Lyme Disease Treatment

by Brian Schwartz, M.D., M.S.

Lyme disease is treatable at all stages, with either oral or intravenous antibiotics. There is some complexity in the treatment decisions, and these differ somewhat for children and adults. There have been few randomized clinical trials of treatment, so optimal choice of antibiotic or optimal duration of treatment are not known. In general, early Lyme disease in adults is treated with doxycycline 100 mg orally twice daily or amoxicillin 500 mg orally three times daily for 20 to 30 days. Doxycycline should not be used in children under age nine years or pregnant women. Other antibiotic choices include phenoxymethyl penicillin, tetracycline, cefuroxime axetil, erythromycin, or azithromycin, with the latter two considered to be second line choices.

In a study by Nadelman,, they compared treatment with placebo versus a single 200-mg dose of doxycycline in 482 subjects who had removed attached I. scapularis ticks from their bodies within the previous 72 hours. Erythema migrans developed at the site of the tick bite in a significantly smaller proportion of the subjects in the doxycycline group than of those in the placebo group (1 of 235 subjects [0.4 percent] vs. 8 of 247 subjects [3.2 percent], P<0.04). The efficacy of treatment was 87 percent (95 percent confidence interval, 25 to 98 percent). Objective extracutaneous signs of Lyme disease did not develop in any subject, and there were no asymptomatic seroconversions. These data suggest that a single 200-mg dose of doxycycline given within 72 hours after an I. scapularis tick bite can prevent the development of Lyme disease.

Doxycycline for 30 day courses has been used to treat certain cardiac, nervous system, and joint manifestations of Lyme disease. Other specific manifestations of Lyme disease are generally treated with intravenous antibiotics, most often ceftriaxone 2 gm twice daily for 14 to 30 days, and these include Lyme meningitis, neuroborreliosis, arthritis not responsive to doxycycline, and severe cardiac manifestations.

Symptomatic relief after treatment should be evaluated not on a day-to-day basis, but rather over several months. Patients should have slow, steady progress to their premorbid state. Patients who have lingering symptoms after treatment should not be routinely retreated with antibiotics without clear evidence of antibiotic failure. Non-steroidal anti-inflammatory medications, anti-depressants, exercise, and physical therapy have been used for symptomatic relief after an adequate trial of antibiotic therapy.

Table 3. Treatment Regimens for Lyme Disease*

Early Infection – (Local or Disseminated)
Adults Doxycycline, 100 mg orally 2 times/days(d) for 20 to 20d
Amoxicillin, 500 mg orally 3 times/d for 20 to 30dAlternatives in case of doxycycline or amoxicillin allergy:
Cefuroxime axetil, 500 mg orally twice daily for 20 to 30d
Erythromycin, 150 mg orally 4 times a day or 20 mg/kg/d in divided doses for 20 to 20d
(Age 8 or less)
Amoxicillin, 250 mg orally 3 times a day or 20 mg/kg/d in divided doses for 20 to 30 dAlternatives in case of penicillin allergy:
Cefuroxime axetil, 125 mg orally twice daily for 20 to 30 d
Erythromycin, 250 mg orally 3 times a day or 30 mg/kg/d in divided doses for 20 to 20 d
(Intermittent or Chronic) Doxycycline 100 mg orally 2 times/d for 30 to 60d
Amoxicilln 500 mg orally 4 times/d for 30 to 60d
or Ceftriaxone 2g IV once a day for 14 to 39d
Penicillin G, 20 million U IV in 4 divided doses daily for 30d
Neurologic Abnormalities
(Early or Late) Ceftriaxone 2g IV once a day for 14 to 30d
Penicillin G, 20 million U IV in 4 divided doses for 30 dAlternative in case of ceftriaxone or penicillin allergy:
Doxycycline, 100 mg orally 3 times a day for 30d
Facial palsy alone Oral regimens may be adequate
Cardiac Abnormalities
First-degree AV block
(P-R interval >0.3 sec)
Oral regimens, as for early infection
High-degree AV block Ceftriaxone, 2 gm IV once a day for 30d**
Penicillin G, 20 million U IV in 4 divided doses daily for 30d**

Adopted by the Infectious Disease Society of America
*Treatment failures have occurred with any of the regimens given, and a second course of therapy may be necessary.
**Once the patient has stabilized, the course may be completed with oral therapy.

How can individuals protect themselves?

Individuals should be educated to check themselves, very carefully, at the end of each day in tick-infested habitats, for ticks on their skin. Any ticks should be removed and discarded. Since I. scapularis must feed for 24-48 hours to transmit the disease, this will likely prevent most, if not all, Lyme disease. Other behaviors, such as DEET (n,n-diethyl-m-toluamide) use on skin (an insect repellent) or permethrin use on clothing (an insecticide, which kills ticks, derived from flowers approved for this use), tucking pants into socks, wearing long sleeves and long pants, and wearing light-colored clothing for easier spotting of ticks, can also be used. Purists will argue that such personal protective behaviors have not been documented to decrease the risk of Lyme disease. However, a growing body of epidemiologic evidence, albeit indirect, suggests that such behaviors are beneficial in protecting persons from tick bites and thus Lyme disease. Such environmental interventions as elimination of leaf litter, deer exclusion with fencing, deer elimination, insecticide (acaricide) applications, and even the use of guinea fowl around the home, have been shown, in some instances, to decrease tick burden around residential areas. However, there are not really any practical environmental methods to prevent Lyme disease transmission around the home in endemic areas. Insecticide has to be reapplied on a regular basis and many communities have concerns about such repeated applications, so this method of control probably has only limited applicability.

Controlling ticks by keeping grass and brush trimmed

Controlling ticks by keeping grass and brush trimmed

Is there a vaccination available to prevent Lyme disease?

There is no vaccine currently available for Lyme disease. LYMErix, once available as a vaccine for Lyme disease, was removed from the market in February, 2002 because of possible side effects.

Updated: October 10, 2012

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