Lyme Disease and Related Tick-Borne Infections

Description

Alternative Names

Treatment

Antibiotics are the agents of choice in all phases of Lyme disease. In nearly all cases they can cure Lyme, even in later stages. It should be noted that these recommendations apply only to Lyme disease in the US. The agents that cause Lyme disease in Europe may require different treatments.

Preventive Antibiotics After a Tick Bite

An expert group has recommended that people bitten by deer ticks should not routinely receive antibiotics to prevent the disease.

Nevertheless, an important study in 2001 reported that a single 200-mg dose of the antibiotic doxycycline given within 72 hours of the tick bite was effective in preventing disease (87% protection). If 72 hours have passed, simply waiting for symptoms and then treating the disease at that point is very effective and cures nearly all cases. Previous studies have found no benefits from taking a long course of antibiotics (10 to 14 days) for prevention. The study was small and warrants additional research.

In general, the risk of developing Lyme disease after being bitten by a tick ranges from only 1.1% to 3.4%. And the only people who still might need preventive antibiotics are unvaccinated individuals in high-risk areas who have been bitten by ticks that are in the nymph stage and that are at least partially swollen after feeding. (Adult ticks or nymph ticks that are not swollen pose a very low risk.)

Treating Early Stage Lyme Disease

Three to four weeks of either doxycycline or amoxicillin is the standard regimen. The following are treatment guidelines for treating patients who have been bitten by a tick and have symptoms or a reasonably clear diagnosis of early Lyme disease:

• Doxycycline. This antibiotic is effective against both Lyme disease and ehrlichiosis and so is the standard antibiotic for any patient over eight years old (except pregnant women). It may also be effective for patients with Bell's palsy (although such patients may have other neurologic problems that need more aggressive treatments). Doxycycline cannot be used routinely in children under eight years old. It is a form of tetracycline and as such discolors teeth and inhibits bone growth. It can also cause birth defects, so it should not be used during pregnancy.
• Either amoxicillin (one of the penicillins) or cefuroxime (Ceftin)--a drug known as a cephalosporin--is the alternative for young children. Amoxicillin is the first choice and also probably the best antibiotic for pregnant women. Unfortunately, many people are allergic to penicillin. In addition, strains of bacteria are emerging that are resistant to penicillins. Either agent is usually given for 20 days. Large studies are needed to determine which agent is more effective in children.
• Erythromycin or similar agents called macrolides are used if none of these agents are appropriate.
• Intravenous ceftriaxone--another cephalosporin--is usually warranted if there are signs of infection in the central nervous system (the brain or spinal region).

A 2003 study suggested that a 10-day regimen of doxycycline was sufficient for curing most cases. The duration is a matter of some debate, since many physicians are concerned about persistent symptoms and so prescribe the antibiotic for 20 days. Whether prescribing antibiotics for longer periods of time adds any benefit, however, is uncertain. For example, according to the same 2003 study, extending the duration to 20 days did not prevent persistent Lyme symptoms any more effectively than the 10-day regimen.

Side Effects of Antibiotics. The most common side effects of nearly all antibiotics are gastrointestinal problems, including cramps, nausea, vomiting, and diarrhea. Allergic reactions can also occur with all antibiotics, but are most common with medications derived from penicillin or sulfa. These reactions can range from mild skin rashes to rare but severe, even life-threatening, anaphylactic shock. Some drugs, including certain over-the-counter medications, interact with antibiotics; patients should report to the physician all medications they are taking.

Treating Late Stage Lyme Disease

Lyme Arthritis. Either oral doxycycline (about two months) or intravenous ceftriaxone (one month) are options for Lyme arthritis. The oral antibiotic has fewer side effects and is less expensive. Some patients on the oral medication, however, develop neurologic Lyme complications, which then require intravenous antibiotics. Newer potent oral antibiotics are under investigation. Patients should discuss these issues with their physician.

Lyme Encephalopathy and Other Neurologic Symptoms. Intravenous (IV) antibiotic treatments (usually ceftriaxone) are typically used for 21 to 30 days. Good alternatives are intravenous cefotaxime or penicillin G. This treatment is nearly always successful in treating Lyme encephalopathy. Symptoms usually resolve in a week, but in some cases it can take months.

Heart Arrhythmia. Lyme disease, in some cases, effects the electrical conduction to the heart and can disrupt heart rhythms. Mild heart involvement usually responds to oral antibiotics. Severe disturbances in heart rhythms require intravenous antibiotics. Heart monitoring is important. For some patients, it may be necessary to insert a pacemaker for a week or two, although a permanent pacemaker is rarely needed.

Treating Post-Lyme Disease Syndrome

In about 10% of cases after treatment symptoms persist, a condition referred to as post-Lyme disease syndrome. In such cases, patients have persistent fatigue, muscle and joint aches, and neurologic symptoms. Treatment for this syndrome is highly controversial.

Intravenous Antibiotics. Some physicians believe that patients with such chronic symptoms have been inadequately treated previously. They recommend extremely aggressive treatments with 30 days of intravenous antibiotics followed by a month of oral doxycycline. This approach has some significant risks.

An important 2001 study compared a group of patients with this antibiotic regimen with a group that received a placebo (dummy agent). All of these patients had been previously treated for Lyme and reported persistent pain, fatigue, and neurologic symptoms. After treatment, there were no differences among any of the treatment approaches, including the placebo. In general, 36% of patients improved, 39% worsened, and 25% experienced no change. None of the patients showed any evidence of persistent infection with B. burgdorferi. Two 2004 studies confirmed that additional antibiotics have no beneficial effects on patients with Lyme disease symptoms who had previously received antibiotic therapy.

Such findings do not mean that post-Lyme disease syndrome is simply a psychologic problem, but rather that this condition is probably not treatable with antibiotics. Such patients still require a careful and well-thought out treatment plans.

Other Treatments. Some other approaches for post-Lyme disease syndrome include the following:

• Pain control and cognitive behavioral therapies may be helpful. Cognitive behavioral treatment, which helps patients learn to cope and manage their symptoms, may be very helpful. According to one study, this process can take many months of three to four sessions a week before the patient experiences its full benefits.
• Some experts believe that the condition is caused by a persistent and abnormal immune response. In such cases, anti-inflammatory agents may be tried.
• In rare cases of severe and persistent arthritis of the knee or other joints, surgery may be required.

Alternative Therapies. Some individuals use vitamin B complex, omega-3 and omega-6 fatty acids (found in primrose oil and fish oils), and magnesium supplements (magnesium L-lactate dihydrate) to help relieve symptoms. No evidence exists on their benefits. Newsletters and Internet sites have cropped up in recent years espousing untested treatments to long-term sufferers of Lyme disease symptoms and who are frustrated with traditional medical channels. Some remedies are dangerous, and most are ineffective. Any such therapies should be discussed with a physician.