Lyme disease medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

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

Antimicrobial Therapy

  • All patients who develop Lyme disease should receive antimicrobial therapy.

Antimicrobial Therapy

Lyme boreliosis (non-neuroborreliosis)

  • 1. Early Lyme Disease[1]
  • 1.1 Erythema migrans
  • 1.1.1 Adult
  • Preferred regimen (1): Doxycycline 100 mg PO bid for 10-21 days
  • Preferred regimen (2): Amoxicillin 500 mg PO tid for 14-21 days
  • Preferred regimen (3): Cefuroxime axetil 500 mg bid for 14-21 days
  • Alternative regimen (1): Azithromycin 500 mg PO qd for 7–10 days
  • Alternative regimen (2): Clarithromycin 500 mg PO bid for 14–21 days (if the patient is not pregnant)
  • Alternative regimen (3): Erythromycin 500 mg PO qid 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 in 3 divided doses (maximum of 500 mg per dose)
  • Preferred regimen (2): Cefuroxime axetil 30 mg/kg PO per day in 2 divided doses（maximum, 500 mg per dose)
  • 1.1.2.2 children ≥ 8 years of age
  • Preferred regimen (1): Doxycycline 4 mg/kg PO per day in 2 divided doses （maximum, 100 mg per dose）
  • Preferred regimen (2): Azithromycin 10 mg/kg PO qd (maximum, 500 mg qd)
  • Preferred regimen (3): Clarithromycin 7.5 mg/kg PO bid (maximum, 500 mg per dose)
  • Preferred regimen (4): Erythromycin 12.5 mg/kg PO qid (maximum, 500 mg per dose)
  • 1.2 When erythema migrans cannot be reliably distinguished from community-acquired bacterial cellulitis
  • 1.3. Lyme carditis, adult[2]
  • Parenteral regimen
  • 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[3]
  • 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
  • 2.3 Acrodermatitis chronica atrophicans
  • 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

  • 1. Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines[4]
  • 1.1 Early neurologic disease
  • 1.1.1 Cranial nerve palsy (adult)
  • Preferred regimen (1): Amoxicillin 500 mg PO tid for 14 (14–21) days
  • Preferred regimen (2): Doxycycline 100 mg PO bid for 14 (14–21) days
  • Preferred regimen (3): Cefuroxime 500 mg PO bid for 14 (14–21) days
  • Alternative regimen (1): Azithromycin 500 mg PO qd for 7–10 days
  • Alternative regimen (2): Clarithromycin 500 mg PO bid for 14–21 days
  • Alternative regimen (3): Erythromycin 500 mg PO qid for 14–21 days
  • Note: Avoid clarithromycin among pregnant women
  • 1.1.2 Cranial nerve palsy (pediatric)
  • Preferred regimen (1): Amoxicillin 50 mg/kg/day PO tid (maximum 500 mg/dose) for 14 (14–21) days
  • 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 (3): Cefuroxime 30 mg/kg/day PO q12h (maximum 500 mg/dose) for 14 (14–21) days
  • Alternative regimen (1): Azithromycin 10 mg/kg/day PO (maxmium 500 mg/dose) for 7–10 days
  • Alternative regimen (2): Clarithromycin 7.5 mg/kg PO bid (maximum 500 mg/dose) for 14–21 days
  • Alternative regimen (3): Erythromycin 12.5 mg/kg PO bid (maximum 500 mg/dose) for 14–21 days
  • 1.1.3 Meningitis or radiculopathy (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
  • Note: for non-pregnant adult patients intolerant of β-lactam agents, Doxycycline 200–400 mg/day PO/IV q12h may be considered.
  • 1.1.4 Meningitis or radiculopathy (pediatric)
  • Preferred regimen: Ceftriaxone 50–75 mg/kg IV q24h (maximum, 2 g/day) for 14 (10–28) days
  • Alternative regimen (1): Cefotaxime 150–200 mg/kg/day IV q6-8h (maximum, 6 g/day) for 14 (10–28) days
  • Alternative regimen (2): Penicillin G 200,000–400,000 U/kg/day IV q4h (maximum, 18–24 MU/day) for 14 (10–28) days
  • 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
  • 1.2 Late neurologic disease
  • 1.2.1 Central or peripheral nervous system disease (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
  • 1.2.2 Central or peripheral nervous system disease (pediatric)
  • Preferred regimen: Ceftriaxone 50–75 mg/kg IV q24h (maximum, 2 g/day) for 14 (10–28) days.
  • Alternative regimen (1): Cefotaxime 150–200 mg/kg/day IV q6–8h (maximum, 6 g/day) for 14 (10–28) days
  • Alternative regimen (2): Penicillin G 200,000–400,000 U/kg/day IV q4h (maximum, 18–24 MU/day) for 14 (10–28) days
  • 2. American Academy of Neurology (AAN) Practice Parameter[5]
  • 2.1 Meningitis
  • 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

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.
  • The majority of patients with post-treatment Lyme disease syndrome gradually improve over months/years of the primary infection.

References

  1. ↑ 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 (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. ↑ Wormser, Gary P.; Dattwyler, Raymond J.; Shapiro, Eugene D.; Halperin, John J.; Steere, Allen C.; Klempner, Mark S.; Krause, Peter J.; Bakken, Johan S.; Strle, Franc; Stanek, Gerold; Bockenstedt, Linda; Fish, Durland; Dumler, J. Stephen; Nadelman, Robert B. (2006-11-01). "The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 43 (9): 1089–1134. doi:10.1086/508667. ISSN 1537-6591. PMID 17029130.
  3. ↑ Wormser, Gary P.; Dattwyler, Raymond J.; Shapiro, Eugene D.; Halperin, John J.; Steere, Allen C.; Klempner, Mark S.; Krause, Peter J.; Bakken, Johan S.; Strle, Franc; Stanek, Gerold; Bockenstedt, Linda; Fish, Durland; Dumler, J. Stephen; Nadelman, Robert B. (2006-11-01). "The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 43 (9): 1089–1134. doi:10.1086/508667. ISSN 1537-6591. PMID 17029130.
  4. ↑ Wormser, Gary P.; Dattwyler, Raymond J.; Shapiro, Eugene D.; Halperin, John J.; Steere, Allen C.; Klempner, Mark S.; Krause, Peter J.; Bakken, Johan S.; Strle, Franc; Stanek, Gerold; Bockenstedt, Linda; Fish, Durland; Dumler, J. Stephen; Nadelman, Robert B. (2006-11-01). "The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 43 (9): 1089–1134. doi:10.1086/508667. ISSN 1537-6591. PMID 17029130.
  5. ↑ 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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