24h for 2–4 weeks (maximum, 2 g)
        • Preferred regimen (1): Cefotaxime 150–200 mg/kg/day IV q6–8h for 2–4 weeks (maximum, 6 g per day)
        • Alternative regimen (1): Penicillin G 200,000–400,000 U/kg/day IV q4h for 14 for 2–4 weeks (maximum, 18–24 million U per day) (patients with normal renal function)
    • 3.3 Acrodermatitis chronica atrophicans

Lyme neuroborreliosis

  • 1. Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines[1]
    • 1.1 Early neurologic disease (Stage 2 - early disseminated Lyme disease)
      • 1.1.1 Cranial nerve palsy
        • 1.1.1.1 Adult
          • Preferred regimen (1): Amoxicillin 500 mg PO q8h for 14 (14–21) days
          • Preferred regimen (2): Doxycycline 100 mg PO q12h for 14 (14–21) days (avoid in pregnancy)
          • Preferred regimen (3): Cefuroxime 500 mg PO q12h for 14 (14–21) days
          • Alternative regimen (1): Azithromycin 500 mg PO q6h for 7–10 days
          • Alternative regimen (2): Clarithromycin 500 mg PO q12h for 14–21 days
          • Alternative regimen (3): Erythromycin 500 mg PO q6h for 14–21 days
        • 1.1.1.2. Pediatric
          • Preferred regimen (1): Amoxicillin 50 mg/kg/day PO q8h for 14 (14–21) days (maximum, 500 mg/dose)
          • Preferred regimen (2): Doxycycline (for children aged ≥ 8 years) 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg/dose)
          • Preferred regimen (3): Cefuroxime 30 mg/kg/day PO q12h for 14 (14–21) days (maximum, 500 mg/dose)
          • Alternative regimen (1): Azithromycin 10 mg/kg/day PO q6h for 7–10 days (maximum, 500 mg/day)
          • Alternative regimen (2): Clarithromycin 7.5 mg/kg PO q12h for 14–21 days (maximum, 500 mg/dose)
          • Alternative regimen (3): Erythromycin 12.5 mg/kg PO q12h for 14–21 days (maximum, 500 mg/dose)
      • 1.1.2 Meningitis or radiculopathy
        • 1.1.2.1 Adult
          • Preferred regimen (1): Ceftriaxone 2 g IV q24h for 14 (10–28) days
          • Alternative regimen (1): Cefotaxime 2 g IV q6-8h for 14 (10–28) days
          • Alternative regimen (2): Penicillin G 18–24 MU/day IV q4h for 14 (10–28) days (patients with normal renal function)
        Note: For adult patients intolerant of β-lactam agents, doxycycline (avoid in pregnancy) 200–400 mg/day PO/IV q12h may be considered.
        • 1.1.2.2 Pediatric
          • Preferred regimen (1): Ceftriaxone 50–75 mg/kg IV q24h for 14 (10–28) days (maximum, 2 g/day)
          • Alternative regimen (1): Cefotaxime 150–200 mg/kg/day IV q6-8h for 14 (10–28) days (maximum, 6 g/day)
          • Alternative regimen (2): Penicillin G 200,000–400,000 U/kg/day IV q4h for 14 (10–28) days (maximum, 18–24 MU/day) (patients with normal renal function)
        Note: For children intolerant of β-lactam agents, doxycycline (children aged ≥ 8 years) 4–8 mg/kg/day PO/IV q12h (maximum, 200–400 mg/day may be considered)
    • 1.2 Late neurologic disease (Stage 3 - late disseminated Lyme disease)
      • 1.2.1 Central or peripheral nervous system disease
        • 1.2.1.1 Adult
          • Preferred regimen: Ceftriaxone 2 g IV q24h for 14 (10–28) days
          • Alternative regimen (1): Cefotaxime 2 g IV q8h for 14 (10–28) days
          • Alternative regimen (2): Penicillin G 18–24 MU/day IV q4h for 14 (10–28) days (patients with normal renal function)
        • 1.2.1.2 Pediatric
          • Preferred regimen: Ceftriaxone 50–75 mg/kg IV q24h for 14 (10–28) days (maximum, 2 g/day)
          • Alternative regimen (1): Cefotaxime 150–200 mg/kg/day IV q6–8h for 14 (10–28) days (maximum, 6 g/day)
          • Alternative regimen (2): Penicillin G 200,000–400,000 U/kg/day IV q4h for 14 (10–28) days (maximum, 18–24 MU/day) (patients with normal renal function)
  • 2 American Academy of Neurology (AAN) Practice Parameter[2]
    • 2.1 Meningitis
      • 2.1.1 Adult
      • 2.1.2 Pediatric
        • Preferred regimen (1): Ceftriaxone 50–75 mg/kg/day IV q24h (maximum, 2 g/day)
        • Preferred regimen (2): Cefotaxime 150–200 mg/kg/day IV q6–8h (maximum, 6 g/day)
        • Preferred regimen (3): Penicillin G 200,000–400,000 U/kg/day IV q4h (maximum, 18–24 MU/day) (patients with normal renal function)
        • Alternative regimen (1): Doxycycline (for children aged ≥ 8 years) 4–8 mg/kg/day q12h (maximum 200 mg/day)
    • 2.2 Any neurologic syndrome with CSF pleocytosis
      • 2.2.1 Adult
      • 2.2.2 Pediatric
        • Preferred regimen (1): Ceftriaxone 50–75 mg/kg/day IV q24h (maximum, 2 g/day)
        • Preferred regimen (2): Cefotaxime 150–200 mg/kg/day IV q6–8h (maximum, 6 g/day)
        • Preferred regimen (2): Penicillin G 200,000–400,000 U/kg/day q4h (maximum, 18–24 MU/day) (patients with normal renal function)
        • Alternative regimen (1): Doxycycline (for children aged ≥ 8 years) 4–8 mg/kg/day q12h (maximum 200 mg/day)
    • 2.3 Peripheral nervous system disease (radiculopathy, diffuse neuropathy, mononeuropathy multiplex, cranial neuropathy; normal CSF)
      • 2.3.1 Adult
      • 2.3.2 Pediatric
        • Preferred regimen (1): Doxycycline (for children aged ≥ 8 years) 4–8 mg/kg/day q12h (maximum 200 mg/day)
        • Alternative regimen (1): Ceftriaxone 50–75 mg/kg/day IV q24h (maximum, 2 g/day)
        • Alternative regimen (2): Cefotaxime 150–200 mg/kg/day IV q6–8h (maximum, 6 g/day)
        • Alternative regimen (3): Penicillin G 200,000–400,000 U/kg/day IV q4h (maximum, 18–24 MU/day) (patients with normal renal function)
    • 2.4 Encephalomyelitis
      • 2.4.1 Adult
      • 2.4.2 Pediatric
        • Preferred regimen (1): Ceftriaxone 50–75 mg/kg/day IV q24h (maximum, 2 g/day)
        • Preferred regimen (2): Cefotaxime 150–200 mg/kg/day IV q6–8h (maximum, 6 g/day)
        • Preferred regimen (3): Penicillin G 200,000–400,000 U/kg/day IV q4h (maximum, 18–24 MU/day) (patients with normal renal function)
    • 2.5 Encephalopathy
      • 2.5.1 Adult
      • 2.5.2 Pediatric
        • Preferred regimen (1): Ceftriaxone 50–75 mg/kg/day IV q24h (maximum, 2 g/day)
        • Preferred regimen (2): Cefotaxime 150–200 mg/kg/day IV q6–8h (maximum, 6 g/day)
        • Preferred regimen (3): Penicillin G 200,000–400,000 U/kg/day IV q4h (maximum, 18–24 MU/day) (patients with normal renal function)
    • 2.6 Post-treatment Lyme syndrome
      Note: Antibiotic therapy is not indicated

Follow-up

References

  1. ↑ 1.0 1.1 Wormser GP, Dattwyler RJ, Shapiro ED, Halperin JJ, Steere AC, Klempner MS; et al. (2006). "The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America". Clin Infect Dis. 43 (9): 1089–134. doi:10.1086/508667. PMID 17029130.
  2. ↑ Halperin, J. J.; Shapiro, E. D.; Logigian, E.; Belman, A. L.; Dotevall, L.; Wormser, G. P.; Krupp, L.; Gronseth, G.; Bever, C. T.; Quality Standards Subcommittee of the American Academy of Neurology (2007-07-03). "Practice parameter: treatment of nervous system Lyme disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology". Neurology. 69 (1): 91–102. doi:10.1212/01.wnl.0000265517.66976.28. ISSN 1526-632X. PMID 17522387.
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