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Lyme disease — Clinical Guidelines

Overview

Lyme disease, caused by Borrelia burgdorferi, is a tick-borne illness presenting with characteristic erythema migrans rash, often followed by multisystem manifestations including neurologic, cardiac, and musculoskeletal symptoms. 2 3

Diagnosis

Clinical Presentation: Erythema migrans, fever, fatigue, arthralgias, and neurological symptoms like meningitis or cranial neuritis. 2 3

Laboratory Tests: Serological testing (IgM/IgG antibodies to Borrelia burgdorferi), though early infection may show false negatives. 2 3

Imaging: MRI may support diagnosis in cases of neuroborreliosis or meningoradiculitis. 14 20

Tick Exposure History: Important for risk stratification and guiding prophylaxis decisions. 6

Management

Early Localized Disease: Oral doxycycline (100 mg BID), amoxicillin (500 mg TID), or cefuroxime axetil (500 mg BID) for 14-21 days. 2 12

Early Disseminated Disease: Intravenous ceftriaxone (2 g QD) or penicillin G (18-24 million units QD) for 14-28 days. 2 12

Lyme Arthritis: Similar to disseminated disease treatment; non-persistent arthritis often responds well to antibiotics. 16

Prophylaxis After Tick Bite: Doxycycline (200 mg PO single dose) recommended if tick has fed for ≥36 hours; scutal index can reduce unnecessary prophylaxis. 6

Special Populations

Pediatrics: Similar treatment regimens as adults but with careful monitoring for side effects. 14

Elderly: Consider comorbidities and renal function when selecting antibiotics; close monitoring for complications. 18

Comorbidities: Tailor antibiotic choice based on potential interactions and patient-specific risks. 13

Key Recommendations

Antibiotic Prophylaxis After Tick Bite: Administer doxycycline prophylaxis if the tick has fed for ≥36 hours; consider scutal index to avoid unnecessary treatment. (Evidence: Moderate) 6

Treatment of Early Localized Lyme Disease: Use oral antibiotics such as doxycycline, amoxicillin, or cefuroxime axetil for 14-21 days. (Evidence: Strong) 2 12

Management of Lyme Arthritis: Treat with intravenous or oral antibiotics based on disease severity; arthritis is often non-persistent. (Evidence: Moderate) 16

References

1 Zhou G, Xu X, Zhang Y, Yue P, Luo S, Fan Y et al.. Antibiotic prophylaxis for prevention against Lyme disease following tick bite: an updated systematic review and meta-analysis. BMC infectious diseases 2021. link 2 Lantos PM, Rumbaugh J, Bockenstedt LK, Falck-Ytter YT, Aguero-Rosenfeld ME, Auwaerter PG et al.. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 2021. link 3 Lantos PM, Rumbaugh J, Bockenstedt LK, Falck-Ytter YT, Aguero-Rosenfeld ME, Auwaerter PG et al.. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 2021. link 4 McGlacken-Byrne A, McCloskey C, Fisher A, Mullaney P. Lyme neuroborreliosis causing unilateral cerebellitis presenting as horizontal nystagmus in a 7-year-old: an unusual presentation to an ophthalmology service. Journal of AAPOS : the official publication of the American Association for Pediatric Ophthalmology and Strabismus 2021. link 5 Rauer S, Kastenbauer S, Hofmann H, Fingerle V, Huppertz HI, Hunfeld KP et al.. Guidelines for diagnosis and treatment in neurology - Lyme neuroborreliosis. German medical science : GMS e-journal 2020. link 6 Falco RC, Daniels TJ, Vinci V, McKenna D, Scavarda C, Wormser GP. Assessment of Duration of Tick Feeding by the Scutal Index Reduces Need for Antibiotic Prophylaxis After Ixodes scapularis Tick Bites. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 2018. link 7 Hu LT. Lyme Disease. Annals of internal medicine 2016. link 8 Singh S, Parker D, Mark-Carew M, White R, Fisher M. Lyme Disease in West Virginia: An Assessment of Distribution and Clinicians' Knowledge of Disease and Surveillance. The West Virginia medical journal 2016. link 9 Wormser GP, Nadelman RB, Schwartz I. The amber theory of Lyme arthritis: initial description and clinical implications. Clinical rheumatology 2012. link 10 Paton M. Just a tick. Interview by Mary-Claire Mason. Nursing standard (Royal College of Nursing (Great Britain) : 1987) 2010. link 11 Blanton L, Keith B, Brzezinski W. Southern tick-associated rash illness: erythema migrans is not always Lyme disease. Southern medical journal 2008. link 12 . Treatment of Lyme disease. The Medical letter on drugs and therapeutics 2005. link 13 Schutzer SE, Coyle PK, Chen D. The role of the allergist in Lyme disease. Allergy and asthma proceedings 2001. link 14 Demaerel P, Crevits I, Casteels-Van Daele M, Baert AL. Meningoradiculitis due to borreliosis presenting as low back pain only. Neuroradiology 1998. link 15 Berglund J, Blomberg I, Hansen BU. Lyme borreliosis in rheumatological practice: identification of Lyme arthritis and diagnostic aspects in a Swedish county with high endemicity. British journal of rheumatology 1996. link 16 Blaauw I, Nohlmans L, van den Berg-Loonen E, Rasker J, van der Linden S. Lyme arthritis in The Netherlands: a nationwide survey among rheumatologists. The Journal of rheumatology 1991. link 17 Simpson WJ, Schrumpf ME, Hayes SF, Schwan TG. Molecular and immunological analysis of a polymorphic periplasmic protein of Borrelia burgdorferi. Journal of clinical microbiology 1991. link 18 Patial RK, Kashyap S, Bansal SK, Sood A. Lyme disease in a Shimla boy. The Journal of the Association of Physicians of India 1990. link 19 Daffner KR, Saver JL, Biber MP. Lyme polyradiculoneuropathy presenting as increasing abdominal girth. Neurology 1990. link 20 Graf M, Kristoferitsch W, Baumhackl U, Zeitlhofer J. Electrophysiologic findings in meningopolyneuritis of Garin-Bujadoux-Bannwarth. Zentralblatt fur Bakteriologie, Mikrobiologie, und Hygiene. Series A, Medical microbiology, infectious diseases, virology, parasitology 1987. link80085-8) 21 Gross GP, Cooper PH, Nolan C. Erythema chronicum migrans with purpura and polymorphonuclear infiltrates. Archives of dermatology 1979. link

Lyme disease