Dr. E. Murakami Centre for Lyme

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Treatment
 

Treatment Options

This list is here only to show as a sample, what a typical treatment plan may be by your treating physician. It is in no way meant to be a suggestive treatment plan by Dr. Murakami. Your physician will advise as to what the treatment plan for you will be.

 

Presumptive


 

Patient Group                                Tx Line                Treatment

known tick bite                                    1st                    -single-dose antibiotic prophylaxis  

  • Postexposure prophylaxis with a single dose of doxycycline may be used for a significant exposure meeting all of the following criteria: [1] [13] [14] [15]

  

1. An engorged tick is removed after at least an estimated 36 hours of attachment.

  

2. Prophylaxis is started within 72 hours of tick removal.

  

3. B burgdorferi prevalence in local ticks is known to be greater than 20%.

  

4. Doxycycline is not contraindicated (contraindications include children <8 years of age, pregnancy or lactation).

  

   Primary Options

  

  • doxycycline : oral

 

Acute


 

Patient Group                             Tx Line            Treatment

erythema migrans                            1st                 -oral antibiotic therapy

  

  • Oral antibiotics are recommended for patients with Lyme disease (local or disseminated) with erythema migrans, in the absence of cardiovascular or neurologic manifestations.

  

  • Doxycycline is contraindicated in children <8 years of age, and during pregnancy and lactation. Amoxicillin and cefuroxime may be used safely in these patients.

  

  • Macrolides (e.g., azithromycin or erythromycin) are not recommended as first-line treatment. They should be reserved for patients with intolerance or allergy to first-line agents, with close monitoring for resolution of symptoms.

  

  • First-generation cephalosporins are ineffective for the treatment of Lyme disease.

  

  • Various studies have used 10 to 21 days of treatment, but these have not been compared head to head. In most cases 14 days is adequate, but there is not complete consensus. However, azithromycin is only given for 7 to 10 days.

  

        Primary Options

  

  • doxycycline : oral

  

  • amoxicillin : oral

  

  • cefuroxime: oral

  

        Secondary Options

  

  • azithromycin : oral

  

  • erythromycin base : oral

  

  • clarithromycin : oral

  

Patient Group                             Tx Line                     Treatment

  

erythema migrans                               1st                      -oral antibiotic therapy

indistinguishable from

community-acquired cellulitis

  

  • When erythema migrans cannot be distinguished from community-acquired cellulitis, cefuroxime or amoxicillin/clavulanate is recommended.

  

  • Various studies have used 10 to 21 days of treatment, but these have not been compared head to head. In most cases 14 days is adequate, but there is not complete consensus.

  

        Primary Options

  

  • cefuroxime: oral

  

  • amoxicillin/clavulanate : oral

  

Patient Group                                Tx Line                 Treatment

  

cardiac complications                       1st                      -oral antibiotic therapy

without high-grade heart block

  

  • Oral antibiotic therapy is recommended for patients with cardiac complications but without any of the following: chest pain, syncope, dyspnea, second- or third-degree AV block, or first-degree block with PR interval ?300 milliseconds. [1] [36] Patients with any of these preceding features are treated with parenteral antibiotic therapy.

  

  • Various studies have used 10 to 21 days of treatment, but these have not been compared head to head. In most cases 14 days is adequate, but there is not complete consensus.

  

         Primary Options

  

  • doxycycline : oral

  

  • amoxicillin : oral

  

  • cefuroxime: oral

  

Patient Group                             Tx Line            Treatment

  

neurologic complications                  1st                 - intravenous antibiotic therapy

or high-grade heart block

  

  • Intravenous antibiotics are used for Lyme disease with neurologic complications (e.g., meningitis, radiculitis, encephalitis) or cardiac complications involving high-grade heart block.

  

  • Hospitalization and continuous monitoring are required for patients with chest pain, syncope, dyspnea, second- or third-degree AV block, or first-degree block with PR interval ?300 milliseconds.

  

  • Ceftriaxone is the drug of choice for both adults and children.

  

  • Alternative agents include cefotaxime or penicillin-G for patients with neurologic or cardiac complications of Lyme disease and normal renal function.

  

  • Doxycycline is an alternative agent for patients with neurologic or cardiac complications who are intolerant of penicillins or cephalosporins; however, it should be avoided in children <8 years of age and pregnancy or lactation.

  

  • Various studies have used 10 to 28 days of treatment. In most cases 14 days is adequate, but there is not complete consensus.

  

         Primary Options

  

  • ceftriaxone : IV

 

        Secondary Options

  

  • penicillin G potassium aqueous : IV
  • cefotaxime : IV

 

        Tertiary Options

  

  • doxycycline : IV

                                                       

 

                                                     adjunct                       -temporary pacemaker

  

  • Temporary pacemaker is recommended for patients with advanced AV block. [1] [36]

  

Patient Group                             Tx Line                      Treatment

  

arthritis                                            1st                         -oral antibiotic therapy

  

  • Lyme arthritis can be treated with the same preferred oral regimens as for uncomplicated Lyme disease, for an extended period of treatment (28 days total).

  

  • Persistence or recurrence of symptoms will require retreatment.

  

Primary Options

  

  • doxycycline : oral

  

  • amoxicillin : oral

  

  • cefuroxime: oral

 

Secondary Options

  

  • erythromycin base : oral

  

  • clarithromycin : oral

                                               

                                                     adjunct                 -nonsteroidal anti-inflammatory                                                                                     drugs

  

  

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used for symptom relief for Lyme arthritis, along with antibiotic therapy.

 

Primary Options

  

  • diclofenac: oral

  

  • ibuprofen : oral

 

Ongoing


 

Patient Group                  Tx Line                              Treatment

recurrent or                          1st                                  -oral or intravenous antibiotic therapy

persistent arthritis

  

  • Persistence or recurrence of arthritis symptoms should be retreated with a second 4-week course of oral antibiotics or a 2- to 4-week course of intravenous ceftriaxone. [1] [38] [39]

  

  • Oral treatment is preferable, unless there was no response to oral therapy at all in the first cycle.

  

         Primary Options

  

  • doxycycline : oral  
  • amoxicillin : oral
  • cefuroxime: oral

 

        Secondary Options

  

  • ceftriaxone : IV

 

antibiotic-refractory arthritis                 1st             -arthroscopic synovectomy or                                                                                  pharmacotherapy

  

  • Arthroscopic synovectomy has been used successfully in patients with antibiotic-refractory Lyme arthritis.

  

  • Anecdotal use of intraarticular injections of corticosteroids, systemic administration of nonsteroidal anti-inflammatory drugs (NSAIDs), or disease-modifying antirheumatic drugs (DMARDs) such as hydroxychloroquine have also been reported to help patients with antibiotic-refractory Lyme arthritis.

  

These treatments should only be initiated under specialist supervision.


 

  

Reference1

Wormser GP, Dattwyler RJ, Shapiro ED, et al. 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. 2006;43:1089-1134.[Abstract] http://www.ncbi.nlm.nih.gov/pubmed/17029130[Full Text] http://www.journals.uchicago.edu/doi/full/10.1086/508667

  

Reference13

Hayes EB, Piesman J. How can we prevent Lyme disease? N Engl J Med. 2003;348:2424-2430.[Abstract] http://www.ncbi.nlm.nih.gov/pubmed/12802029

  

Reference14

Lathrop SL, Ball R, Haber P, et al. Adverse event reports following vaccination for Lyme disease: December 1998-July 2000. Vaccine. 2002;20:1603-1608.[Abstract] http://www.ncbi.nlm.nih.gov/pubmed/11858868

  

Reference15

Nadelman RB, Nowakowski J, Fish D, et al. Prophylaxis with single-dose doxycycline for the prevention of Lyme disease after an Ixodes scapularis tick bite. N Engl J Med. 2001;345:79-84.[Abstract] http://www.ncbi.nlm.nih.gov/pubmed/11450675

  

Reference36

Sigal LH. Early disseminated Lyme disease: cardiac manifestations. Am J Med. 1995;98:25S-28S. [Abstract] http://www.ncbi.nlm.nih.gov/pubmed/7726189

  

Reference38

Steere AC, Levin RE, Molloy PJ, et al. Treatment of Lyme arthritis. Arthritis Rheum. 1994;37:878-888.[Abstract] http://www.ncbi.nlm.nih.gov/pubmed/8003060

  

Reference39

Eckman MH, Steere AC, Kalish RA, et al. Cost effectiveness of oral as compared with intravenous antibiotic treatment for patients with early Lyme disease or Lyme arthritis. N Engl J Med. 1997;337:357-363.[Abstract] http://www.ncbi.nlm.nih.gov/pubmed/9233874